Laparoscopic Cholecystectomy in Pregnancy: A Video Case

Saad Shebrain, MD, MBBch; Elizabeth A. Steensma, MD; Dwight Slater, MD

Disclosures

April 21, 2011

Case Presentation

A 19-year-old, gravida 3 para 2, obese woman (body mass index: 35.2 kg/m2) presented to the emergency department (ED) at 28 weeks' gestation with recurrent right upper quadrant abdominal pain, nausea, and emesis. The patient had made numerous ED visits for similar symptoms during her current pregnancy. She was diagnosed with cholelithiasis on ultrasound examination.

Despite maximal nonoperative therapy, her symptoms persisted. Therefore, she underwent laparoscopic cholecystectomy using low intra-abdominal insufflation pressure (12 mm Hg). Pre- and postoperatively, fetal heart tones were monitored and appropriate examinations were performed by an obstetrician. The patient's pain resolved postoperatively, and final pathology demonstrated chronic cholecystitis and cholelithiasis. At term, by repeat cesarean section delivery, she gave birth to a healthy boy.

Acute Abdomen in Pregnancy

The most common nonobstetric surgical emergency during pregnancy isn't cholecystitis but acute appendicitis, which has a reported incidence between 0.05% and 0.13%.[1] Because of the anatomic and physiologic changes that occur during pregnancy, the diagnosis of acute appendicitis in this patient group is challenging.

A high index of suspicion is critical when evaluating a pregnant woman for acute appendicitis. The possibility of acute appendicitis is an indication for surgical exploration because a ruptured appendix is associated with as much as a 36% increase in fetal loss.[2] The perforation rate during pregnancy is higher than in the general population (43% vs 19%).[3] Several studies have considered the safety, feasibility, and effectiveness of laparoscopic appendectomy for the treatment of acute appendicitis in pregnancy.[4,5,6,7]

Gallbladder disease is the second most frequent nonobstetric surgical emergency in pregnancy. In 1 study, the most common causes of biliary surgery during pregnancy were recurrent biliary colic (70%), acute cholecystitis (20%), choledocholithiasis (7%), and acute biliary pancreatitis (3%).[5]

Although approximately 25% of pregnant women fail to respond to conservative therapy, the results of conservative and surgical management, until recently, were reported to be similar with respect to maternal and fetal morbidity and mortality.[8,9,10] Studies showed that a delay in treatment of biliary disease during pregnancy can increase both short- and long-term morbidity.[11] Furthermore, a recent report suggests that the fetal death rate is higher after conservative treatment than after laparoscopic cholecystectomy for symptomatic benign biliary disease.[12] It has been reported that recurrence rates after conservative treatment seem to be trimester dependent, and range between 40% and 92%.[12,13] For this reason, laparoscopic surgery is recommended in all cases of symptomatic gallbladder disease that do not respond adequately to conservative medical treatment and in all complicated forms, such as acute cholecystitis or acute biliary pancreatitis.[8,14]

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