Robotic Approach to Iatrogenic Intra-Abdominal Pregnancy

Study Objective

To present a case of iatrogenic intra-abdominal pregnancy in a morbidly obese patient; discuss surgical considerations in bariatric patients; highlight advantages of robotic surgery in the setting of prior infection; and demonstrate the use of avascular spaces in performing complex hysterectomies.

Design

Video documentation of the surgical procedure

Setting

University of California, San Francisco Hospital operating room

Patients or Participants

36-year-old G5P4004 (BMI 50) diagnosed with intrauterine fetal demise measuring 14 weeks 5 days with a history of four prior cesarean sections. Patient underwent induction of labor complicated by septic abortion, necessitating D&E. Patient ultimately presented to our institution 2 weeks after the D&E with imaging showing fetal parts outside of the uterus.

Interventions

We present a case of an abdominal pregnancy in a morbidly obese patient, review the clinical course, case imaging and demonstrate a stepwise robotic hysterectomy in an inflamed surgical field with distorted anatomy.

Despite the complex pathology, we approach this case systematically We begin by mobilizing the colon and opening the retroperitoneum to identify the ureters. Blunt dissection along the pelvic sidewall, reveals a thick rind encapsulating the placenta, organized blood products, and the abdominal pregnancy.

After safely mobilizing the omentum and small bowel, we visualize the fetus. The fetus and placenta are separated from the uterus and placed in the upper abdomen. Once the uterus is fully visible and mobile, we proceed with hysterectomy using our standard approach.

Measurements and Primary Results

The robotic platform is a valuable tool for morbidly obese patients undergoing complex hysterectomy. The case took 5 hours, and the estimated blood loss was 100mL.

Conclusion

With Knowledge of avascular spaces and thoughtful approach to minimally invasive surgery in the morbidly obese patients, laparotomy may be avoided for medically and surgically complex patients.