Robotic-Assisted Laparoscopic Resection of Interstitial Ectopic Pregnancy: A “Tourniquet” Technique Using Barbed Suture

INTRODUCTION: Interstitial ectopic pregnancy is the rare implantation of a pregnancy in the intramural portion of the fallopian tube, accounting for 2–3% of all ectopic pregnancies. Surrounded by myometrium, the location of these pregnancies can be especially dangerous with potential to grow to larger sizes compared with tubal ectopic pregnancies. Traditionally interstitial ectopic pregnancy has been associated with higher morbidity and mortality potential related to rupture and hemorrhage. Earlier detection and advances in minimally invasive surgery have allowed for more conservative treatments to limit morbidity and preserve fertility. Timely intervention is required to avoid serious complications such as severe hemorrhage or the need for hysterectomy. The location of this type of ectopic pregnancy can be surgically challenging, with significant risk of bleeding at time of resection. OBJECTIVE: This video presents a robotic-assisted laparoscopic resection of an interstitial ectopic pregnancy with right salpingectomy and demonstrates the use of two layers of barbed suture as a tourniquet to maximize hemostasis and also as a method for efficient, yet effective multi-layer closure of the myometrium. METHODS: This video outlines the steps of robotic-assisted laparoscopic resection of an interstitial ectopic pregnancy using highlights from a case that was performed at a tertiary referral center by a surgeon specializing in minimally invasive gynecological surgery. The presented patient is a 27-year-old otherwise healthy gravida 11, para 7, who came to the emergency department with vaginal bleeding and pelvic cramping in the setting of a recently positive home pregnancy test and last menstrual period 7 weeks prior. She was hemodynamically stable without evidence of peritonitis. Her beta-human chorionic gonadotropin (beta-hCG) was over 100,000 mIU/mL. The transvaginal ultrasound showed no intrauterine pregnancy and an abnormally implanted pregnancy measuring 8 weeks of gestation within the right fallopian tube at the level of the right uterine cornua, suspicious for interstitial ectopic pregnancy. RESULTS: The patient was consented for robotic-assisted laparoscopic resection of the interstitial ectopic pregnancy and right salpingectomy. This video highlights our reproducible surgical steps, including 1) identification of the ectopic pregnancy and pertinent surrounding anatomy; 2) injection of dilute vasopressin into the myometrium surrounding the ectopic pregnancy to promote vasoconstriction for maximal hemostasis and myometrial contraction to delineate the borders of pregnancy; 3) placement of 2-0 gauge absorbable monofilament barbed suture in a purse-string surrounding the ectopic pregnancy to act as a tourniquet; 4) en-bloc resection of the pregnancy using combination of monopolar and bipolar energy and use of the fourth robotic arm to maximize exposure; 5) multi- layer closure of the hysterotomy using a second barbed suture. The interstitial ectopic pregnancy was completely resected with minimal blood loss and no intraoperative complications. The patient was able to be discharged home on the same day. CONCLUSIONS: Interstitial ectopic pregnancy can be treated surgically through a systematic minimally invasive approach. Timely intervention and careful surgical technique are essential for ensuring hemostasis, optimizing outcomes, and preserving fertility in these rare cases. This video demonstrates the many benefits of using barbed suture for minimizing blood loss at the time of robotic-assisted laparoscopic resection.