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CHIEF EDITOR’S NOTE: This article is the third of 36 that will be published in 2001 for which a total of up to 36 Category 1
CME credits can be earned. Instructions for how credits can be earned appear on the last page of the Table of Contents.
In the last decade, operative laparoscopic procedures are performed increasingly in both gyne-
cology and general surgery. The major advantages of this newer minimally invasive approach are:
decreased postoperative morbidity, less pain and decreased need for analgesics, early normal
bowel function, shorter hospital stay, and early return to normal activity. With the advancement of
laparoscopic surgery, its use during pregnancy is becoming more widely accepted. The most
commonly reported laparoscopic operation during pregnancy is laparoscopic cholecystectomy
(LC). Other laparoscopic procedures commonly performed during pregnancy include: management
of adnexal mass, ovarian torsion, ovarian cystectomy, appendectomy, and ectopic pregnancy.
The possible drawbacks of laparoscopic surgery during pregnancy may include injury of the
pregnant uterus and the technical difficulty of laparoscopic surgery due to the growing mass of the
gravid uterus. Also, the potential risk of decreased uterine blood flow secondary to the increase in
intraabdominal pressure and the possible risk of carbon dioxide absorption to both the mother and
fetus should be taken into account.
To date, data on laparoscopic surgery during pregnancy are insufficient to draw conclusions on
its safety and exact complication rate. This is due to the few cases reported and the lack of
prospective studies. Furthermore, there is a common tendency to underreport unsuccessful cases.
Finally, most reports in the literature come from centers and surgeons with special interest,
experience, and skills in laparoscopy, and their results may not reflect the real complication rates.
We have reviewed the pertinent English literature from the last decade. The cumulative experience
suggests that laparoscopic surgery may be performed safely during pregnancy, although more
studies are needed to establish its exact rate of adverse events.
Target Audience: Obstetricians & Gynecologists, Family Physicians
Learning Objectives: After completion of this article, the reader will be able to list the potential
complications of laparoscopic surgery during pregnancy and to outline management strategies to mini-
mize complications of laparoscopic surgery during pregnancy.
The new developments in operative laparoscopy in frequently preformed without apparent increase in
gynecology and general surgery have greatly in- the rate of complications. However, patient selection,
creased its use over the last decade. The minimally indications and contraindications are still being de-
invasive approach is used today in many procedures fined (2).
that previously required open laparotomy (1). Al- The major advantages of laparoscopic surgery dur-
though once considered an absolute contraindication, ing pregnancy are:
laparoscopic surgery during pregnancy is now more
1. Small abdominal incisions result in rapid post-
Address for correspondence: Nathan Rojansky, MD, Depart- operative recovery and early mobilization, thus
ment of Obstetrics and Gynecology, Hadassah Ein-Kerem Medi- minimizing the increased risk of thromboem-
cal Center, PO Box 12000, Jerusalem il-91120, Israel. Email:
rojan@cc.huji.ac.il
bolism associated with pregnancy.
The authors have disclosed no significant financial or other 2. Early return of gastrointestinal activity due to
relationship with any commercial entity. less manipulation of the bowel during surgery,
50
Laparoscopic Surgery During Pregnancy Y CME Review Article 51
fetus were observed. Eight patients delivered babies and effectively performed for symptomatic choleli-
who were full-term and healthy, with no perinatal thiasis, especially when symptoms are recurrent or
morbidity or mortality. The authors suggest that lapa- persistent. Reedy et al. (5) sent out a questionnaire to
roscopic cholecystectomy in pregnancy can be safely all members of the Society of Laparoendoscopic
Laparoscopic Surgery During Pregnancy Y CME Review Article 53
Surgeons and obtained complete information on 413 complication of pregnancy that necessitated the sur-
laparoscopic cases. They reported 134 laparoscopic gical intervention. There was no difference between
procedures performed in the first trimester, 224 in the laparoscopy and laparotomy in cumulative infant sur-
second trimester, and 54 in the third trimester. Five vival up to 1 year. No difference in the rate of
postoperative spontaneous abortions were reported in malformation among laparoscopy, laparotomy, and
134 cases performed in the first trimester. There were the total population was found.
no spontaneous abortions reported in the second tri-
mester. The incidence of miscarriage was that re-
ported to occur spontaneously. Three intraoperative Appendectomy
complications considered to be to related to laparo-
scopic surgery were: Appendicitis in the pregnant patient can be difficult
to diagnose and cannot be clearly distinguished by
1. The placement of a Veress needle inside a
gastrointestinal tract symptoms, description or loca-
22-weeks gestation uterus. This was identified
tion of pain, or physical examination. In addition,
before insufflation of CO2 and the needle was
leukocytosis is common in pregnancy, and the count
withdrawn and replaced and the procedure
can be as high as 16.0 ⫻ 109 per liter in the third
completed. The patient continued her preg-
trimester. A negative exploration rate of 35% to 50%
nancy uneventfully and delivered a healthy in-
is commonly seen for symptoms of appendicitis during
fant at term.
the third trimester of pregnancy. The morbidity and
2. Enterotomy at an open laparoscopy.
mortality seen in the pregnant patient with appendicitis
3. Severe upper abdominal pain caused by CO2.
usually comes from a delay in diagnosis and treatment.
This report is important because it is the first that Patients with suspected appendicitis should undergo
addresses the clinical safety and complications of immediate exploration, no matter which trimester of
laparoscopy in pregnancy. The authors concluded pregnancy the symptoms occur (3).
that their data lend support to the assumption that
laparoscopy in pregnancy seems to be safe.
In another study of the same group, Reedy et al. (6)
GYNECOLOGIC LAPAROSCOPIC
analyzed 2,015,000 deliveries in Sweden from 1973
PROCEDURES
to 1993 and found a total of 2181 laparoscopies and
1522 laparotomies performed in singleton pregnan- Only a few small series and case reports concern-
cies between the 4th and 20th weeks of gestation. For ing laparoscopic surgery during pregnancy have been
infants weighing ⬍2500 gm in both laparoscopy and reported. We have found 18 such reports encompass-
laparotomy groups, there was an increased risk of ing 132 cases of endoscopic gynecologic procedures
premature delivery before 37 weeks of gestation and during pregnancy (Tables 3 and 4). Although these
an increased incidence of growth restriction com- procedures are performed with increasing frequency
pared with the total population. However, the authors to date, the use of laparoscopy during pregnancy is
could not determine whether this increased risk was still uncommon. However, the limited data available
related to the anesthesia, surgical procedure, or the support its safety and efficacy during pregnancy.
54 Obstetrical and Gynecological Survey
malformations
1 preterm labor
emergency, the authors recommended elective re-
moval of any adnexal mass ⬎6 cm that persists to the
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
1 normal 16th week of gestation, regardless of its ultrasonic
tion
39 patients
Ovarian cystectomy
Cystectomy
Cystectomy
Puncture
Puncture
tion rate.
DISCUSSION
Ovarian cystectomy during pregnancy
1st trimester, 1 (?
2nd trimester
12–16 weeks
1st trimester
1st trimester
1st trimester
6 –27 weeks
9 –17 weeks
16 weeks
onates who died within 7 days of delivery, probably 3. Another possible adverse effect is the rapid
because of prematurity. The authors did not attribute CO2 absorption with an increase in arterial CO2
this last finding solely to the operation effect itself, pressure and a concomitant possible decrease in
but considered the precipitating illness also as a arterial pH that might affect the fetus. To date,
significant contributing factor to premature labor. there is no evidence to support any detrimental
Finally, and most important, a total of 868 cases of effect of the CO2 pneumoperitoneum on the
laparoscopy performed during pregnancy were re- human fetus. Furthermore, it has been demon-
viewed; 768 in the first trimester, 29 in the second strated that operative laparoscopy has little ef-
trimester, and 71 in the third. There was no increased fect on maternal blood gases (1, 19). Given the
incidence of adverse outcomes as compared with hyperdynamic nature of the pregnant circula-
matched controls. tion, any CO2 that diffuses across the placenta
The main specific complications of laparoscopy should rapidly be removed. Nevertheless, con-
during pregnancy are related to possible injury to the trolled mechanical ventilation can effectively
enlarged uterus and ovaries situated outside the pel- maintain normal CO2 pressure in the majority
vis and to the cardiovascular and respiratory alter- of patients (2). A study on the fetal response to
ations introduced by the pneumoperitoneum pressure CO2 pneumoperitoneum in the pregnant ewe
and CO2 absorption. confirms the lack of adverse effects of CO2
1. Penetrating injuries are more likely to occur at insufflation on the fetal placental perfusion and
the beginning of the procedure when the insuf- blood gases (20). In the animal model, some
flating needle is placed blindly (2). To avoid studies have shown a possible effect of CO2 on
this, the Veress needle, and subsequently the fetal blood gases. Maternal and fetal hypox-
trocar, should be inserted while simultaneously emia, acidosis, and hypercarbia have been
pushing away the uterus and ovary or by ele- noted in both sheep and baboons during insuf-
vating the abdominal wall to provide counter- flation with CO2. Southerland et al. (21)
traction and to increase the distance between showed decreased arterial oxygen tension and
the uterus and the abdominal wall. Further- pH and increased arterial to end-tidal CO2 gra-
more, the needle can be inserted with the aid of dient in the ewe and its fetus. Galan et al. (22)
ultrasound guidance, pointing it away from the in a study of four pregnant baboons found ma-
enlarged uterus or in an alternate site (Palmer ternal respiratory acidosis in three of the four
Point). It is also possible to place the trocar by animals. Fetal umbilical artery Doppler studies,
an open technique or through an alternate site however, were unaltered immediately after in-
as well (1, 2). It should be emphasized that no sufflation compared with baseline
instruments are inserted into the uterine cervix measurements.
or onto it for uterine manipulation during the A significant fetal bradycardia occurred in one
procedure. baboon at 20 mm Hg of intraabdominal pressure.
2. Adequate pneumoperitoneum is essential for Normal interval growth was shown by ultrasound 2
visualization and performance of laparoscopic weeks after the procedure. Although showing possi-
procedures. However, this may be hazardous to ble alteration in fetal blood gases or pulse, these
the pregnant woman who already has an altered reports were not related to poor perinatal outcome.
cardiovascular and respiratory function. The Furthermore, slight acidosis was reported to be nor-
Trendelenburg position and increased intraab- mal and even beneficial (23). However, the effects of
dominal pressure might decrease the total lung moderate acidosis on the fetus are still unknown.
compliance and the functional residual capac- The absolute safety of laparoscopic surgery during
ity. The use of positive-pressure ventilation and pregnancy in humans has yet to be established. In
lower intraabdominal pressure overcome these 1996, Amos et al. (24) reported seven cases of preg-
effects. In addition, high intraabdominal pres- nant patients undergoing laparoscopic surgery—
sure might decrease venous return and cardiac three appendectomies and four cholecystectomies.
output resulting in reduction of uteroplacental There were four fetal deaths among them, three dur-
blood flow. The Trendelenburg position here ing the first operative week and another, 4 weeks
favors venous return, and an intraabdominal postoperative. Of five pregnant patients who under-
pressure level below 15 mm Hg can minimize went laparotomy for similar reasons, four subse-
this complication. quently progressed to term and one was lost to fol-
Laparoscopic Surgery During Pregnancy Y CME Review Article 57
low-up. The authors recommend caution when tidal CO2 may not be sensitive enough to reflect
considering nonobstetrical laparoscopic surgery in acute changes in arterial PCO2. Hence, it may
pregnant women, and they speculate that the bad not be adequate as a guide to adjust pulmonary
outcomes in their series may be related to the pneu- ventilation during laparoscopic surgery. Conse-
moperitoneum effect, demonstrated in animal stud- quently, arterial PaCO2 monitoring has been
ies, showing physiologic alterations in fetal blood recommended. Others (26) have suggested con-
pressure and pulse with both tachycardia and brady- tinuous transcutaneous CO2 pressure measure-
cardia. Contrary to the very small series by Amos et ments as well as squeeze end-tidal CO2 pres-
al. (24), the majority of studies and case reports sure (at large tidal volume) to be of clinical
found in the literature report a favorable outcome. It value in trending and preventing hypercarbia
should be remembered, however, that any surgery during laparoscopic surgery. In experimental
during pregnancy is not an innocent procedure, and animals, hyperventilation has not been suffi-
caution should always be exercised. Experienced cient to prevent hypercarbia and acidosis (21–
laparoscopic surgeons with strict adherence to good 23). Also, maintenance of maternal end-tidal
technical and anesthetic principles have been suc- CO2 in the low to mid-30s did not prevent
cessful in diminishing pregnancy-related laparo- adverse events in the report by Amos et al. (24).
scopic complications, and together with good obstet- However, laparoscopy in Amos series was per-
rical management, successful outcomes can be formed for conditions generally felt to increase
achieved in most patients (2, 3). the risk of fetal loss. Gasless laparoscopy was
Suggested precautions that should be exercised proposed by Akira et al. (27) and Tanaka et al.
when laparoscopic surgery is performed in pregnant (28) as a safe alternative to standard laparos-
patients include: copy during pregnancy. Whether this newer
1. Intraoperative fetal monitoring may be per- approach is better for this purpose is unclear
formed routinely in these patients so that if fetal and awaits additional data.
distress develops, the pneumoperitoneum pres- 6. Tocolytic agents need not be used prophylacti-
sure can be diminished or the patient can be cally, but can be administered if the patient dem-
hyperventilated in an attempt to correct the onstrates uterine irritability or contractions.
problem. Intraoperative transvaginal ultrasound 7. A gestational age of 26 to 28 weeks seems to be
fetal monitoring may be used, because transab- the limit for successful completion of laparo-
dominal ultrasound monitoring may be imprac- scopic surgery. Late in the second trimester, the
tical and problematic if the signal is lost during size of the uterus interferes with adequate vi-
abdominal insufflation. sualization of intraabdominal organs. The in-
2. The patient should be positioned in the left creasing uterine size may necessitate changes
lateral decubitus position to prevent uterine in port-site placement to other places rather
compression of the inferior vena cava. This than periumbilical site as the pregnancy
may prevent further compromise in uteropla- progresses.
cental blood supply. Morrell et al. (25) have In conclusion, surgical procedures during preg-
suggested lateral rotation of the operating table nancy are uncommon and laparoscopic procedures
to displace the uterus. are even less common. Many doctors still hesitate to
3. A Hasson trocar open technique is safer to use the minimally invasive approach due to lack of
prevent inadvertent puncture of the uterus, es- solid data on its safety and possible adverse effects
pecially with increasing gestational age, al- on gestation. From this literature review, it seems
though this point has not been investigated. that laparoscopic surgery is safe and advantageous
Ultrasonic guidance during insertion of a Ver- for both the mother and her fetus when performed
ess needle can decrease the danger of injury to by an experienced team. A final conclusion, how-
the uterus. ever, can be reached only when far more experi-
4. Intraabdominal pressure should be kept as low ence has been gained to evaluate the safety, appro-
as possible and should be no higher than 15 mm priate indications, patient selection, efficacy, and
Hg. complication rate of this new surgical approach
5. Maternal end-tidal volume CO2 should be mon- during pregnancy.
itored and kept within the normal range. End- References (29–66) can be found in the tables.
58 Obstetrical and Gynecological Survey
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