PMC10166142_01
The ultrasound examination before the laparoscopy.
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Transvaginal ultrasonography (TVS) showed that the endometrium was approximately 1.6 cm thick but no gestational sac was found in the uterine cavity, bilateral uterine horns, or bilateral adnexal areas (Figure 1A and B). A gestational sac-like echo was seen 2 cm to the right of the umbilical orifice immediately anterior to the right of the abdominal aorta (near the branch of the iliac artery), measuring approximately 2.2 cm x 1.9 cm x 1.6 cm; a yolk sac and fetal buds were clearly visible (Figure 1C). The heart rate was 155 beats/min (Figure 1D). 
(A and B) Photographs taken during laparoscopic surgery.
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No significant free fluid was seen in the pelvis, and careful exploration of the broad ligament, omentum, intestinal canal, and mesenteric surface did not reveal any embryonic tissue (Figure 2A). The operator also prepared plasma and red blood cells and asked the vascular surgeon to consult and assist in the exploration because of the risks associated with the operation, including the risk of hemorrhagic shock if the vessel ruptured. The retroperitoneal space and arterial vascular sheath were opened, and an ultrasonic knife was used to separate the fat on the surface of the parietal aorta and inferior vena cava and small vascular branches layer-by-layer; the gestational lesion was then freed (Figure 2B); its diameter was approximately 2.5 cm (Figure 2C).