Salpingectomy for ectopic pregnancy

• Review for indications.

• Review operative care principles and start an IV infusion.

• Give a single dose of prophylactic antibiotics:

- ampicillin 2 g IV;

- OR cefazolin 1 g IV.

• Open the abdomen:

- Make a midline vertical incision below the umbilicus to the pubic hair, through the skin and to the level of the fascia;

- Make a 2-3 cm vertical incision in the fascia;

- Hold the fascial edge with forceps and lengthen the incision up and down using scissors;

- Use fingers or scissors to separate the rectus muscles (abdominal wall muscles);

- Use fingers to make an opening in the peritoneum near the umbilicus. Use scissors to lengthen the incision up and down in order to see the entire uterus. Carefully, to prevent bladder injury, use scissors to separate layers and open the lower part of the peritoneum;

- Place a bladder retractor over the pubic bone and place self-retaining abdominal retractors.

• Identify and bring to view the fallopian tube with the ectopic gestation and its ovary.

• Apply traction forceps (e.g. Babcock) to increase exposure and clamp the mesosalpinx to stop haemorrhage.

• Aspirate blood from the lower abdomen and remove blood clots.

• Apply gauze moistened with warm saline to pack off the bowel and omentum from the operative field.

• Divide the mesosalpinx using a series of clamps (Fig P-58 A-C). Apply each clamp close to the tubes to preserve ovarian vasculature.

• Transfix and tie the divided mesosalpinx with 2-0 chromic catgut (or polyglycolic) suture before releasing the clamps.

• Place a proximal suture around the tube at its isthmic end and excise the tube.

Figure P-58

 Clamping, dividing and cutting the mesosalpinx 

• Close the abdomen:

- Ensure that there is no bleeding. Remove clots using a sponge;

- In all cases, check for injury to the bladder. If a bladder injury is identified, repair the injury;

- Close the fascia with continuous 0 chromic catgut (or polyglycolic) suture;

Note: There is no need to close the bladder peritoneum or the abdominal peritoneum.

- If there are signs of infection, pack the subcutaneous tissue with gauze and place loose 0 catgut (or polyglycolic) sutures. Close the skin with a delayed closure after the infection has cleared;

- If there are no signs of infection, close the skin with vertical mattress sutures of 3-0 nylon (or silk) and apply a sterile dressing.

SALPINGOSTOMY

Rarely, when there is little damage to the tube, the gestational sac can be removed and the tube conserved. This should be done only in cases where the conservation of fertility is very important to the woman since she is at risk for another ectopic pregnancy.

• Open the abdomen and expose the appropriate ovary and fallopian tube.

• Apply traction forceps (e.g. Babcock) on either side of the unruptured tubal pregnancy and lift to view.

• Use a scalpel to make a linear incision through the serosa on the side opposite to the mesentery and along the axis of the tube, but do not cut the gestational sac. 

• Use the scalpel handle to slide the gestational sac out of the tube.

• Ligate bleeding points.

• Return the ovary and fallopian tube to the pelvic cavity.

• Close the abdomen.

POST-PROCEDURE CARE

• Review postoperative care principles.

• If there are signs of infection or the woman currently has fever, give a combination of antibiotics until she is fever-free for 48 hours:

- ampicillin 2 g IV every 6 hours; 

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours; 

- PLUS metronidazole 500 mg IV every 8 hours.

• Give appropriate analgesic drugs.

• Offer other health services, if possible. 

• If salpingostomy was performed, advise the woman of the risk for another ectopic pregnancy and offer family planning (Table S-3).

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