Background. Ruptured ectopic pregnancy (REP) is a common gynaecological emergency in resource-poor settings, where laparotomy is the standard treatment despite laparoscopic surgery being regarded as the optimal treatment. There is a lack of prospective randomised data comparing laparoscopic surgery with laparotomy in the surgical management of women with REP. Objective. To compare operative laparoscopy with laparotomy in women with REP. Methods. This was a randomised parallel study. One hundred and forty women with suspected REP were randomised to undergo operative laparoscopy or laparotomy. The outcome measures were operating time, hospital stay, pain scores and analgesic requirements, blood transfusion, time to return to work, and time to full recovery. Results. Operating time was significantly longer in the laparoscopy group (67.3 v. 30.5 minutes, p<0.001). Duration of hospital stay, pain scores and need for analgesia were significantly less in the laparoscopy group. Women in this group returned to work 8 days earlier and their time to full recovery was significantly shorter compared with those in the laparotomy group. Significantly more women undergoing laparotomy required blood transfusion than women in the laparoscopy group. In the latter group, 14.5% of women required blood transfusion compared with 26.5% in the laparotomy group (p=0.01). Conclusion. Operative laparoscopy in women treated for REP is feasible in a resource-poor setting and is associated with significantly less morbidity and a quicker return to economic activity.

A randomised controlled trial comparing laparoscopy with laparo tomy in the management of women with ruptured ectopic pregnancy To the Editor: We read with interest the article that appeared in the March 2017 issue of SAMJ [1] and would like to commend the authors on the publication of this important topic, demonstrating the advantages of laparoscopic surgery for the management of women with ruptured ectopic pregnancy (REP). Even though the authors randomised the patients, in our opinion they failed to categorise the group of patients they refer to by not quantifying the haemoperitoneum. The description of such patients can be difficult, as there is no agreed standardisation. Do they refer to REP as including women in whom haemoperitoneum was demonstrated on an ultrasound scan and, if that was the case, what was the amount of blood in the peritoneal cavity? Does REP include the 30% of women who present with unquantified haemoperitoneum, [2] or the 6% of patients with significant haemoperitoneum (≥800 mL), as defined by Odejinmi et al. [3] Although the authors demonstrate the advantages of the operative laparoscopy approach to the management of ectopic pregnancy, particularly in the low-cost setting, in eliminating patients with an Hb ˂8 g/dL, a pulse rate ˂100 beats/minute, and a systolic blood pressure ˂90 mmHg, they may have been managing patients with minimal haemoperitoneum, whose outcomes would have been no different from women with unruptured ectopic pregnancies. This can also be inferred by the small difference in pre-and postoperative Hb levels in both groups of randomised patients. Furthermore, Snyman et al. [1] have highlighted that laparoscopy took significantly longer than laparotomy. Surely, the pivotal fact in a REP should be the time taken to haemostasis-not the total operating time. Moreover, the increased time is most probably a function of the experience of the operating surgeon, as there is ample evidence from units with experienced laparoscopic surgeons that laparoscopy is equally quick-if not quicker-compared with laparotomy. We fear that these data, if presented without qualification, might send a message reverting modern accepted practices. In our institution, we have been able to offer operative laparoscopy to nearly all women, irrespective of location of the ectopic pregnancy or haemodynamic status, but this has taken time, effort and education of all involved in the management of ectopic pregnancy. [4] It is hoped that, using their randomised study as a baseline, the authors will be able to update the academic community on their progress and changing trends in the laparoscopic management of ectopic pregnancy in a low-cost setting in a few years' time.