laparotomy with cornual wedge resection or hysterectomy has been the traditional treatment for the rare cases of cornual pregnancy . in the last 2 decades
, several reports have been published of minimally - invasive surgical techniques used to successfully treat cornual ectopic pregnancies .
consistent with the goals of minimally - invasive surgery , these techniques have introduced a surgical alternative with reduced blood loss , less postoperative pain , shorter hospital stay , and a more expeditious recovery . in this report
, we describe a simple , stepwise laparoscopic technique used successfully for the management of two patients with large cornual pregnancies , along with a review of risks , benefits , and the pertinent literature .
carol was a 28-year - old , african american female , gravida 3 , para 2 at 8-weeks gestation based on her last menstrual period .
she originally presented to the emergency department complaining of intermittent vaginal bleeding for 24 hours .
her medical history was significant for morbid obesity , pseudotumor cerebri , sagittal sinus thrombosis , and asthma complicated by a previous lung collapse requiring intubation .
her obstetric history revealed one uncomplicated , full - term pregnancy with a normal vaginal delivery .
her second pregnancy was complicated by cervical incompetence requiring rescue cerclage placement , but ended successfully with a normal vaginal delivery at term .
the patient reported no plans for future pregnancies and that this was an undesired pregnancy .
her physical examination on presentation showed stable vital signs , a benign abdominal and pelvic examination with minimal old blood in the vaginal vault .
abdominal and transvaginal ultrasounds revealed an eccentric gestational sac , 2.7 cm x 2.5 cm , located in the right uterine fundus with a thin myometrial mantle measuring 3.5 mm in thickness , consistent with an interstitial tubal pregnancy .
the embryo had a crown - rump length of 7.7 mm , with no cardiac activity .
after much discussion and counseling regarding treatment options including the limited data on the risk of uterine rupture with future pregnancy , the decision was made to proceed with laparoscopic surgical excision . during the course of these discussions , the patient received one dose of intramuscular methotrexate with planned outpatient management , but she was then brought back to the hospital on day 3 for definitive surgical management , as the consensus among the providers was that definitive surgical treatment was more prudent .
an intact 6 cm x 4 cm right cornual pregnancy with a thinned - out hyperemic myometrial capsule was noted ( figure 1 ) .
dilute vasopressin ( 10 iu in 100 ml of normal saline ) was prepared , and a total of 46 ml was injected throughout the cornual pregnancy by using a long 20-gauge spinal needle , introduced directly through the anterior abdominal wall in the midline under direct visualization with the laparoscope .
a linear incision was made with monopolar cautery in the thin myometrial capsule , along the long axis of the cornual pregnancy .
a well - formed gestational sac was clearly identified and expressed from the cornua using blunt , sharp and hydro - dissection ( figure 3 )
. a large , very thin capsule ( mantle ) overlying the myometrium that had previously housed the ectopic pregnancy was noted and excised at the base in an elliptical fashion , with bipolar cautery and scissors .
significant myometrial thickness was still maintained at the base of the cornua , and no gross myometrial defect was noted . the remaining myometrial bed at the right cornua was judiciously cauterized to obtain excellent hemostasis ( figure 4 ) .
the specimen was retrieved from the pelvis with the 10-mm autosuture endo catch ( us surgical , norwalk , ct ) and sent to pathology where the diagnosis of an ectopic pregnancy was confirmed . a spinal needle introduced directly through the abdominal wall .
a linear incision along the capsule of the cornual pregnancy has been made after complete blanching with vasopressin .
only a minimal portion of the right cornua has been removed ( minicornual excision ) with complete excision of the ectopic gestation .
the patient tolerated the procedure well with a total operative time of 2 hours and estimated blood loss of 50 ml .
the patient 's quantitative -hcg was closely followed until it returned to essentially zero ( table 1 ) .
traditionally , cornual ectopic gestations have been treated with exploratory laparotomy and wedge resection of the uterine cornua or even hysterectomy . with the advent of minimally - invasive techniques and the growing evidence and expertise in the field ,
laparoscopic mini - cornual excision offers a valuable option for patients desiring definitive minimally - invasive surgical treatment of cornual ectopic pregnancy . because patient safety is always the prime goal , mini - cornual excision for cornual pregnancies
should only be recommended to hemodynamically stable patients in a tertiary care facility with the necessary laparoscopic skills and expertise to ensure patient safety .
the availability of blood products , immediate anesthesia , and critical care staff , and surgical equipment and facilities are also essential for the safe practice of this minimally - invasive procedure . with these conditions and appropriate patient selection , laparoscopic treatment of interstitial pregnancy
offers significant advantages over laparotomy , such as short hospital stay , faster return to normal activities , and decreased health care cost , without compromising treatment or patient safety .
as illustrated in this case series , we advocate a simple method of a stepwise , minimally - invasive treatment of cornual ectopic pregnancies .
several reports over the last 2 decades have illustrated various techniques for treatment of cornual pregnancy , including methotrexate injection , cornuostomy , salpingostomy , and the use of endoloop ( ethicon , cincinnati , ohio ) for small cornual pregnancies .
several reports have also indicated the need for ligation of the ascending branches of the uterine arteries or mesosalpingeal vessels to maintain hemostasis .
one can argue that suturing may decrease the risk of future uterine rupture , but at this time , evidence is minimal that either approach is superior . in this stepwise technique of mini - cornual excision ( table 2 ) ,
excellent hemostasis is adequately achieved with generous injection of dilute vasopressin along with judicious use of cautery to minimize tissue necrosis .
no vascular ligation is utilized , maintaining adequate blood supply and avoiding the unnecessary tissue ischemia that potentially impairs healing and compromises the tensile strength of the cornual region , negatively impacting future pregnancies . in our technique ,
only a minute portion of the cornua is excised ( the thin overlying myometrial capsule ) , preserving most of the integrity and architecture of the uterus and likely maintaining significant tensile strength at the surgical site .
simply stated , the cornual pregnancy is  deroofed ,  leaving the base intact .
stepwise approach for mini - cornual excision several important issues associated with mini - cornual excision must be addressed , including hemorrhage , chronic ectopic pregnancy , recurrent cornual pregnancy , and the care of future pregnancies .
risk of hemorrhage remains the paramount concern for all clinicians caring for women with cornual ectopic pregnancies .
mini - cornual excision is not advisable in cases of ruptured cornual pregnancy due to the catastrophic hemorrhage and the associated hypovolemic shock commonly encountered in these cases .
expeditious laparotomy after initial resuscitation remains the mainstay in such cases . the same principle applies if uncontrollable hemorrhage is encountered during laparoscopic mini - cornual excision
. however , several measures can be used preemptively to minimize this possibility , such as vasopressin and bipolar cautery in this case , and the use of endoloops prior to manipulation of the cornual pregnancy .
the potential for chronic ectopic pregnancy due to inadequate removal of the ectopic gestation is a rare but real concern .
non - excisional management options for cornual pregnancy , such as methotrexate , cornuostomy , salpingostomy , and including mini - cornual excision , all carry a small risk of incompletely removing the cornual gestation and the persistence of chorionic villi in the cornua .
this is usually diagnosed by failure of serum hcg to drop to non - pregnant levels .
the advantage that mini - cornual excision offers over other methods is that the cornual pregnancy is deroofed , providing easy access that facilitates complete removal of the gestational sac and chorionic villi , minimizing the risk of chronic cornual pregnancy .
however , more studies are necessary to examine and compare this new technique with other non - excisional methods .
recurrent cornual pregnancy remains a risk , similar to any surgical treatment for an ectopic gestation at any site .
conservative management of cornual pregnancy , i.e. , without radical cornual resection , obviously carries a risk of recurrence at the same location .
patients should be carefully counseled about the associated risks of cornual pregnancy resection as well as the benefit of maintaining uterine integrity , vascularity , and structure , especially in patients desiring future fertility .
risk to future pregnancies and the care of any subsequent pregnancies remain valid concerns after mini - cornual excision , particularly regarding the potential risk of uterine rupture .
this concern originates from the potential risk of leaving a weakened cornual region following mini - cornual excision , allowing for potential uterine rupture with future gestations .
in addition , excessive use of electrocautery may cause significant concealed damage to the myometrium that can further weaken the cornual region and increase the risk of uterine rupture with future pregnancies .
if a significant gap is created in the cornual region while evacuating the contents , the incision should be approximated with laparoscopic suturing , and , if not feasible , a minilaparotomy may be necessary .
these considerations should be clearly addressed when counseling patients regarding their management options and the risk of uterine rupture with future pregnancies . with regards to the care of future pregnancies ,
all patients should be carefully counseled on the importance of early presentation with future pregnancies for complete evaluation , primarily to rule out a recurrent cornual or ectopic pregnancy , and also to establish reliable dates and timely delivery plans .
two case reports describe successful , uncomplicated vaginal delivery following laparoscopic management of cornual pregnancy .
however , at this time , we recommend close monitoring of future pregnancies for patients treated conservatively for cornual pregnancy , with a planned cesarean delivery at term or upon failure of tocolytic therapy for preterm labor .
cornual pregnancy is a potentially life - threatening condition that should be managed safely in a timely fashion .
the stepwise approach presented here ; mini - cornual excision , achieves a rapid , systematic , safe , and definitive treatment of cornual pregnancy that is minimally - invasive with minimal blood loss and rapid return to normal activities .
careful patient selection and counseling regarding treatment options is essential , particularly for patients desiring future pregnancy .
 cornual pregnancy often poses a diagnostic and therapeutic challenge , with a significant risk for morbidity and mortality . traditional treatment for cornual pregnancy 
 has been through laparotomy , wedge resection , or hysterectomy . 
 early diagnosis is now possible through transvaginal ultrasonography and highly - sensitive -human chorionic gonadotropin assays . 
 consequently , several less - invasive therapies and techniques have been introduced over the last 2 decades . 
 we present a simple , stepwise laparoscopic technique for the definitive , minimally - invasive excision of cornual pregnancy , along with a review of the pertinent literature . 
INTRODUCTION
CASE REPORT
METHODS
RESULTS
DISCUSSION
CONCLUSION