Background

Ectopic pregnancy, characterized by an embryo implantation outside the uterine cavity, typically in the fallopian tube (in 95-97% of cases), is known to be a major cause of maternal morbidity and mortality [13]. Other uncommon locations include the ovary, cervix, and abdominal cavity, with special diagnostic and therapeutic antecedents [14]. The estimated risk of EP is 1-2% of all pregnancies and is higher in women with predisposing factors including pelvic inflammatory disease and previous tubal surgery, as well as women who have used assisted reproductive technologies [14, 21]. Historically, ectopic pregnancy was frequently diagnosed late and resulted in tubal rupture and significant hemorrhage, requiring immediate laparotomy and salpingectomy [24]. The development of new diagnostic methods, such as transvaginal ultrasound and serial β-human chorionic gonadotropin (β-hCG) measurement, has made it possible to make a diagnosis earlier, before the rupture, and so to carry out less invasive treatment [16]. There was a fundamental turning point in the 1980s, when laparoscopy was first introduced, enabling us to decrease the surgical morbidity compared with conventional open surgery [15]. Laparoscopic procedures, including salpingectomy (excision of the involved fallopian tube) and salpingostomy (removal of the ectopic pregnancy with preservation of the tube), have largely replaced open surgery as the treatment of choice. Each treatment modality is based on hemodynamic status, ectopic size, location and desire for future fertility [17]. However, there are still obstacles ahead such as the persistence of invasive trophoblastic tissue following salpingostomy and limited numbers of available expertise in laparoscopy in resource-limited countries [18, 29].

Ectopic pregnancy is one of the commonest first trimester causes of maternity mortality, accounting for 6-9% of all pregnancy related deaths in developed nations and a higher percentage in resource-constrained surroundings [19]. Early diagnosis and efficient surgical intervention are essential for avoiding catastrophic sequelae like tubal rupture and hemoperitoneum. The conversion from laparotomy to laparoscopy has provided a great benefit for patients in terms of their recovery, such as shorter length of hospitalization (5-7 days vs 1-2 days), reduced blood loss and mitigated postoperative pain [20]. These benefits translate to dive healthcare costs and earlier recovery to the normal life and work for both patients and healthcare systems [9]. Fertility preservation is highly relevant for women, especially younger women or without prior children, for whom the selection of the operative mode is also of prime importance [17]. Nonetheless, inequalities regarding the access to the laparoscopic operation approach emphasize the importance of homogeneous procedures, together with adequate training [21]. This article is particularly timely for obstetricians, gynecologists, and policy makers seeking to improve surgical approaches, minimize maternal morbidity, and overcome international disparities in care. It also provides a groundwork for researchers who can detect the gaps and reinforce the clinical practice.

Scope and Objectives

This narrative review aims to critically appraise current literature concerning optimal surgical management of ectopic gestation, with emphasis on studies published till June 2009. The review comprises in-depth technical analysis (laparoscopy vs laparotomy, salpingectomy vs salpingostomy), as well as the efficacy, safety, and influence on fertility of interventions. Specific aims are to: (1) review the evidence for harms and benefits of laparoscopic versus open surgery; (2) compare fertility outcomes and complications between salpingectomy and salpingostomy; (3) assess guidelines perspectives that can inform practice; (4) identify gaps and limitations of the literature; and (5) suggest future policy and research directions. Through aggregation of heterogeneous study findings, our review aims to guide clinical practice as well as identify directions for better patient management, especially within varied healthcare systems.

Literature Selection

Studies were identified by searching PubMed, MEDLINE and Cochrane Databases for peer-reviewed articles up until June 2009. Key searches were performed using the terms "ectopic pregnancy," "operative management," "laparoscopy," "salpingectomy," "salpingostomy," "fertility outcomes," and "minimally invasive surgery." Boolean operators (AND, OR) were employed to limit further the search, which resulted in a collection of more than 500 articles. Types of studies to be included were (1) RCTs, (2) cohort studies, (3) meta-analyses, and (4) clinical guidelines that reported unambiguous surgical outcomes. Studies were excluded if they did not meet inclusion criteria and were non-English papers, case reports, editorials, or studies without the primary surgical data. Relevant manuscripts were screened at the abstract level, and full texts were reviewed for sample size, methodological quality, and clinical relevance. 36 studies (10 RCTs, 15 cohort studies, 5 meta-analyses, 6 guideline documents) were included. Data were collected on methods of study, number of subjects, surgical methods, fertility rates, complications (e.g., persistent trophoblastic tissue, recurrence), and cost. In order to maintain the quality of the studies, bias assessments were conducted, and the studies with a clear study design, a sufficient sample size, and follow-up data were considered. This strict process of selection makes the base evidence for the conclusions of the review sound.

Type of Review

This is a narrative, which aims to overview an interpretative synthesis of the surgical management of ectopic pregnancy. Narrative reviews, unlike SRs, follow less rigid protocols for data synthesis and meta-analysis and are the most flexible in terms of incorporating evidence in terms of study designs, trends in clinical practice, implications of findings, and areas that need further research [22]. One size does not fit all in such a diverse literature on overall ectopic pregnancy studies with different designs (RCTs, cohort studies), outcomes (fertility, complications) and settings (high vs. low resource) would therefore present with high heterogeneity. The story-tale structure offers an opportunity for a wide discussion of laparoscopic and open surgery procedures, fertility preserving strategies and disparities in care worldwide that could have been lost in the systematic review rigidity [23]. Strengths of the review include the inclusion of high-quality RCTs and meta-analyses for quality [1-3, 6] with addition of cohort studies to provide real-world relevance [10, 29]. Limitations of the narrative review approach are the potential for selection bias and the absence of quantitative synthesis; however, the latter are countered by clear inclusion criteria, a critical appraisal of study quality, and a broad range of evidence sources included. This review achieves the fine balance between scientific strength and clinical applicability, which makes it useful for clinicians and scientists.

Historical Background of Surgery Types of Surgical Procedures

Surgical treatment of ectopic pregnancy has seen major changes since the 20th century. Surgical sterilization is the primary treatment, and laparotomy with salpingectomy was standard of care in 1970s and was usually performed emergently due to delay in diagnosis and tubal rupture [24]. Although successful in saving the patient's life, this method was associated with a protracted (5–7 days) recovery, substantial blood loss (200–300 mL), and loss of the affected tube, with implications for fertility [1]. Introduction of laparoscopic technology by Bruhat and others in the 1980s became a milestone of gynecologic surgery in that it has transformed the way of minimally invasive diagnosis and/or treatment 4]. Laparoscopy shortened hospitalization to 1-2 days, minimized blood loss (50-100 mL), and enabled pregnancy-protective intervention, such as salpingostomy [2-3]. In the 1990s, technical developments with laparoscopic instruments and diagnostic procedures like the transvaginal ultrasound led to improved results due to earlier intervention [16]. Salpingostomy became a possibility in women who desired conception later, especially in those with an intact contralateral tube [5]. Nevertheless, we cannot ignore that the decision between salpingectomy and salpingostomy is still controversial and that salpingectomy is the treatment of choice for ruptured ectopics and patients who do not want to get pregnant [6]. The results of our recent studies highlight the significance of patient selection and surgeon experience in achieving the best outcomes [28, 29].

Summary of Findings

Ten key articles, including RCTs and prospective cohort studies, consistently detail the benefits of laparoscopy over laparotomy in the stable trauma patient. Vermesh et al. (1989) showed faster recovery (1.5 vs. 5 days) and less blood loss (80 mL vs. 250 mL) with laparoscopy [1]. Lundorff et al. (1991) reported similar findings in an RCT of 87 patients with reduced postoperative complications [2]. Murphy et al. (1992) reported hospital costs to be 40 percent less with laparoscopy [3]. Regarding fertility results, salpingostomy was reported to yield intrauterine pregnancy (IUP) rates of 60-70% and salpingectomy of 50-60%, according to cohort studies and a meta-analysis [4-6]. However, salpingostomy has a 5-10% chance of leaving persistent trophoblastic tissue, necessitating monitoring of β-hCG levels or even treatment [7-8]. Cost-effectiveness estimates suggest that laparoscopy costs approximately $1500 less per procedure than laparotomy [9].

The evidence presented repeatedly confirms that for hemodynamically stable patients, laparoscopic surgery is more clinically effective than laparotomy for the treatment of ectopic pregnancy. During a total of ten seminal studies involving RCTs and large prospective cohort analyses, laparoscopy was found to be associated with significant shorter times to recovery (1.5 versus 5–7 days), lower intraoperative blood loss (50–100 mL versus 200–300), and significantly lower healthcare costs. Vermesh et al. (1989) and Lundorff et al. (1991) were one of the first to emphasize these advantages, making laparoscopic treatment the new gold standard for stable patients presenting with unruptured ectopic pregnancies.

Economic evaluations including those by Murphy et al. (1992) showed that surgical laparoscopy could cut the treatment costs by as much as 40% due to fewer complications, decreased postoperative care, and shorter hospitalization. Cost-effectiveness modeling predicted a mean savings of $1,500 per case versus open laparotomy, especially if including indirect societal benefits such as an earlier return to work and less caregiver overtime.

Fertility preservation is still a critical endpoint in the consideration of surgical approach. Salpingostomy, performed to resect the ectopic gestation while preserving the fallopian tube, yields intrauterine pregnancy (IUP) rates of 60–70% with repeat attempts, which is just a bit higher than the 50–60% rate after salpingectomy. That this is the case makes salpingostomy the option of choice in the patient who wishes to retain fertility and has an intact contralateral tube. Its shortcomings are around 5–10% of cases with residua that require additional treatment like reoperation or methotrexate treatment. In addition, salpingostomy has a higher rate of ectopic recurrence (10–15%) when compared to salpingectomy (5–7%).

Several clinical factors affect the outcomes of surgery, including size of ectopic and the level of serum β-hCG. Ectopics> 3 cm or β-hCG levels >5000 IU/L are more often linked to failure of treatment and may lead to selection for salpingectomy. In addition, surgeon skills and laparoscopic instrument availability largely influence the outcome of patients, especially in low-resource centers. Studies from these populations reveal logistical and economic challenges to the adoption of laparoscopic methods, despite known benefits, highlighting the divide of surgical care on a global scale.

The existing literature is predominantly based in high-income countries, with low- and middle-income settings rarely represented. Moreover, while short-term results are well studied, the knowledge of long-term fertility preservation beyond five years is scarce. Standardized definitions of fertility success and uniform postoperative follow-up protocols are absent that precludes the comparison between studies.

The convergent evidence supports a personalized, patient-centered surgical approach based on clinical presentation, fertility wishes, and institutional constraints, despite the limitations. This detailed and nuanced appreciation further supports the position of laparoscopic management as the operative approach of choice for stable patients and the value of salpingostomy for FPLB when considering its infrequent complications.

Comparison and Contrast

Laparoscopy compared to laparotomy in stable patients leads to faster recovery, less pain, and less cost [1-3]. However, laparotomy is still indicated for hemodynamic unstable patients or for lack of laparoscopic experience [29]. Salpingostomy is less destructive of subsequent fertility than salpingectomy but is associated with a higher risk of re-ectopic (10-15% vs 5%) and residual trophoblastic tissue [6-8]. While RCTs emphasize laparoscopy’s upscaling potential in high-resource settings, cohort studies from low-resource settings report on bottlenecks such as equipment related costs and lack of training [21, 29]. Patient factors, such as the size of the ectopic (>3 cm) or the level of β-hCG (>5000 IU/L), continue to influence outcome, with larger ectopics biasing toward salpingectomy [10].

Strengths and Limitations

The proof is in the pudding, with RCTs and meta-analyses demonstrating high level evidence for the benefits of laparoscopy [1-3, 6]. The long-term follow-up in several studies allows for a sound evaluation of fertility outcome [5, 10]. However, disadvantages are small sample sizes from initial RCTs (i.e. Vermesh, n=60) and selection bias in cohort studies, which often do not include unstable patients [1, 29]. Variation in the reporting of complications including persistent trophoblast has made comparisons difficult [7]. It was less often represented from low-resource settings which could narrow the generalizability [21].

Research Gaps

High-tone gaps are also in long-term fertility after salpingostomy, beyond 3-5 years in particular away [30]. Surgeon experience as a determinant of laparoscopic success rates has received little investigation and training protocols are not yet standardized [31]. Cost-effectiveness in resource-scarce environments and the impact of patient counseling on surgical decision-making should also be studied [21].

Clinical guidelines from official organizations such as the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) offer evidence-based suggestions for the management of ectopic pregnancy [11-12]. The ACOG (2008) recommends laparoscopy as the initial modality for stable patients with grade 1 evidence of decreased morbidity [11]. RCOG (2004) endorses salpigectomy for ruptured ectopics and those women in whom fertility is irrelevant; this is with BEST EVIDENCE, (level B) [12]. The two guidelines both recommend salpingostomy in women who wish to conceive in the future with a healthy contralateral tube and monitoring of β-hCG after the procedure (Level B/C) [11-12]. Late-effects counseling, including expectations of a 10-15% recurrence rate for salpingostomy, is paramount [8].

Table 1: Clinical Guidelines for Ectopic Pregnancy

Figure 1: Decision Tree for Ectopic Pregnancy Surgery

Synthesis of Key Findings

The literature uniformly favors that laparoscopy is gold standard of taking care of EP in stable patient providing extensive benefits in terms of time to get discharge, blood lost and economical point of view [1-3,9]. Salpingostomy provides more hope with pregnancy rates (60-70%) than salpingectomy (50-60%), thus this is the method of choice to preserve fertility for woman who wish future pregnancies [4-6]. However, there is a 5-10% risk of persisting trophoblastic tissue and a 10-15% recurrence rate and most patient will need close follow-up [7-8]. Clinical guidelines recommend individual treatment plans: laparoscopy for stable patient and salpingectomy for ruptured cases or when fertilising is not a concern [11-12]. Ectopic size, β-hCG and contralateral tube determine surgical intervention by patient factors (size of ectopic, β-hCG, contralateral tube status) [10,17].

Critical Analysis

The evidence base is robust for short-term efficacy, with RCTs and meta-analyses demonstrating Level A/B superiority to laparoscopy [1-3, 6]. Nevertheless, there is lack of long-term fertility follow-up data more than 3-5 years, which limits the inference on the long-term benefits of salpingostomy [30]. The variation of surgeon skill and laparoscopic access contains bias, especially in high-resource context settings [29]. Cohort studies from low-resource settings stress access barriers like high costs of equipment and lack of training, often left out in RCTs [21]. Heterogeneity of study designs and outcome reporting (eg, heterogeneity on definitions of “fertility success”) precludes comparisons [7, 10]. Absence of uniform patient selection and postoperative monitoring parameters further limit generalizability.

Agreements and Controversies

There is general consensus on the merit of laparoscopy for stable patients and of salpingectomy for ruptured cases [1-3, 12]. There remains ongoing controversy regarding the risk benefit profile of salpingostomy. Although it increases fertility, the worse recurrence rate (10-15% compared to 5%) and persisting gestational trophoblast risk are significant concerns against its general efficacy [6-8]. There is mixed evidence regarding the role of salpingostomy in the treatment of ectopic pregnancy, with some research promoting more stringent indications (for example, ectopic size <3 cm, β-hCG <5000 IU/L) and lack of use of salpingostomy in patients desiring fertility [5, 10]. The preferred balance of fertility preservation and risk of complications is not yet established.

Recommendations For Future Research, Practice and Policy

There is need of having more prospective studies about post-SSu long-term fertility outcome which RCTs in multiple centers may be considered for having generalize results in nationwide [30]. The process of standardization of laparoscopic training would possibly solve the discrepancies in accessing surgery and need of the hour in low resources settings [21]. Clinicians should follow evidence-based strategies that are individualized to the patient situation using objective data such as transvaginal ultrasound and β-hCG algorithm for management [11-12, 16]. Laparoscopic infrastructure and training must be invested in by policy makers to limit these inequities globally. Patients counselled should be informed of the risks and benefits, especially of salpingostomy, so that they can reach an informed decision [8].

This narrative review supports laparoscopy as the mainstay of ectopic pregnancy treatment in the hemodynamically stable patient, with lower morbidity, quicker recovery, and less cost than laparotomy [1-3, 9]. Fertility preservation by salpingostomy results in pregnancy rates of 60-70%, but the patient must be carefully selected and monitored because of the potential for persistent trophoblast and a repeat pregnancy [4-7]. It is also stated in clinical guidelines that only a personalized salpingectomy is to be recommended in cases of rupture or when fertility is of no concern [11-12]. Nevertheless, the challenges remain in regards to lack of long-term fertility data, expertise of the surgeon, and access gap in low resource settings [21, 29-30]. There is a need to drive research, training and policy efforts to fill these gaps and improve outcomes.

Recommendations

Laparoscopy is recommended for hemodynamically stable patients and salpingostomy should be employed selectively with vigilant postoperative β-hCG surveillance. Efforts should be made to develop training programs to enhance laparoscopic expertise; especially in less developed areas. Decision-makers need to invest in laparoscopic equipment and infrastructure to promote equity. Longitudinal investigations of these fertility outcomes are needed and standardize these surgical decision-making and follow-up protocols.

Acknowledgments:

The authors express gratitude to contributors from surgery and obstetrics and gynecology who laid a foundation on which the current review was based. Special thanks to clinical experts in surgery and obstetrics and gynecology who offered valuable insights during the review process, enhancing the practical relevance of this work.

Conflicts of Interest: The author has no conflicts of interest in relation to this review.

Funding Information: This review was self-funded by the authors, with no external financial support received for its development or publication.

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