Re: Laparoscopic cornual resection of interstitial pregnancy using the Endo GIATM Universal Stapler

Abstract

Dear Editor We read with interest work published by Das et al. discussing tips and techniques used in minimal access procedures for treating interstitial pregnancy, primarily focusing on laparoscopic cornual resection performed with the Endo GIA Universal Stapler (Medtronic, Watford UK). We agree that interstitial pregnancies pose a high risk to the mother and using a technique that rapidly obtains haemostasis is of great importance. However, the main aim of preserving the uterus is to preserve future fertility, and this long-term goal has to be considered alongside any short-term aims. Cornual (‘wedge’) resection involves removal of a significant amount of healthy myometrium. This is unnecessary and goes against the principles of good surgical practice, which aim to restore an organ’s normal anatomy and function. Although the resection succeeds in preserving the patient’s future fertility, it carries a risk of uterine rupture due to the loss of myometrium and extensive uterine scarring. Liao et al. reported an incidence of subsequent uterine rupture and dehiscence after wedge resection of 30%. This is considerably higher than uterine rupture rates post-myomectomies. In our recent review, we concluded that wedge resection should realistically only be performed in cases of ruptured interstitial pregnancies with troublesome bleeding. A success rate 99.16% (95% confidence interval 97.51–100) was reported in patients with interstitial pregnancies who underwent a cornuostomy, which involves less myometrial trauma and, in our opinion, is likely to result in less long-term complications such as uterine rupture and the morbidity and mortality that this entails, than more aggressive treatments such as wedge resection. We note that when using the Endo GIA Universal Stapler, the cornua is resected, breaching the myometrium, and placing two triple-staggered rows of titanium ministaples. Although this technique provides a speedy management option, we have reservations regarding the long-term effects that performing a wedge resection and leaving staples in situ has. These staples will not dissolve to allow tissue healing and will not stretch to allow any future pregnancy to grow. This is likely to leave an even weaker area of myometrium than the traditional wedge resection. In conclusion, although this technique may seem to offer patients benefit in that it is quick, straightforward to learn, anddoes not require advanced laparoscopic skills such as intracorporeal suturing, the long-term fertility outcomes are likely to be worse than the traditional wedge resection. Laparoscopic cornuostomy is safe, effective and because of less trauma to the myometrium, is likely to have less risk of rupture in future pregnancies. When managing complex, rare early pregnancy cases, early diagnosis is important to facilitate onwards referral to centres with the experience and skills necessary to manage patients safely, both in the short and long term.