Laparoscopy

Definition: Laparoscopy is the insepection of the peritoneal cavity by means of a telescope introduced through the abdominal wall after creation of a pneumo-peritoneum (Azad et al., 1998). Laparoscopic surgery is the execution of established surgical procedures in a way which leads to the reduction of the trauma of the access and thereby accelerates the recovery of the patient. (Azad et al., 1998)

Historical landmarks: The word laparoscopy is derived from a Greek word lapra, meaning the soft part of the body between ribs and hip, flank, loin and skopein, which means to look at or to survey. First documented laparoscopy was undertaken in 1901 by Damitri Oksarovich Ott (1858-1929) of St.Petersburg, Russia, using a gynecologic head mirror, an external light source and a speculum to perform the procedure. He termed the procedure Ventroscopy. (Ott D, 1901). In 1902, George Kellin outlined the technique of visualizing the peritoneal cavity and its contents in a dog by inserting a cystoscope inserted through a trocar and creating pneumoperitoneum with filtered air. At the same time, a Swedish surgeon, Jacobaeus in 1910, coined the term laparoscopy which

has subsequently become the accepted terminology used to describe almost all varieties of this form of intervention. He published his experience on the technique of laparoscopy in humans for the first time. (Jacobaeus HC, 1910). The next technological advance in laparoscopic technology was provided in 1920 by Benzamin Orndoff who developed a sharp pyramidal point on laparoscopic trocar to facilitate puncture. (Orndof BH, 1920) Professor Kalk pioneered the use of laparoscopy for disorders of the liver and biliary tract. He introduced the oblique viewing optics from longitudinal axis permitting better inspection of organs, as the image could be changed by altering the viewing direction of the optics such that the lens moved around the object. In 1929 he was the first to describe dual puncture technique. The use of second puncture opened the way for the development of operative laparoscopy (Ajay et al., 2007). The next significant development in laparoscopic technology occurred in 1938 when Janos Varess described a spring loaded needle with an inner stylet that automatically converted the sharp cutting edge to a rounded end by incorporating a side hole, for creation of

pneumoperitoneum. The needle had initially been used to create a pneumothorax to treat tuberculosis. (Veress J, 1938). The first description of operation performed under laparoscopic vision came

from Fervers in 1933. He performed laparoscopic adhesiolysis with biopsy instruments. He used oxygen as distending medium and experienced great concern at the audible explosion and flashes of light produced by electrocautery within the abdominal cavity. He recommended changing to carbon di oxide as insufflating gas for creating pneumoperitoneum. (Ajay et al., 2007) Kurt Semm, a gynecologist, played the vital role in the development of operative laparoscopy. It was Semm who developed the automatic insufflating device that monitored intraabdominal pressure and gas flow in 1963. (Semm K, 1989). Prior to this, air was introduced by most workers into peritoneal cavity with the help of a syringe. Semm designed the pre tied suture loop (Roeder knot) to allow adequate hemostasis. He also developed a high volume suction/irrigation apparatus with design modifications to prevent tube clogging. Many more instruments i.e. needle holder, micro scissors, clip applier, morcellator were

conceptualized, created and first utilized at Kiel University by him. He also created pelvitrainer, designed to teach surgeon the video eye hand coordination and suture tying techniques. He was the first person to perform laparoscopic appendectomy in 1982 and soon thereafter, using his instruments, Erich Muhe, a surgeon from Boblingen performed first laparoscopic cholecystectomy in 1985. Unfortunately his technical presentation to Congress of German

Surgical Society met with considerable resistence. The surgey was later performed with the help of video camera in france by Phillipe Mouret in 1987. (Ajay et al., 2007) No one has contributed widely to the development and use of laparoscopy in general surgery than George Berci in Los Angeles, both in the design of instrumentation and identifying clinical situations in surgical practice where laparoscopy would materially benefit management of the patient. He pioneered the use of laparoscopy for the management of diagnostic dilemmas, especially in emergency situations, and was instrumental in the development of laparoscopy for trauma. (Berci G et al., 1977)

Physiological changes during laparoscopy: Although the surgical technique of laparoscopic surgery is of a minimally invasive nature, a number of physiological changes occur as a result of creating a CO2 pneumoperitoneum / pneumoextraperitoneum, and postural changes involved in patient positioning. These changes may be particularly noticeable in elderly and very young patients, and significant in those with preexisting diseases such as cardiovascular, pulmonary and

neurological disorders. In addition, other pathophysiological changes related to access and instrument injuries leading to bleeding, gas embolism or peritonitis may occur. It must be

remembered that conventional open surgery too, has significant effects on body physiology as the result of wound related trauma and pain, pulmonary dysfunction, bowel dysfunction from exposure and handling, endocrine and metabolic changes, as well as postural changes required for optimal surgical exposure.

1-Pulmonary changes: The physiology of the respiratory system is affected by pneumoperitoneum. With insufflations, causing an increase in intra-abdominal pressure (IAP), the diaphragm is pushesd upwards causing stiffness of the chest wall, causing the total volume of the lungs to be reduced. Hence the pulmonary compliance decreased to 35-40% and also non negligible increase in the maximum respiratory system resistance. (Makinin MT et al., 1996). Hypoxemia may occur from ventilation perfusion mismatch and intrapulmonary shunting but is rare in healthy patients. (Hydon GH et al., 1996). Carbon dioxide is usually administered at a rate of 1-2 ml/min. Being a highly soluble gas; it is readily absorbed into the circulation through the peritoneum, causing hypercarbia and acidosis. Several studies have shown the effect of CO 2 pneumoperitoneum on the arterial partial pressure of CO2 and end tidal CO2 (ETCO2). One study has compared laparoscopic Roux-

en-Y gastric bypass (GBP) against open surgery. It found that ETCO2 was raised from 35 mmHg to 40 mmHg, i.e. by 14%, whereas PaCO2 also was raised by 10% from 38 mmHg to 42 mmHg. (Nguyen NT et al., 2010). PaCO2 levels were initially 34 mmHg and increased to 42 mmHg with pneumoperitoneum. (Demiroluk S et al., 2002). It was found that patients with normal cardio-respiratory system had increased ETCO2 and PaCOv, decreased pHa values in a study comparing ventilator effects of laparoscopic cholecystectomy in 10 ASA (American Society of Anesthesiologists) I and II patients and in 10 ASA III and VI patients. However, changes were more pronounced in the ASAIII and VI patients.(Wittgen CM et al., 1991) Carbon dioxide is mainly excreted by the lungs, depending on alveolar and mixed venous CO2 exchange rates, which are themselves controlled by the cardiac output, alveolar ventilation and respiratory quotient. (Seed RF et al., 1970). Normal excretion of CO2 is 100-200 ml/min and is increased by 14-48 ml/min when CO2 is administered intraperitoneally.(Lewis DG et al., 1972). After a long laparoscopic operation, achieving a normal CO 2 value can take several hours after desufflation, since the use of peripheral storage capacity will lengthen the duration of increased PaCO2. (Wahba RWM et al., 1993)

2-Cardiovascular changes: Cardiovascular system effects during Carbon dioxide pneumoperitoneum are caused mainly by hypercarbia followed by acidosis and increased intra-abdominal pressure. An euvolemic status is of great importance prior to surgery to decrease any cardiac depression via reduced preload has caused and by the

pneumoperitoneum.

Hypercarbia

direct

indirect

sympathoadrenal stimulating effects on cardiovascular functions. These effects are not pronounced with mild hypercarbia (PaCO2 45-50 mmHg), whereas moderate to sever hypercarbia affects cardiac function since it is then a myocardial depressant and has direct vasodilatory effect. (Rasmussen JB et al., 1978). Dexter et al studied 2 groups of patients, one with pneumoperitoneum of 7 mmHg and the other with a pressure of 15 mmHg. Both groups showed an increase in heart rate and mean arterial pressure, but the cardiac output and stroke volume were more considerable depressed in the 15 mmHg group. (Dexter et al., 1999). Westerbanb et al., studies showed a 30% decrease of cardiac index in patients during laparoscopic cholecystectomy. (Westerbanb et al., 1992). Kraut et al., showed a mild decrease in cardiac output and stroke volume using insufflation pressure of 15 mmHg. The addition of 10 cm of PEEP (Positive End Expiratory Pressure) resulted in significantly reduced cardiac output and stroke index.

Those authors therefore concluded that combination of increased IAP and PEEP should be avoided. (Kraut et al., 1999). With a post-inflation IAP of 15 mmHg, Joris et al., showed a mean arterial pressure increase of 35%, systemic vascular resistance increase of 65%, pulmonary vascular resistance increase by 90%, and a

decrease in cardiac index by 20%. The authors suggested that increased vascular resistance could partly increase the cardiac index. (Joris et al., 1993)

3-Renal changes: There is a complex interplay between increased IAP and renal function. Harman suggested that the decrease in renal function from increased IAP is a result of direct renal parenchymal compression, rather than a decrease in cardiac output (CO). (Harman et al., 1982). However, decrease in blood flow to all intra-abdominal organs except the adrenal gland has been demonstrated at IAP of 20 and 40 mmHg. (Caldwell et al., 1987). There is decreased renal cortical blood flow and increased medullary blood flow with increasing IAP. (Chiu et al., 1995). Of the three factors, compression of the renal parenchyma, decreased CO, and impaired venous return- local compressive effects appear to have the greatest effect on renal function. IAP greater than 15 mmHg results in elevated plasma renin and aldosterone levels,

which may contribute to further local vasoconstriction and diminished renal blood flow. (Gudmundsson et al., 2002). The exact mechanism for elevated plasma renin activity and aldosterone levels is unclear. It is most likely a combination of decreased CO, diminished renal perfusion, and increased renal venous pressures( Studies have shown some improvement in renal function with intravascular volume expansion and use of vasoactive drugs. With the use of either isotonic or hypertonic saline, the adverse effects of IAP on urine output and renal blood flow were reversed, but creatinine clearance remained diminished.(London et al., 2000). The use of renal dose dopamine (2 /kg per min) may have some beneficial effect in limiting the renal dysfunction during prolonged pneumoperitoneum. (Perez et al., 2002). In a clinical study, clonidine was shown to suppress the renin-angiotensinaldosterone system by decreasing plasma renin activity. This resulted in decreased and catecholamine possible renal levels, more stable from

hemodynamics

protection

vasoconstriction. (Joris et al., 1998). In patients with normal preoperative renal function, elevated IAP from pneumoperitoneum causes observable physiological changes but limited clinical detriment. However, in patients with baseline renal insufficiency,

care should be made in monitoring fluid status closely, and using pharmacological agents as needed. (

4-Endocrine changes: The bodys neuroendocrine response to surgical stress and trauma has been well studied. Elevated IAP also results in a complex neuroendocrine response. An increase in IAP from baseline to 20 mmHg, causes an increase in plasma epinephrine and nor epinephrine levels regardless of the type of gas used to obtain pneumoperitoneum. (Mikami et al., 1998). Most clinical studies that have documented the neuroendocrine response to pneumoperitoneum have compared conventional open

cholecystectomy (OC) to laparoscopic cholecystectomy (LC). Both OC and LC show similar intraoperative elevation in plasma adreno-corticotrophic hormone (ACTH), cortisol, norepinephrine, epinephrine, insulin and glucose concentrations. (Karayiannakis et al., 1997). In the OC patients, plasma epinephrine, norepinephrine, and glucose levels remain elevated in the first 24-h postoperative period. (Glaser et al., 1995). Plasma thyroid markers are also elevated at a similar magnitude for OC and LC. (Ortega et al., 1996). Elevation of vasopressin or antidiuretic hormone (ADH) is seen early in LC but not OC, in concert with changes in systemic vascular resistance. (Joris et al., 1998). The proposed mechanism

for rise in vasopressin/ADH levels has been previously mentioned. Another proposed mechanism may be the activation of peritoneal nerve endings, which are stimulated by intra-abdominal pH changes secondry to carbon dioxide pneumoperitoneum. The neurohypophysis is stimulated to release vasopressin via a vagal neurogenic pathway. (Mann et al., 1999). Alternatively, decreased venous return may stimulate right atrial volume receptors which trigger the pituitary to release vasopressin/ADH. (Ortega et al., 1996). Regardless, theelevated levels of vasopressin/ADH results in decreased urine output in LC compared with that in OC, but this physiological effect reverses within an hour after

pneumoperitoneum is terminated. Clinically, increased IAP and increased vasopressin/ADH lead to profound intraoperative oliguria in many patients despite adequate intravascular volume. Attempts to correct intraoperative oliguria with fluid and sodium replacement may lead to significant volume overload. ( The systemic stress response syndrome during both LC and OC is similar to that observed with neuroendocrine markers mentioned above. However stress hormone levels remain elevated in the immediate postoperative period in OC patients, while these levels return to baseline quickly in LC patients. This may contribute to the quicker recovery seen in patients undergoing LC as compared to OC. (

5-Immunological changes: Operative procedures under general anesthesia result in significant immunesuppression, and the severity of immune suppression is directly related to the magnitude of the operation. Laparoscopic surgery does not suppress the immune system to the same degree as open procedures, and this contribute to the diminished postoperative pain and quick recovery after LC. (Grace et al., 1991).The physiological response to surgery or trauma is an immediate elevation of the stress hormones and a decrease in overall cellular immune response. Acute phase response and cytokine levels dont directly correlate with the bodys immune status but they are well studied markers for the activation of the immune system. C-reactive protein (CRP) has been shown to rise 4-12 h after surgery and peak at 24-72 h. (Ohzato et al., 1992). Clinical studies have shown a lower elevation of CRP during LC and in the postoperative period compared to OC. (Halevy et al., 1995). Interleukin-6 (IL-6) is another cytokine that is elevated in postsurgical states, and its elevation correlates with the degree of surgical injury. (Cruickshank et al., 1990). Most studies have shown that serum levels of IL-6, like CRP, is less affected by LC than by OC. (Grande et al., 2002). Intial studies comparing open and laparoscopic assited colon resection were unable to demonstrate a difference in CRP levels, but this may be due to

small patient numbers, a non-randomized population , and heterogenous group of operations for both malignant and benign diseases. Recent studies of colorectal resection are more consistent with the cholecystectomy data that demonstrate a smaller elevation in immune markers with a laparoscopic approach than with the open procedure. (Delgado et al., 2001). In addition to the cytokine and acute phase response studies, there have been numerous studies evaluating the effect of laparoscopy on the cellular components of the immune system. Comparing OC to LC there was a greater increase in overall peripheral leukocyte count with OC. (Redmond et al., 1994). Cellmediated immunity (CMI) as measured by T-cell proliferation, was more depressed in patients undergoing OC than in LC patients. (Griffith et al., 1995). Brune et al., showed less suppression of CMI following LC by comparing levels of interferone-, tumor necrosis factor-, and interleukin-2 with those in a control group undergoing OC. (Brune et al., 1999). CMI was suppressed in postoperative day 1 in both groups, but the effect was more profound in OC patients than in LC patients. T- cell function has also been examined by studying animal models of delayed type hypersensitivity. Allendorf et al., showed a greater reduction in delayed typersen-sitivity in a rat model following open cecectomy versus laparoscopic cecectomy. (Allendorf et al., 1996). Similarly,

Trokel et al. showed that delayed type hyper-sensitivity is better preserved after laparoscopy than after laparotomy in a rat model. (Trokel et al., 1994). Thus, most studies to date support improved postoperative immune system preservation in laparoscopic surgery compared to open surgery. (

Advantages of laparoscopy: In addition to avoiding large, painful access wounds of conventional surgery, laparoscopy allows the operation to be carried out with minimal parietal trauma with the avoidance of exposure, cooling, desiccation, handling, and forced retraction of abdominal tissues and organs. Thus the overall traumatic assult on the patient is reduced drastically, and as a result of this: Postoperative pain, ileus and wound complications such as infection and dehiscence are reduced and recovery

accelerated. Abdominal adhesion formation, which may become the source of recurrent pain, intestinal obstruction and female infertility is reduced. Surgically induced immunosuppression, which may have important implications is decreased. Postoperative chest complications are reduced.

 Cosmetic results are greatly improved. Visual enhancement by the magnifying effect of the telescope and improved exposure in places such as the pelvic and subphrenic spaces. The greatly reduced contact with patients blood and body fluid, which has important implications for both patient and surgeon in relation to the transmission of viral diseases. (Azad et al., 1998)

Disadvantages and limitations of laparoscopy: The main difficulties with laparoscopy emanate from the necessity to insufflate the peritoneal cavity or extraperitoneal space with gas, and access the space via needle and trocar inserted through the abdominal wall. Surgeon related difficulties include eye and hand co-ordination and the remote nature of the surgical manipulation, loss of direct hand manipulation and tactile feedback and the two dimensional imaged provided by the current camera systems. Diathermy injuries are a particular potential hazard. However, appropriate training and experience, open technique laparoscopy, and the development of better instrumentation including three dimensional video-endoscopy and exploratory ultrasound probe will minimize these difficulties. (Azad et al., 1998)

The disadvantages of laparoscopy include: The need to purchase and maintain expensive high technology equipment. Laparoscopic procedures require more technical expertise and take longer, at least initially, than an open approach. Potential injury to the vessels and viscera as the result of needle-cannula insertion, inappropriate instrumentation and diathermy burns. The insufflations may cause postoperative abdominal pain and shouldr tip pain not uncommomly; and gas embolus, deranged cardiovascular function, tension pneumothorax, and significant hybercarbia very rarely. Haemostasis can be difficult to achieve because of technical difficulties and because blood obscures vision by absorbing light. Intact organ retrieval is seriuosely limited. (Azad et al., 1998)

Contraindications to laparoscopy: A.anatomic limitations: 1.Port access: a.Reoperative abdomen, especially in the reoperative abdomen injuries can occur when placing laparoscopic ports. In several early

prospective studies, there were fewer injuries when open cutdown access methods (Hasson technique) were employed, as compared to blind (Veress needle) port insertion methods. (Mayol et al., 1997). It is now believed that the incidence of injuries is similarly small using either technique, even in the reoperative abdomen, provided the site chosen for insufflations and insertion of the first port is distant from previous abdominal incisions. If the Veress needle technique is used, failure to establish a pneumoperitoneum after two or three phases should be considered as a reason to change to an open (Hasson) technique. In more than 30% of patients with history of prior surgery, the bowel or other organs are directly adherent to the abdominal scar, rendering these areas problematic for both open and blind access methods. (Audebert et al., 2000) The difficulty of laparoscopy in the reoperative abdomen is due to the formation of adhesions, which obliterate the peritoneal space and hinder visibility. Attempts at laparoscopy in a field previously operated upon by open technique can be very time consuming particularly in the case of multiple previous operations or peritonitis. Many surgeons set a time limit for laparoscopic lysis of adhesions, after which conversion is carried out unless the end of the adhesiolysis is clearly ain sight. (Steven et al.,

b.Intraperitoneal mesh: because of the difficulty dissecting intestinal adhesions from prosthetic mesh, previous intraperitoneal mesh placement is considered a contraindication to laparoscopic access in that area. Conversely, it is often possible to repair recurrent ventral or inguinal hernias where mesh was used by placing trocars remote from the previous incisions and the mesh. (

c. Cirrhosis and portal hypertension: in cirrhotic patients, the hazards encountered in abdominal access are often due to abdominal wall varices, and meticulous open technique is required for safe port placement. (Abdel-Atty et al., 1999). In the aascites patient without portal hypertension, the Veress needle approach may be used, but it is necessary to place the patient in the reverse trendelenberg position to get the air-filled bowel away from the inferior course of the needle. In addition, it may be necessary to withdraw ascitis before pneumoperitoneum can be established. Ascitis becomes frothy (secondary to the albumin) when it is directly insufflated, which makes visualization difficult.

Laparoscopic wounds in cirrhotic patients can be complicated by postoperative leakage of ascitis. Cholecystectomy is generally considered to be prohibitively hazardous in the presence of advanced cirrhosis (Child C) because of the abund-ance of large fragile collateral vessels at the liver hilum; however, laparoscopic

cholecystectomy may provide an advantage over open operation in Childs A and B cirrhotic patients because of decreased wound complication rates. (Yerdel et al., 1997)

2-Peritoneal space: a.Peritonitis: early reports predicted that laparoscopic operations in the presence of bacterial peritonitis would predispose to subsequent abscessformation. However, laparoscopic

appendectomy following perforation and laparoscopic closure of perforated peptic ulcers are operations that have been safely carried out with complication rates reported equivalent to the open approach. (Khalili et al., 1999)

b.Mechanical bowel obstruction: laparoscopy in the set of diffusely dilated small bowel loops is difficult because the working space provided by the pneumoperitoneum is reduced. Further, small bowel manipulation and retraction in this setting carries a higher risk of serosal tears or entrotomy. Aithough some surgeons believe laparoscopy is contraindicated for mechanical obstructions, others have reported success in selected cases and have noted wound healing benefits and early return of bowel function. (Strickland et al., 1999). It must be accepted that the conversion rate will be high and, if complex adhesions are encountered, the surgeon should

have a low threshold for laparotomy. It is helpful to decompress the bowel as much as possible preoperatively, and to start running the bowel at the decompressed ileocecal valve. ( c.Gravid uterus: pelvic and lower abdominal laparoscopic surgery is often not possible in the third trimester of gestation due to space considerations. Although laparoscopy has been reported, open operation is recommended. (

B.physiologic limitations: 1.Pulmonary: a.CO2 retention/hypoventilation: abdominal insufflation with CO2 is associated with two potential problems. First, absorption of CO2 across the peritoneal surface may cause hypercarbia, which, in turn results in respiratory acidosis. Second, transmission of increased intra-abdominal pressure through the paralyzed diaphragm raises intra-thoracic pressure by 5-15 mmHg, depending on

diaphragmatic compliance. Absorption of CO2 and the ensuing hypercarbic acidosis requires intraoperative compensation by the anesthetist; increasing the minute ventilation, usually by

hyperventilating the patient, lowers the PaCO2 and raises the pH. In patients with marginal pulmonary reserve, the morbidly obese, and those who require positive end expiratory pressure for adequate oxygenation, adequate compensation may not be possible

and, in these cases, refractory acidosis may develop. (Stuttmann et al., 1995). End-tidal CO2 monitoring is essential in the management of the ventilation of patients undergoing laparoscopy, but may underestimate the true arterial pCO2 by as much as 10 mmHg in the individual with chronic lung disease. Thus, arterial monitoring may be wise in these patients. In children and in patients who cannot be adequetly ventilated during laparoscopic surgery, lower peak insufflations pressures should be used. If this fails, alternative measures including the use of an abdominal walllifting device, administration of an alternative insufflations gas such as nitrous oxide or helium, or conversion to open technique should be considered. (Hunter et al., 1995)

2.Cardiac/circulatory: a.Decreased venous return/metabolic acidosis: venous return to heart decreases in response to periton physioeal gas insufflations. This effect is most prominant in hypovolemic patients, as the pneumoperitoneum will easily compress the poorly distended vena cava. In a well hydrated patient, venous return to the heart is nearly normal. Cardiac output is decreased by impairment of venous return, and metabolic (lactic) acidosis results from decreased visceral perfusion. This may be exacerbated by the decreased capacity for respiratory compensation. (Taura et al., 1998)

Laparoscopy in the elderly was once thought to be contraindicated because of the effect of pneumoperitoneum on cardiac and pulmonary physiology. With improved anesthetic techniques, these contraindications no longer exist. Several studies have confirmed the benefits of laparoscopy in the elderly, including decreased hospital stay and fewer wound and pulmonary complications when compared to traditional operative approaches. (Shwandner et al., 1999)

b.Hemorrhage/shock: patients with severe cardiac disease or with profound hypovolemia may not compensate well and may manifest a dramatic fall in cardiac output with peritoneal gas insufflation. Although laparoscopy has been recommended as a diagnostic tool in some intensive care unit patients, it should not be performed in patients who manifest shock, particularly from acute hemorrhage. (Orlando et al., 1997)

3.Intracranial pressure: a.Trendelenberg position/intra-abdominal pressure: peritoneal gas insufflations can cause increased intracranial pressure during lower abdominal or gynecologic procedures that require the use of the trendelenberg position. When accompanied by an associated acidosis, laparoscopy can cause hazardous intracranial pressure

elevations in susceptible patients, especially those with acute brain injury. (

b.Ventriculoperitoneal

shunt:

technical

failures

of

ventriculoperitoneal shunts (VPS) have been reported following laparoscopic surgery. Also, a theoretical risk of intracranial insufflations exists in the case of a defective shunt valve. (Baskin et al., 1998). Some experts recommend that in patients with VPSs requiring laparoscopic surgery, the shunt should be exteriorized before to gas insufflations and replaced following desufflation of the abdomen. In practice, the valve in the VPSs is rarely incompetent, and these additional measures are believed by most neurosurgeons to be unnecessary. (

4-Pregnancy: a.Maternal/fetal effects: peritoneal gas insufflations with CO2 has been found in laboratory studies to cause increased intrauterine pressure, decreased uterine blood flow, and maternal and fetal acidosis. (Curet et al., 1996). No long term data are available concering the development of the child after maternal laparoscopy, but recent clinical data suggest that adverse outcomes are rare when laparoscopy is performed in the second trimester of pregnancy. (Conron et al., 1999)

b.Advantages of the second trimester: because of the possible teratogenicity of anesthetic agents, elective surgical procedures in general are contraindicated in the first trimester. In the third trimester, the risk of pre-term labor also contra-indications elective surgical procedures. The second trimester (13-26 weeks gestation) is a relatively safe period for indicated