Results:
Literature search
By searching PubMed, Web of Science, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL), we identified 832 records. We removed duplicates and the remaining 505 records were screened for eligibility. Only 18 studies were further included for full-text screening. We included four studies from this step. We didn’t find any missing papers after the screening of the references of the included trials and previous systematic review (223 references) and finally, we included six studies, four of them were eligible for meta-analysis. The literature search process was described in a PRISMA flow diagram in Figure (1).
Characteristics of the included studies
We included one case series study, one cross-sectional, and four retrospective cohort studies with 70 cases of interstitial ectopic pregnancy in the laparoscopic surgery group and 83 cases in the open surgery group. Summary of the included studies and their results are shown in (Table 1) and baseline characteristics of their patients are shown in (Table 2).
Results of Risk of Bias Assessment
Two cohort studies had a fair quality according to NIH quality assessment tool for Observational Cohort and Cross-Sectional Studies. The other two cohort studies and the only cross-sectional study were poor quality. The only case series study was fair in quality according to the NIH quality assessment tool for case series studies. For more details and answers to all assessment questions in each study, see supplementary table 1 for cohort studies and table 2 for a case series study.
Analysis of Outcomes
Postoperative hospital stay (days)
The pooled mean difference (MD) showed that laparoscopic surgery was significantly associated with less hospital stay duration than open surgery (MD = -1.42 days, 95% CI [-1.72, -0.76], P > 0.0001); Fig.2. Pooled results were homogenous (P = 0.88, I² = 0%).
Operation time (minute)
The pooled effect estimate revealed no significant difference between laparoscopic surgery and open surgery in terms of operative time (MD = -11.22 minutes, 95% CI [-42.44, 20], P = 0.48); Fig.3 (A). Pooled results were heterogeneous (P = 0.03, I² = 73%) and the detected heterogeneity was best resolved after excluding Hwang et.al. 2010 (P = 0.44). Homogeneous results favored the laparoscopy group by a shorter operation time of 28 minutes compared with laparotomy (MD = -28.72, 95% CI [-53.62, -3.81], P = 0.02); Fig.3 (B).
Blood loss (ml)
The pooled mean difference (MD) showed no significant difference between laparoscopic surgery and open surgery in terms of blood loss (MD = -9.43, 95% CI [-214.18, 195.32], P = 0.93); Fig.4. Pooled results were homogenous (P = 0.39, I² = 0%).
Post and intraoperative complications
The pooled relative risk (RR) revealed no significant difference between laparoscopic surgery and open surgery in terms of post and intraoperative complications (RR = 1.543, 95% CI [0.201, 11.849],P = 0.677); Fig.5. Pooled results were homogenous (P = 0.645, I² = 0%).
Need for blood transfusion
The pooled mean difference (MD) showed no significant difference between laparoscopic surgery and open surgery in terms of need for blood transfusion (RR = 0.677, 95% CI [0.431, 1.062], P = 0.089); Fig.6. Pooled results were homogenous (P = 0.409, I² = 0%).
Qualitative evidence
For pregnancy outcome as reported by Sagiv et. al (22), three out of five women undergoing laparotomy, became infertile, one underwent a tubal ligation, and only one woman became pregnant and delivered by cesarean section. But out of women eight managed by laparoscopy, three women were undesirable for pregnancy, one not reported, one had an early miscarriage, and three became pregnant and delivered by cesarean section.
Tulandi et. al (23) reported that in patients managed by laparoscopy, hemoperitoneum encountered was 1385.7 ± 978.8 mL in the laparotomy group and 460.0 ± 70.7 mL in the laparoscopy group. In the laparotomy group, no patient needed any subsequent treatment but in the laparoscopy group, the first treatment failed in one patient and needed methotrexate as subsequent treatment.
Warda et. al (24) presented four cases of interstitial pregnancy, the first case was a 36-year-old woman treated with cornuostomy by laparotomy and then she received a third intracytoplasmic sperm injection cycle then she delivered an intact female after a pregnancy period devoid of any complications. The other three cases aged 30, 30, and 36 years were treated with laparoscopic cornuostomy and removal of products of conception. They also underwent another in-vitro fertilization cycle then they delivered without any complications and with no adverse neonatal outcomes.