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.