IS Laparascopic surgery safe in pregnancy ?

Is laparascopic surgery safe in pregnancy ?

Dr.Abdullah Al mashali

Clinical Scenario:

30 yrs female 20 weeks pregnant complains of RUQ abdominal pain every 3-4 days

- pain Occurs after fatty meals

- US showed : multiple stones, no wall thickening

- blood labs: Normal LFTs, amylase, lipase

Dx: Cholelithiasis

Questions?

Should I offer her a cholecystectomy?

Timing of surgery?

Open or laparoscopic?

- If laparoscopic ?

- what pre-operative care should be done ?

- What entry technique should be used?

- Port placement?

- Appropriate level of pneumoperitoneum?

- Patient positioning?

Ultersound

Should be the initial imaging test of choice

MRI

- MR Imaging without the use of intravenous contrast can be

performed at any stage of pregnancy.

- MRI is preferred over CT scan for diagnosis of non-obstetric abdominal pain in the gravid patient

Traditionally, the recommendation for non-emergent procedures during pregnancy has been to avoid surgery during the first and third trimesters to minimize the risk of

spontaneous abortion and preterm labor, respectively.

- Recent literature has demonstrated that pregnant patients may undergo laparoscopic surgery safely during any trimester without an increased risk to the mother or fetus .

Both laparoscopic cholecystectomy and appendectomy have been successfull

performed late in the third trimester without increasing the risk of preterm labor or fetal demise .

Laparoscopy and Trimester of Pregnancy

SO...

Laparoscopy can be safely performed during any trimester of pregnancy when operation is indicated .

Fetal Heart Monitoring:

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- Fetal heart monitoring of a fetus considered viable should be done

preoperatively and postoperatively in urgent abdominal surgery .

Tocolytics:

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- Tocolytics should not be used prophylactically in pregnant women

undergoing surgery but should be considered perioperatively when signs of preterm labor are present.

Perioperative care

Beyond the first trimester should be placed in

the left lateral decubitus position or partial left lateral decubitus position

minimize compression of the vena cava

to

Patient Positioning

left lateral decubitus position

Initial Port Placement

Initial Port Placement

- In first trimester the initial access to abdomen can be done through umbilical accroding the fundus level.

- In second and third trimester:

- left subcostal approach is recommended as initial access to the abdomen to avoid the uterus injury.

Insufflation Pressure

Insufflation Pressure

- CO2 insufflation of 10-15 mmHg can be safely used for

laparoscopy in the pregnant patient.

-The level of insufflation pressure should be adjusted to the patient’s physiology

Venous Thromboembolic (VTE) Prophylaxis

Venous Thromboembolic (VTE) Prophylaxis

- Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis

for deep venous thrombosis in the gravid patient.

- In patients who require anticoagulation during pregnancy, unfractionated heparin has proven

safe and is the agent of choice.

Laparoscopic Appendectomy

- Is the treatment of choice for pregnant patients with acute appendicitis.

- CO2 insufflation of 10-15 mmHg by Veress needle at Palmer's point.

- Port placement.

Appendiectomy

Laparoscopic cholecystectomy

cholecystectomy

- Is the treatment of choice in the

pregnant patient with symptomatic gallbladder disease, regardless of

trimester.

- Pregnant women with acute cholecystitis should undergo cholecystectomy.

- A study reports when cholecystitis is

managed by surgery incidence of fatal mortality is only 2.6%. However, on conservative management it is 8.0%.

Ramin KD, Ramsey PS. Disease of the gallbladder and pancreas in

pregnancy. Obstet Gynecol Clin North Am 2001;28:571-80.