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Laparoscopic Management of Heterotopic Istmocornual Pregnancy: A Different Technique

Laparoscopic Management of Heterotopic Istmocornual Pregnancy: A Different Technique
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  LaparoscopicManagementofHeterotopicIstmocornualPregnancy:A Different Technique Nuri Peker, MD*, Elif Ganime Aydeniz, MD, Savas¸ G € undo  gan, MD, and Fatih S¸enda  g, MD From the Department of Obstetrics and Gynecology, Acibadem University Atakent Hospital, Istanbul, Turkey (all authors). ABSTRACT StudyObjective: To present a modified technique for laparoscopic cornual resection for the surgical treatment of heterotopicistmocornual pregnancy. Design:  A step-by-step explanation of the surgery using video (Canadian Task Force Classification III-c). Setting:  Heterotopic pregnancy is the coexistence of pregnancy in both the intrauterine and extrauterine sides. The incidenceis 1 in 30 000 in spontaneous pregnancies; however, the incidence increased to 1 in 100 to 1 in 500 pregnancies with theincreasing number of artificial reproductive technologies [1,2]. Although management is controversial, there are 2 mainapproaches classified as surgical and nonsurgical. The administration of potassium chloride, methotrexate, and/orhyperosmolar glucose is a nonsurgical intervention; however, there are some limitations such as systemic side effects andthe possible adverse effect on a live fetus [1–3]. For this reason, surgical intervention involving cornual resection is themain treatment option. Case Report:  A 32-year-old patient was admitted to our clinic with sudden-onset pain at the left groin. She was at the 11thweekofgestation.Shehadadiagnosisofinfertilityfor7years,andshebecamepregnantafteraninvitrofertilizationcycle.Atsonographic examination, 2 gestational sacs were detected, 1 with a live fetus settled into the uterus and the second (20-mmlength) on the left cornual side without a yolk sac and embryo and the left adnexa accompanied with coagulated blood. Im-mediate laparoscopic surgery was planned. At the laparoscopic exploration, left istmocornual pregnancy that was rupturedand bleeding were observed. We performed a modified technique for laparoscopic cornual resection in which the uterinecorn was tightened with the noose twice, and the corn was sutured circularly to avoid excessive bleeding. Initially, the mes-osalpinx was coagulated and transected with bipolar energy. Afterward, the uterine corn was tightened with the noose twice,and the fallopian tube was removed. To reduce the bleeding during remnant cornual tissue extraction, a permanent 0 mono-filament suture was passed deep into the myometrium and tightened to achieve better hemostasis. Then, the remnant cornualtissue was extracted with harmonic scissors, and the uterine wound was repaired with continuous suture to reduce the risk of uterine rupture during the ongoing pregnancy. Depot progesterone was administered just before the surgery and the day after.She was discharged on the first postoperative day. At the follow-up, she did not experience any problems during pregnancy,and she was delivered with cesarean section at 39 weeks’ gestation. Conclusion:  In conclusion, laparoscopic surgery is a safe and feasible option for the treatment of heterotopic pregnancy, andcontrolofbleedingcanbeachievedbetterwithourmodifiedtechnique.JournalofMinimallyInvasiveGynecology(2016) - , - – -  2016 AAGL. All rights reserved. Keywords:  Heterotopic; Laparoscopy; PregnancyThe authors declare that they have no conflict of interest.Correspondingauthor:NuriPeker,MD,DepartmentofGynecologyandOb-stetrics, Acibadem University Atakent Hospital, Merkez mahallesi, Turgut € Ozal bulvarı, Halkalı, K.C¸ekmece Istanbul 34000, Turkey.E-mail: dr.ata1980@hotmail.comSubmitted June 17, 2016. Accepted for publication July 9, 2016.Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter  2016 AAGL. All rights reserved.http://dx.doi.org/10.1016/j.jmig.2016.07.008  Supplementary Data Supplementary data related to this article can be found athttp://dx.doi.org/10.1016/j.jmig.2016.07.008. References 1. Habana A, Dokras A, Giraldo JL, Jones EE. Cornual heterotopic preg-nancy: contemporary management options.  Am J Obstet Gynecol .2000;182:1264–1270.2. Chin HY, Chen FP, Wang CJ, Shui LT, Liu YH, Soong YK. Heterotopicpregnancyafter invitro fertilization-embryo transfer.  Int J Gynaecol Ob-stet  . 2004;86:411–416.3. Sentilhes L, Bouet PE, Gromez A, Poilblanc M, Lefebvre-Lacoeuille C,DescampsP.Successfulexpectantmanagement fora cornualheterotopicpregnancy.  Fertil Steril . 2009;91:934.e11–934.e13.     p    r     i    n     t      &    w    e     b     4      C     /     F     P      O 2  Journal of Minimally Invasive Gynecology, Vol -  , No -  , -  /  - 2016 
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