International Journal of Gynecology and Obstetrics 123 (2013) 139141

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

Laparoscopy versus laparotomy in the management of ectopic pregnancy

with massive hemoperitoneum
Aviad Cohen , Benny Almog, Abed Satel, Joseph B. Lessing, Ziv Tsafrir, Ishai Levin
Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To compare the safety and feasibility of operative laparoscopy versus laparotomy in women with rup-
Received 12 March 2013 tured ectopic pregnancy and massive hemoperitoneum. Methods: In a retrospective cohort study at a university-
Received in revised form 10 May 2013 afliated medical center, records of women with ruptured ectopic pregnancy and massive hemoperitoneum
Accepted 23 July 2013 (N 800 mL) were reviewed. Results: Sixty women were diagnosed with ruptured ectopic pregnancy and massive
hemoperitoneum: 48 underwent emergency laparoscopy; 12 underwent emergency laparotomy. There was no
Keywords:
difference in hemodynamic status at presentation between the groups. Median operating time was signicantly
Hemodynamic instability
Massive hemoperitoneum
shorter in the laparoscopy group (50 minutes [range, 4363 minutes] vs 60 minutes [range, 6072 minutes];
Ruptured ectopic pregnancy P = 0.01). Median intra-abdominal blood loss was signicantly greater in the laparotomy group (1500 mL
[range, 14002000 mL] vs 1000 mL [range, 8001200 mL]; P = 0.002). There was no difference between
the groups regarding treatment with blood products, perioperative complications, and hospitalization period.
Conclusion: In patients with ruptured ectopic pregnancy and massive hemoperitoneum, laparoscopy is feasible
and safe, with signicantly shorter operating times compared with laparotomy. While the mode of surgery
should be based on the surgeons experience and preference, the signicantly lower hemoperitoneum volume
associated with laparoscopy may be a reection of shorter operating times and quicker hemorrhage control.
2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Ectopic pregnancy, a life-threatening condition, occurs in approxi-
mately 1.3%2% of all pregnancies [1]. Although deaths associated with
ectopic pregnancy have decreased during the past 20 years, 9%13% of
all pregnancy-related deaths are associated with the condition [2].
Laparoscopic surgery is the gold standard for treatment of ectopic
pregnancy in hemodynamically stable women [3]. In these women,
the advantages of operative laparoscopy over an open approach are
well recognized and include less operative blood loss, shorter operating
time, less analgesic requirement, shorter hospital stay, shorter period of
convalescence, and signicant cost savings [49].
It is estimated that approximately 15% of women with ectopic preg-
nancy experience hypovolemic shock [10]. In these cases, both the vol-
ume of hemoperitoneum and the patients hemodynamic status are
critical factors in deciding whether to perform laparoscopy or laparoto-
my. Previous studies have claimed that laparoscopy is feasible in
women with ruptured ectopic pregnancy and hemodynamic instability
[11,12]. However, these studies involved small series of hemodynami-
cally stable and unstable patients and did not demonstrate a benet of
the laparoscopic approach in women with hemodynamic instability.
Corresponding author at: Lis Maternity Hospital, 6 Weizman Street, Tel Aviv 64239,
Israel. Tel.: +972 3 692 5622; fax: +972 3 692 5755.
E-mail address: co.aviad@gmail.com (A. Cohen).
The aim of the present study was to determine whether the lap-
aroscopic route is both feasible and quick in hemodynamically
unstable patients.
2. Materials and methods
A retrospective cohort study was conducted at Tel Aviv Sourasky
Medical Center, Tel-Aviv, Israel, which is a tertiary university-afliated
medical center. The institutional review board of the study center
approved the study design, protocol, and waiver of informed consent.
Medical records of all patients who underwent surgery for ectopic
pregnancy at the study center between January 1, 2000, and December
31, 2008, were reviewed. Women were included if they had been diag-
nosed with ruptured ectopic pregnancy and had massive hemoperi-
toneum on both ultrasound and clinical examination, and if the
volume of hemoperitoneum was measured and conrmed during sub-
sequent surgery. All women were transferred for surgery once the
attending physician established the diagnosis. The decision on whether
to perform laparoscopy or laparotomy was taken by the attending phy-
sician based on vital signs and hemoglobin level. Ultrasound assessment
of the amount of uid in the cul-de-sac did not contribute to the deci-
sion on the mode of surgery because it was considered to be inaccurate
and biased. The treatment of choice was salpingectomy in all women.
Because it has been shown that there is poor correlation between vital
signs and blood loss in women with ectopic pregnancy [13], the study

0020-7292/$ see front matter 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijgo.2013.05.014
140 A. Cohen et al. / International Journal of Gynecology and Obstetrics 123 (2013) 139141

population comprised patients in whom hemoperitoneum of at least Table 2

800 mL was measured at surgery, providing a classication of category Hemodynamic status of patients at initial presentation.a

II hemorrhagic shock [14]. Characteristic Laparotomy Laparoscopy P value

The records of women who underwent laparoscopy were compared group (n = 12) group (n = 48)
with those of patients who underwent laparotomy for the same indica- Systolic pressure, mm Hg 107 (8055) 109 (8061) 0.8
tion. The following parameters were compared between the 2 groups: Diastolic pressure, mm Hg 68 (8055) 68 (8061) 0.9
demographic variables; hemodynamic variables at initial presentation Pulse rate, beats/min 100 (11085) 97 (10580) 0.3
Hemoglobin before surgery, g/dL 9.3 (11.08.4) 9.8 (10.48.5) 0.5
(blood pressure, heart rate, hemoglobin level); operating time (skin to
Time from admission to surgery, min 160 (24060) 140 (18090) 0.7
skin); intraoperative variables (operation time, volume of hemoperi-
a
toneum); and postoperative variables (blood transfusion, hospitaliza- Values are given as median (range) unless otherwise indicated.

tion period, postoperative complications). Patients with signs and

symptoms of hypovolemic shock were initially resuscitated with intra-
venous uids and blood products as necessary.
Statistical analysis was performed using SPSS version 18 (IBM,
Armonk, NY, USA). The ShapiroWilk test was used to evaluate data dis-
tribution. Because the data were not normally distributed, comparisons
were analyzed using the MannWhitney U test as appropriate. Propor-
tions were compared via the Fisher exact test. P b 0.05 was considered
to be statistically signicant.
3. Results
During the period studied, 702 women were diagnosed with ectopic
pregnancy at the study institute and 293 were referred for surgery. Of
these, 60 women met the inclusion criteria. Of all women diagnosed
with massive hemoperitoneum, 48 (80%) underwent laparoscopy and
12 (20%) underwent laparotomy. Two patients in the laparoscopy
group had undergone previous pelvic surgery, whereas none of the
patients in the laparotomy group had previous surgical intervention.
Two (4%) women who were initially treated with laparoscopy were
converted to laparotomy owing to technical difculties. There were no
signicant differences between the groups in terms of maternal age,
gravidity, parity, and gestational age (Table 1). Hemodynamic vari-
ables such as pulse rate, systolic blood pressure, diastolic blood pres-
sure, and hemoglobin level at initial presentation did not differ
between the groups (Table 2). In addition, the time interval between
admission and surgery was not signicantly different between the
groups (Table 2). Operating time among women who underwent lap-
aroscopy was signicantly shorter than among women who underwent
laparotomy (50 minutes [range, 4363 minutes] vs 60 minutes [range,
6072 minutes]; P = 0.01) (Table 3). The median volume of hemo-
peritoneum among patients who underwent laparotomy was signi-
cantly greater than among those who underwent laparoscopy
(1500 mL [range, 14002000 mL] vs 1000 mL [range, 8001200 mL];
P = 0.002) (Table 3).
There was no difference between the groups in terms of blood trans-
fusion, postoperative hemoglobin concentration, and length of hospital
stay. All women in the laparoscopy group had uneventful postoperative
courses. After surgery, 1 woman who underwent laparotomy was diag-
nosed with pneumothorax due to positive-pressure ventilation. Because
2 women in the laparotomy group were initially treated with laparosco-
py, the groups were also compared according to intention to treat but
the results were unchanged.
4. Discussion
Laparoscopy is the preferred management method in most cases of
ruptured ectopic pregnancy. Laparoscopic surgery has been considered
contraindicated in certain situations such as interstitial and cornual
pregnancy [15,16], obesity [17], and severe adhesions [18]. However,
with improvement of surgical skills and instrumentation, many of
these absolute contraindications are now obsolete. As many as 15% of
women with ectopic pregnancy experience hypovolemic shock [10],
and laparoscopy for hemorrhage control remains controversial owing
to lack of sufcient data. Laparoscopic surgery in women with hemody-
namic instability carries added physiological effects that can be harmful
and need to be considered. Pneumoperitoneum in laparoscopy causes
intra-abdominal pressure that can reduce the venous return and de-
crease cardiac output [19]. By contrast, the Trendelenburg position in-
creases cardiac return, and the pneumoperitoneum can establish a
degree of hemorrhage control owing to compression of blood vessels
[20]. It is important to note that normal vital signs are poor predictors
for identifying women with ruptured ectopic pregnancy and massive
bleeding [13].
Several studies indicate the advantages and safe use of laparoscopic
surgery in women with ruptured ectopic pregnancy and hemodynamic
instability. Soriano et al. [11] compared laparoscopic surgery between
33 women classied as being hemodynamically unstable and 178 who
were considered to be hemodynamically stable. Only 3 women with he-
modynamic instability were converted to laparotomy. In addition, there
was no difference in postoperative complications between the groups.
Similarly, Sagiv et al. [12] showed the feasibility of laparoscopic surgery
in hemodynamically unstable women, with a low conversion rate to
laparotomy (5.5%). A recent prospective study by Odejinmi et al. [21]
demonstrated that laparoscopy in women with hemoperitoneum
greater than 800 mL can be performed with success rates of 70% and
100% with condent and experienced operators, respectively. Although
these studies have shown the feasibility of laparoscopic surgery in he-
modynamically unstable patients, an important question that must be
answered is whether this approach is superior to laparotomy in terms
of operation time and surgical outcome.
One of the major drawbacks of laparoscopy in women with massive
abdominal bleeding is the time required to insert the instruments and
create a pneumoperitoneum. The present results indicate that laparos-
copy in women with massive hemoperitoneum is the fastest approach,
with a low conversion rate to laparotomy (4%). The results were still

Table 3
Intraoperative and postoperative characteristics.a
Table 1
Patient characteristics.a Characteristic Laparotomy Laparoscopy P value
group (n = 12) group (n = 48)
Characteristic Laparotomy group Laparoscopy group P value
Hemoperitoneum, mL 1500 (14002000) 1000 (8001200) 0.002
(n = 12) (n = 48)
Operation time, min 60 (6072) 50 (4363) 0.01
Age, y 33 (2738) 32 (2835) 0.5 Blood transfusion, no. of 2 (2.03.5) 2 (2.03.0) 0.9
Parity 0 (01) 1 (02) 0.1 packed-cell units per person
Gravidity 2 (13) 3 (24) 0.1 Hemoglobin before discharge, g/dL 9.4 (7.710.5) 8.5 (7.69.5) 0.8
Gestational age, wk 6.9 (5.58.5) 6.3 (6.07.5) 0.6 Hospital stay, d 4.0 (3.05.0) 4.0 (3.75.2) 0.19
a a
Values are given as median (range) unless otherwise indicated. Values are given as median (range) unless otherwise indicated.
 A. Cohen et al. / International Journal of Gynecology and Obstetrics 123 (2013) 139141
valid when comparing the 2 groups according to the intended treat-
ment. A contributing factor for short operating time is a direct trocar
insertionstandard practice at the study centerwhich is safe and sig-
nicantly shortens the time required to insert the trocar into the abdo-
men and create a pneumoperitoneum [2224]. Another important
nding was that women who underwent laparoscopy had reduced
volumes of blood loss at the end of the surgery. Since women in the
2 groups presented with comparable hemodynamic status and hemo-
globin level, and since the time interval from admission to surgery
was comparable, we believe that the smaller amount of blood found
intra-abdominally was the result of a shorter operating time, better
visualization, the creation of pneumoperitoneum with blood vessel
tamponade, and quicker hemorrhage control. In the presence of exces-
sive bleeding in a relatively short time, regardless of the surgical ap-
proach, it is imperative to stabilize all patients with uid resuscitation
before and during surgery.
The main limitations of the study were its retrospective nature,
relatively small sample size, and possible variability in the reports of
hemoperitoneum. Also, blood loss could be attributable to tubal injury
or the operative technique itself. However, these are inherent aws of
surgery and are probably impossible to control for.
The present results demonstrate that laparoscopy is safe and feasible
for the treatment of hemodynamically unstable patients. Moreover, it is
quicker than laparotomy and, therefore, is associated with reduced
intra-abdominal bleeding because of faster hemorrhage control.
Thus, we believe that the decision on the operative route should not
be based on the amount of blood in the abdomen. With this in mind, it is
important to emphasize that the fastest and safest approach is always
the one that the surgeon feels more comfortable with, and this should
always be a factor in the decision regarding the type of intervention.
Conict of interest
The authors have no conicts of interest.
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