"Is interventional laparoscopy indicated and safe when performed in pregnant women?" This is a critical question. As a rule, pregnancy has been considered a relative contraindication to interventional laparoscopy. Recently several studies have demonstrated that selected laparoscopic procedures can be performed safely during pregnancy. However, complications such as fetal loss and premature labor do occur, but with the use of appropriate techniques these can be avoided. To prevent these complications guidelines were developed to ensure no increased morbidity was generated for the pregnant patient and that the safety of the fetus was not placed in jeopardy.

Currently, SAGES has published guidelines for laparoscopic surgery during pregnancy. These will be discussed in the latter portion of this section.

Any intraabdominal surgical intervention will increase the risk of abortion and miscarriage. The ultimate decision to perform a laparoscopy during pregnancy is left to the surgeon and should be made only after they carefully analyze the risks versus the benefits of performing such a procedure. Laparoscopic intervention should be performed when the risk of no surgical intervention with subsequent potential fetal loss outweighs the risk of the surgery itself. A crucial question for the surgeon to take into consideration is, "Can this procedure be delayed until the delivery of the fetus or until the second trimester of pregnancy?"

The presence of a large gravid uterus in pregnant patients makes laparoscopic procedures difficult and risky. Thus, these procedures should be evaluated on an individual case basis. Common sense should to be used. However, it is a general consensus that laparoscopic procedures are the safest when performed during the second trimester of pregnancy.

For obvious reasons, no prospective human studies have been done. Extensive animal studies were performed by several authors.

Hunter and colleagues meticulously investigated the physiological impact of a CO2 pneumoperitoneum in these clinical settings. Their conclusions were a CO2 pneumoperitoneum created minimal impact on the patient and the fetus when using intraabdominal pressure of 15 mm Hg. or less. A recent study by Curet MJ et al. also demonstrated that if an intraabdominal pressure interior to15 mm Hg of CO2 were used, it did not affect the outcome or morbidity of the procedure. However, an increase in intraabdominal pressure, a decrease in intrauterine blood flow and induced maternal and fetal acidosis were demonstrated. Gynecological literature has now accumulated multiple series of interventional gynecological procedures performed in the gravid patient again proving laparoscopy is safe when performed by expert laparoscopic surgeons.

Although some authors have reported some anecdotal, successful cases of gasless, interventional laparoscopy, we preferentially use a CO2 pneumoperitoneum with pressures below the 10 mm Hg. range.

Damage to the gravid uterus is of concern when creating a pneumoperitoneum in the pregnant patient. Intrauterine placement of a Veress needle has been reported and can generate severe injury to the fetus. The initial insertion of the Veress needle should be selected with great care. The Verres needle can be placed in any aspect of the upper abdominal quadrant.

If there is any doubt, the pneumoperitoneum should be created with a blunt trocar or a Hasson Cannula.

It remains essential to monitor the gravid patient and the fetus during the laparoscopic intervention. The gravid patient should be monitored carefully for oxygenation and hemodynamic status. Arterial Blood Gases and maternal End Tidal CO2 should be obtained liberally. Pneumatic sequential stockings should be placed on the patient in the operating room and their use continued while the patient remains hospitalized.

If there is any evidence or findings of laparoscopy induced physiological stress to the patient or the fetus, the surgeon should consider converting this procedure to an open procedure.

There are now numerous reports of laparoscopic appendectomies and cholecystectomies performed in pregnant patients. Almost all of these procedures have been performed during the first and second trimester. Overall most patients and the fetus have done well and outcome studies verified these results.

We have not modified our management of choledocholithiasis in the gravid patient. As with other authors, our experience is limited in this particular setting. We do believe that using the appropriate protective measures, these patients are best managed with a laparoscopic cholecystectomy with cystic duct cannulation and postoperative ERCP.

The management of a pregnant patient with an acute abdomen and/or a suspected acute appendicitis can also be selectively approached with laparoscopy.

Elective procedures in General Surgery should be avoided at all costs. The gynecological literature is reporting an increasing number of elective cases such as removal of adnexal masses, etc. Again, most reports are showing that under the correct circumstances, these laparoscopic procedures have been proven to be safe.

SAGES GUIDELINES FOR LAPAROSCOPY DURING PREGNANCY

CLICK SAGES LOGO TO VIEW GUIDELINES

References:

• Reedy MB: Laparoscopy during pregnancy. A survey of laparoendoscopic surgeons. J Reprod Med 1997 Jan;42(1):33-8.
• Curet MJ et al. Effect of CO2 pneumoperitoneum in pregnant ewes. J Surg Res 1996 Jun; 63(1):339-44.
• Howard MF et al: Laparoscopic adnexal surgery during pregnancy. J Am Assoc Gynecol Laparosc 1994 Nov;2(1):91-3.
• Neiswender LL et al. Laparoscopic excision of pelvic masses during pregnancy. J Am Assoc Gynecol Laparosc 1997 Feb;4(2):269-72.
• Yuen PM et al: Laparoscopic management of adnexal masses during pregnancy. Acta Obstet Gynecol Scand 1997 Feb;76(2):173-6.
• Iafrati MD et al. Gasless laparoscopic cholecystectomy in pregnancy. J Laparoendosc. Surg 1995 Apr(2):127-30.
• Reedy MB: Laparoscopy during pregnancy. A survey of laparoendoscopic surgeons. J Reprod Med 1997 Jan;42(1):33-8.
• Dufour P et al. Appendicitis and pregnancy. Seven case reports. J Gynecol Obstet Biol Reprod (Paris) 1996;25(4):411-5.
• Friedman RL et al. Acute cholecystitis with calculous biliary duct obstruction in the gravid patient. Management by ERCP, papillotomy, stone extraction and laparoscopic cholecystectomy. Surg Endosc 1995 Aug;9(8):910-3).
• Gurbuz At et al. The acute abdomen in the pregnant patient. Is there a role for laparoscopy? Surg Endosc 1997 Feb;11(2):98-102.
• SAGES 1997: Guidelines for laparoscopic surgery during pregnancy.
• Conron R et al: Laparoscopic procedures in pregancy.AM SURG 1999,65: 259