Surgical Management of Cesarean Scar Ectopic with Fertility Preservation

Abstract

Study Objective To highlight retroperitoneal anatomy and show surgical techniques to minimize blood loss during cesarean scar ectopic resection. Design A step-by-step explanation of the surgery using video (instructive video). Setting University Hospital. Patient was in dorsal lithotomy position. Patients or Participants A 33 year-old woman G4P1 with a cesarean scar ectopic pregnancy at 10weeks gestation that failed methotrexate injection. Interventions This video highlights entry into the retroperitoneal space and dissection technique for identifying the uterine arteries at their origins. Bulldog clamps are placed on all vascular pedicles that supply the uterus (bilateral uterine arteries and bilateral infundibulopelvic ligaments) to aid with hemostasis. Additionally, Vasopressin is used to further reduce blood loss. Applying these techniques allowed for successful resection of the ectopic pregnancy with only 50 cc of estimated blood loss. Control of bleeding resulted in thorough resection of the ectopic pregnancy while conserving as much surrounding myometrium as possible. The uterine defect is repaired in three layers. Measurements and Main Results Operative time was 199 minutes, with an estimated blood loss of 50ml. Surgical resection of the ectopic pregnancy allowed the patient to preserve her fertility. Subsequently, the patient had an uncomplicated pregnancy which resulted in a live birth. Conclusion Knowledge of the avascular spaces and dissection techniques that allow for access to the origin of the uterine artery can be very useful in complex cases. Bulldog clamps can be used for transient occlusion of blood supply to the uterus resulting in resection of a cesarean scar ectopic with minimal blood loss. This is an option for patients who desire future fertility.