The new developments in operative laparoscopy in gynecology and general surgery have greatly increased its use over the last decade. The minimally invasive approach is used today in many procedures that previously required open laparotomy (1). Although once considered an absolute contraindication, laparoscopic surgery during pregnancy is now more frequently preformed without apparent increase in the rate of complications. However, patient selection, indications and contraindications are still being defined (2).
The major advantages of laparoscopic surgery during pregnancy are:
- 1. Small abdominal incisions result in rapid postoperative recovery and early mobilization, thus minimizing the increased risk of thromboembolism associated with pregnancy.
- 2. Early return of gastrointestinal activity due to less manipulation of the bowel during surgery, which may result in fewer postoperative adhesions and intestinal obstruction.
- 3. Smaller scars.
- 4. Fewer incisional hernias.
- 5. Decreased rate of fetal depression due to decreased pain and less narcotic use (2).
- 6. Shorter hospitalization time and prompt return to regular life.
It seems that in comparison with laparotomy, laparoscopic procedure may be better tolerated, especially by the pregnant patient, due to the minimal postoperative discomfort and the prevention of an abdominal scar in the presence of a growing uterus. This has led to enthusiasm for and acceptance of this minimally invasive surgery during gestation in several gynecological and nongynecological procedures.
Some concern have been raised by several authors that laparoscopy may hold an increased risk to the fetus: 1) It may decrease uterine blood flow by increasing intraabdominal pressure; 2) it may cause fetal hypotension and hypoxia because of decreased maternal venous return and cardiac output, and/or 3) although not proven in humans, it may cause fetal acidosis by CO2 absorption.
During the last decade, more than a few case reports and retrospective studies have appeared, evaluating the safety and specific risks inherent to laparoscopy during pregnancy. No prospective controlled studies have been reported yet. We have undertaken to review the current English literature and summarize the commutative knowledge on this subject. A MEDLINE search of the last 10 years was performed using the keywords: laparoscopy, pregnancy. The most commonly reported laparoscopic procedures during pregnancy are laparoscopic cholecystectomy, appendectomy, and management of adnexal masses such as ovarian detorsion, ovarian cystectomy, and ectopic pregnancy.
Nongynecologic surgery is required in approximately 2 of each 1000 pregnancies (3). The most commonly preformed operations in pregnancy are cholecystectomy and appendectomy, which occur in 0.05% and 0.10%, respectively. We found 37 case reports and small series for a total of 176 patients who underwent such procedures during gestation (Tables 1 and 2). Since surgical treatment of the pregnant patient has the added potential risk of injury to two patients—the mother and her fetus—the obstetrician or gynecologist should be involved in the management of these patients.
Pregnancy has been associated with an increased incidence of cholelithiasis, and although most women are asymptomatic, biliary colic occurs in approximately 0.05% to 0.1% of pregnant women (4). However, timing of surgery in the pregnant patient with biliary tract disease is a controversial issue. Patients with obstructive jaundice, acute cholecystitis unresponsive to medical management, or peritonitis should undergo prompt operative intervention in any trimester. Operations on patients with recurrent attacks of biliary colic should be deferred until the postpartum period if possible. If symptoms are too frequent and severe, or if they are associated with gestational weight loss, then the second trimester is the safest time to perform surgery.
During the second trimester, the miscarriage rate is only 5.6% compared with 12% in the first trimester. In addition, the rates of preterm labor are very low during the second trimester, as compared with the potential risk of 40% for premature delivery in the third trimester. Finally, the potential risk of teratogenesis during the second trimester is very small and the uterus is still of such proportion that do not obliterate the operative field as might occur during the third trimester.
In a retrospective case-control study, Curet et al. (3) compared 16 pregnant patients who underwent laparoscopic surgery with 18 control patients who underwent open laparotomy during their first or second trimester (Tables 1 and 2). In the study group, 4 patients underwent appendectomy and 12 underwent cholecystectomy. They also selected another 41 patients from a literature survey to make up a total of 57 cases in their series. There was no difference between laparotomy and laparoscopy outcomes in their series. Moreover, the incidences of obstetric complications were in the range seen in pregnant patients who did not have any surgery. None of the delivery complications observed was related to the type of surgery the patient underwent or the method of access into the abdominal cavity. These data suggest that laparoscopic surgery can be performed safely in the pregnant patient during both the first and second trimester.
Gouldman et al. (4) reported eight laparoscopic cholecystectomies performed in pregnant patients (one during the first trimester and seven during the second trimester). CO2 insufflation pressure was 12 mm Hg, and in seven patients, a Hasson trocar was used, whereas a Veress needle was used in another patient. No postoperative complications to mother or fetus were observed. Eight patients delivered babies who were full-term and healthy, with no perinatal morbidity or mortality. The authors suggest that laparoscopic cholecystectomy in pregnancy can be safely and effectively performed for symptomatic cholelithiasis, especially when symptoms are recurrent or persistent. Reedy et al. (5) sent out a questionnaire to all members of the Society of Laparoendoscopic Surgeons and obtained complete information on 413 laparoscopic cases. They reported 134 laparoscopic procedures performed in the first trimester, 224 in the second trimester, and 54 in the third trimester. Five postoperative spontaneous abortions were reported in 134 cases performed in the first trimester. There were no spontaneous abortions reported in the second trimester. The incidence of miscarriage was that reported to occur spontaneously. Three intraoperative complications considered to be to related to laparoscopic surgery were:
- 1. The placement of a Veress needle inside a 22-weeks gestation uterus. This was identified before insufflation of CO2 and the needle was withdrawn and replaced and the procedure completed. The patient continued her pregnancy uneventfully and delivered a healthy infant at term.
- 2. Enterotomy at an open laparoscopy.
- 3. Severe upper abdominal pain caused by CO2.
This report is important because it is the first that addresses the clinical safety and complications of laparoscopy in pregnancy. The authors concluded 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) analyzed 2,015,000 deliveries in Sweden from 1973 to 1993 and found a total of 2181 laparoscopies and 1522 laparotomies performed in singleton pregnancies between the 4th and 20th weeks of gestation. For infants weighing <2500 gm in both laparoscopy and laparotomy groups, there was an increased risk of premature delivery before 37 weeks of gestation and an increased incidence of growth restriction compared with the total population. However, the authors could not determine whether this increased risk was related to the anesthesia, surgical procedure, or the complication of pregnancy that necessitated the surgical intervention. There was no difference between laparoscopy and laparotomy in cumulative infant survival up to 1 year. No difference in the rate of malformation among laparoscopy, laparotomy, and the total population was found.
Appendicitis in the pregnant patient can be difficult to diagnose and cannot be clearly distinguished by gastrointestinal tract symptoms, description or location of pain, or physical examination. In addition, leukocytosis is common in pregnancy, and the count can be as high as 16.0 × 109 per liter in the third trimester. A negative exploration rate of 35% to 50% is commonly seen for symptoms of appendicitis during the third trimester of pregnancy. The morbidity and mortality seen in the pregnant patient with appendicitis usually comes from a delay in diagnosis and treatment. Patients with suspected appendicitis should undergo immediate exploration, no matter which trimester of pregnancy the symptoms occur (3).
GYNECOLOGIC LAPAROSCOPIC PROCEDURES
Only a few small series and case reports concerning laparoscopic surgery during pregnancy have been reported. We have found 18 such reports encompassing 132 cases of endoscopic gynecologic procedures during pregnancy (Tables 3 and 4). Although these procedures are performed with increasing frequency to date, the use of laparoscopy during pregnancy is still uncommon. However, the limited data available support its safety and efficacy during pregnancy.
Adnexal torsion is an emergency condition where the adnexa rotate on its pedicle compromising its blood supply. Early diagnostic and therapeutic laparoscopy is of importance in preserving the adnexa, inasmuch as it avoids negative unnecessary laparotomy and offers definitive treatment (7) (Table 3).
Torsion of the adnexa has been described as a complication of ovarian hyperstimulation syndrome (OHSS). It has been found that 75% of patients with OHSS complicated by torsion were pregnant. This observation emphasizes the importance of applying a minimally invasive therapeutic approach in these cases (8, 9). Shalev et al. (10–12) have advocated laparoscopy for diagnosis and primary treatment of torsion. They reported 41 patients, including 10 pregnant patients, successfully managed by laparoscopy. All the pregnant patients had had a favorable outcome. Others have reported similar favorable results (see Table 3). Wittich et al. (7) reported a case of successful laparoscopic detorsion during the first trimester of pregnancy where acute appendicitis was diagnosed initially. The authors noted that pregnancy progressed normally to term. Garzarelli et al. (8) reported two cases of a patient with an ovarian cyst with adnexal torsion in the first trimester that were treated by laparoscopic aspiration of the cysts and unwinding of adnexa. Progression of pregnancy was uneventful in both cases. Levy et al. (2) reported three cases of laparoscopic unwinding of an hyperstimulated adnexa during the second trimester of pregnancy. In these cases, ovaries were first aspirated and then untwisted and placed in their anatomical position. In one case, bleeding appeared after the unwinding, which necessitated laparotomy and ligation of the bleeding vessel. The authors concluded that laparoscopic treatment of ovarian torsion is a safe procedure if special precautions (see “Discussion”) are adhered to and it can be carried out in advanced gestation. In their opinion, laparoscopic surgery should not be considered an absolute contraindication even during advanced pregnancy, but there are actually very few cases reported in the second trimester and none in the third trimester. One of the three patients delivered three viable healthy premature babies in the 27th week of gestation, whereas the other two cases delivered at term.
Morice et al. (13) reported on six pregnant women with adnexal torsion that were treated laparoscopically during 6 to 13 weeks of gestation. No miscarriages occurred. The authors concluded that in the hands of the skilled surgeon, laparoscopy is well suited for the diagnosis and treatment of adnexal torsion occurring during the first trimester of pregnancy. They felt, however, that beyond 16 weeks of gestation, or when there is suspicion of adnexal malignancy, laparotomy is preferable. In the latter case, the authors recommend to carry out an open cystectomy because removal of the lesion permits a complete pathologic diagnosis and avoids recurrence of torsion.
The reported incidence of adnexal mass complicating pregnancy ranges from 1 in 81 to 1 in 2500 live births with an average of 1 in 600 (1). Corpus luteum cysts account for one third of the adnexal masses; benign cystic teratomas contribute to another third. Malignancy may occur in 2% to 5% of these patients (1, 14) (Table 4).
Currently, conservative management of these simple cystic masses is recommended until the second trimester. This often results in spontaneous resolution of non-neoplastic functional cysts (14, 15). Masses that persist into the second trimester are removed to prevent torsion or rupture during pregnancy, prevent possible obstruction at delivery, and to rule out malignancy.
One study (16) suggests that elective removal of an adnexal mass during pregnancy was less morbid than removal of a symptomatic mass in an emergency setting. To avoid the potential risks of a surgical emergency, the authors recommended elective removal of any adnexal mass >6 cm that persists to the 16th week of gestation, regardless of its ultrasonic appearance. Another study by Yuen and Chang (1) reported on six pregnant women who underwent laparoscopic surgery for persistent adnexal masses in the second trimester. Laparoscopic removal of an adnexal mass was performed in all patients without any intraoperative or postoperative complications, and all patients delivered healthy infants vaginally, at term. They believe that with attention to the surgical technique, laparoscopic removal of persistent adnexal mass during the second trimester of pregnancy is safe and carries the same benefits over laparotomy as in patients not pregnant. Parker et al. (15) presented a study in which 12 women who had laparoscopic removal of a benign cystic teratoma during pregnancy (gestational age at surgery ranged from 9 to 17 weeks). No intraoperative or postoperative maternal or fetal complications occurred. From the above mentioned reports, one can infer that laparoscopic surgery for treatment of gynecologic conditions during the first and second trimester is probably safe and carries no substantial increase in complication rate.
It is difficult to differentiate between the effects of surgery during pregnancy and the specific adverse outcomes of laparoscopy during that period. The relative effect of many factors on pregnancy is difficult to isolate. These include the indication for surgery, type of surgery, maternal condition, type of anesthesia, and the anesthetic agents used as well as many other factors. Mazze and Kallen (17) published the largest study on adverse outcomes after nonobstetric operations in patients who were pregnant. Several important findings emerged from this study. First, the incidence of stillbirths or congenital anomalies was not increased in each trimester when compared with the predicted incidence. Duncan et al. (18) also reported similar results. Second, there was an overall increase in low birth weight infants and neonates who died within 7 days of delivery, probably because of prematurity. The authors did not attribute this last finding solely to the operation effect itself, but considered the precipitating illness also as a significant contributing factor to premature labor. Finally, and most important, a total of 868 cases of laparoscopy performed during pregnancy were reviewed; 768 in the first trimester, 29 in the second trimester, and 71 in the third. There was no increased incidence of adverse outcomes as compared with matched controls.
The main specific complications of laparoscopy during pregnancy are related to possible injury to the enlarged uterus and ovaries situated outside the pelvis and to the cardiovascular and respiratory alterations introduced by the pneumoperitoneum pressure and CO2 absorption.
- 1. Penetrating injuries are more likely to occur at the beginning of the procedure when the insufflating needle is placed blindly (2). To avoid this, the Veress needle, and subsequently the trocar, should be inserted while simultaneously pushing away the uterus and ovary or by elevating the abdominal wall to provide countertraction and to increase the distance between the uterus and the abdominal wall. Furthermore, the needle can be inserted with the aid of ultrasound guidance, pointing it away from the enlarged uterus or in an alternate site (Palmer Point). It is also possible to place the trocar by an open technique or through an alternate site as well (1, 2). It should be emphasized that no instruments are inserted into the uterine cervix or onto it for uterine manipulation during the procedure.
- 2. Adequate pneumoperitoneum is essential for visualization and performance of laparoscopic procedures. However, this may be hazardous to the pregnant woman who already has an altered cardiovascular and respiratory function. The Trendelenburg position and increased intraabdominal pressure might decrease the total lung compliance and the functional residual capacity. The use of positive-pressure ventilation and lower intraabdominal pressure overcome these effects. In addition, high intraabdominal pressure might decrease venous return and cardiac output resulting in reduction of uteroplacental blood flow. The Trendelenburg position here favors venous return, and an intraabdominal pressure level below 15 mm Hg can minimize this complication.
- 3. Another possible adverse effect is the rapid CO2 absorption with an increase in arterial CO2 pressure and a concomitant possible decrease in arterial pH that might affect the fetus. To date, there is no evidence to support any detrimental effect of the CO2 pneumoperitoneum on the human fetus. Furthermore, it has been demonstrated that operative laparoscopy has little effect on maternal blood gases (1, 19). Given the hyperdynamic nature of the pregnant circulation, any CO2 that diffuses across the placenta should rapidly be removed. Nevertheless, controlled mechanical ventilation can effectively maintain normal CO2 pressure in the majority of patients (2). A study on the fetal response to CO2 pneumoperitoneum in the pregnant ewe confirms the lack of adverse effects of CO2 insufflation on the fetal placental perfusion and blood gases (20). In the animal model, some studies have shown a possible effect of CO2 on fetal blood gases. Maternal and fetal hypoxemia, acidosis, and hypercarbia have been noted in both sheep and baboons during insufflation with CO2. Southerland et al. (21) showed decreased arterial oxygen tension and pH and increased arterial to end-tidal CO2 gradient in the ewe and its fetus. Galan et al. (22) in a study of four pregnant baboons found maternal respiratory acidosis in three of the four animals. Fetal umbilical artery Doppler studies, however, were unaltered immediately after insufflation compared with baseline measurements.
A significant fetal bradycardia occurred in one baboon at 20 mm Hg of intraabdominal pressure. Normal interval growth was shown by ultrasound 2 weeks after the procedure. Although showing possible alteration in fetal blood gases or pulse, these reports were not related to poor perinatal outcome. Furthermore, slight acidosis was reported to be normal and even beneficial (23). However, the effects of moderate acidosis on the fetus are still unknown.
The absolute safety of laparoscopic surgery during pregnancy in humans has yet to be established. In 1996, Amos et al. (24) reported seven cases of pregnant patients undergoing laparoscopic surgery—three appendectomies and four cholecystectomies. There were four fetal deaths among them, three during the first operative week and another, 4 weeks postoperative. Of five pregnant patients who underwent laparotomy for similar reasons, four subsequently progressed to term and one was lost to follow-up. The authors recommend caution when considering nonobstetrical laparoscopic surgery in pregnant women, and they speculate that the bad outcomes in their series may be related to the pneumoperitoneum effect, demonstrated in animal studies, showing physiologic alterations in fetal blood pressure and pulse with both tachycardia and bradycardia. Contrary to the very small series by Amos et al. (24), the majority of studies and case reports found in the literature report a favorable outcome. It should be remembered, however, that any surgery during pregnancy is not an innocent procedure, and caution should always be exercised. Experienced laparoscopic surgeons with strict adherence to good technical and anesthetic principles have been successful in diminishing pregnancy-related laparoscopic complications, and together with good obstetrical management, successful outcomes can be achieved in most patients (2, 3).
Suggested precautions that should be exercised when laparoscopic surgery is performed in pregnant patients include:
- 1. Intraoperative fetal monitoring may be performed routinely in these patients so that if fetal distress develops, the pneumoperitoneum pressure can be diminished or the patient can be hyperventilated in an attempt to correct the problem. Intraoperative transvaginal ultrasound fetal monitoring may be used, because transabdominal ultrasound monitoring may be impractical and problematic if the signal is lost during abdominal insufflation.
- 2. The patient should be positioned in the left lateral decubitus position to prevent uterine compression of the inferior vena cava. This may prevent further compromise in uteroplacental blood supply. Morrell et al. (25) have suggested lateral rotation of the operating table to displace the uterus.
- 3. A Hasson trocar open technique is safer to prevent inadvertent puncture of the uterus, especially with increasing gestational age, although this point has not been investigated. Ultrasonic guidance during insertion of a Veress needle can decrease the danger of injury to the uterus.
- 4. Intraabdominal pressure should be kept as low as possible and should be no higher than 15 mm Hg.
- 5. Maternal end-tidal volume CO2 should be monitored and kept within the normal range. End-tidal CO2 may not be sensitive enough to reflect acute changes in arterial PCO2. Hence, it may not be adequate as a guide to adjust pulmonary ventilation during laparoscopic surgery. Consequently, arterial PaCO2 monitoring has been recommended. Others (26) have suggested continuous transcutaneous CO2 pressure measurements as well as squeeze end-tidal CO2 pressure (at large tidal volume) to be of clinical value in trending and preventing hypercarbia during laparoscopic surgery. In experimental animals, hyperventilation has not been sufficient to prevent hypercarbia and acidosis (21–23). Also, maintenance of maternal end-tidal CO2 in the low to mid-30s did not prevent adverse events in the report by Amos et al. (24). However, laparoscopy in Amos series was performed for conditions generally felt to increase the risk of fetal loss. Gasless laparoscopy was proposed by Akira et al. (27) and Tanaka et al. (28) as a safe alternative to standard laparoscopy during pregnancy. Whether this newer approach is better for this purpose is unclear and awaits additional data.
- 6. Tocolytic agents need not be used prophylactically, but can be administered if the patient demonstrates uterine irritability or contractions.
- 7. A gestational age of 26 to 28 weeks seems to be the limit for successful completion of laparoscopic surgery. Late in the second trimester, the size of the uterus interferes with adequate visualization of intraabdominal organs. The increasing uterine size may necessitate changes in port-site placement to other places rather than periumbilical site as the pregnancy progresses.
In conclusion, surgical procedures during pregnancy are uncommon and laparoscopic procedures are even less common. Many doctors still hesitate to use the minimally invasive approach due to lack of solid data on its safety and possible adverse effects on gestation. From this literature review, it seems that laparoscopic surgery is safe and advantageous for both the mother and her fetus when performed by an experienced team. A final conclusion, however, can be reached only when far more experience has been gained to evaluate the safety, appropriate indications, patient selection, efficacy, and complication rate of this new surgical approach during pregnancy.
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