Retroperitoneal ectopic pregnancy (REP) is one of the most special species of abdominal pregnancy. Due to possible invasion of retroperitoneal macrovascular, inconspicuous clinical manifestation and difficulty of diagnosis from imaging, the diagnosis and treatment of REP are easy to be delayed. REP represents a great challenge to surgeons due to the rarity and varying clinical presentations, from asymptomatic patients to patients with unstable haemodynamics, in cases of advanced ruptured ectopic gestation presenting with life-threatening retroperitoneal haemorrhage. Therefore, although REP accounts for only 1% of ectopic pregnancy, the mortality of which is eight times higher than other species of ectopic pregnancy in abdominal cavity.1 Most of the sites of retroperitoneal ectopic pregnancy are located near the abdominal aorta and inferior vena cava, as well as rectovaginal space, obturator, perivascular space, or near the pancreas or kidney. Therefore, after excluding tubal pregnancy and common abdominal pregnancy, it is necessary to focus on the space between the retroperitoneal abdominal aorta and inferior vena cava.2
Surgical treatment, whether laparotomy or minimally invasive surgery, is the preferred option for retroperitoneal perivascular pregnancies.3 Video 1 shows the details of the laparoscopic management of a dangerous case of ectopic pregnancy, which adhered to the surface of the abdominal aorta and inferior vena cava (figure 1). During the operation, the boundary between the gestational sac and the blood vessel was not clear, and the ultrasound knife was used to separate it close to the side of the gestational sac. Tearing was strictly prohibited and the residual tissue on the surface of the vessels was meticulously electrocoagulated with bipolar forceps. The pregnancy tissue should be removed in a specimen bag to avoid being left in the abdominal cavity.
Laparoscopic management of a dangerous case of ectopic pregnancy, which adhered to the surface of the abdominal aorta and inferior vena cava.
The gestational sac adhered to the surface of the abdominal aorta and inferior vena cava with no clear boundary and the ultrasound knife was used to separate it close to the side of the gestational sac.
In conclusion, when a female with a positive pregnancy test and an ‘empty’ uterus, with or without abdominal pain and vaginal bleeding, comes to visit, it is crucial not only to investigate for tubal pregnancy but also to consider the possibility of pregnancies in rare ectopic sites, such as REP. We choose laparoscopic surgery because it is minimally invasive, has a clear vision and has a wide exploration range. We can use electrical appliances such as ultrasonic knives and bipolar forceps for fine separation and precise hemostasis. These result in less bleeding, controllable operation time and enhanced recovery. But when should we do laparoscopic surgery? For the patient, stable vital signs without intraperitoneal haemorrhage. For the doctors, accurate preoperative judgement by transabdominal sonography/CT/MRI is very important. An experienced surgeon familiar with the anatomy of retroperitoneal vessels is vital for this choice. Finally, postoperative monitoring of the β-human chorionic gonadotropin should always be remembered.