Laparoscopic Cholecystectomy in Pregnancy: A Video Case

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

Disclosures

April 21, 2011

Safety Issues in Laparoscopic Procedures During Pregnancy

Historically, pregnancy was considered a relative contraindication to laparoscopic surgical intervention. As techniques have evolved and operative skill levels increased, laparoscopy is now considered a strong alternative to open procedures.[15,26] Much of the evidence to support this shift in paradigm stems from a 1997 study using the Swedish Health Registry.[27] Outcomes in this study were compared between 2233 laparoscopic and 2491 open laparotomy procedures performed in Sweden between 1973 and 1993. The investigators found no statistically significant differences in birth weight, gestational age at delivery, congenital malformations, fetal loss, or intrauterine growth restriction. Several subsequent studies have confirmed these findings[8,26] and broadened the practice of laparoscopy in pregnancy, applied most commonly in appendiceal and biliary pathology.

Benefits. Laparoscopic surgery has been associated with reduced postoperative pain and reduced narcotic use. In pregnancy, this is especially important because maternal narcotic use can lead to fetal depression.[15,28] Lower risks for wound complications, such as infection and pain,[29,30] and decreased uterine irritability as a result of less manipulation[31] and preterm delivery,[16] have also been reported. Smaller incisions may also have benefits, because they may heal faster than laparotomy incisions. This may allow women to deliver vaginally vs by cesarean section, which is commonly required when laparotomy is performed near term. All of these factors contribute to the safety and overall benefits of laparoscopic surgery in pregnancy.

Timing. With respect to the timing of performing a laparoscopic procedure, the optimal time is during the second trimester after organogenesis and prior to impedance of vision by the uterus.[32,33,34] However, laparoscopy can be performed safely in any trimester[15,35,36] depending on the specific situation and patient characteristics. Reports of performing laparoscopy as late as 34 weeks' gestation have been documented[37,38] without increased risk for negative outcomes. The ability to perform these procedures depends on the patient's body habitus, uterine size and location, and the presence of any additional comorbidities. Several studies have demonstrated that laparoscopic cholecystectomy and appendectomy can be successfully performed late in the third trimester,[4,38] superseding the old suggestion that the gestational age limit for successful completion of laparoscopic surgery during pregnancy is 26-28 weeks.[39] Postponing necessary operations until after parturition could, in some cases, increase the rate of complications for both mother and fetus.[40,41,42,43]

Positioning. Patient positioning is an important aspect of setting up a laparoscopic procedure in a pregnant woman. Given that the gravid uterus can potentially compress the inferior vena cava, leading to decreased venous return and subsequent drop in cardiac output by 10%-30%, offloading is important in maintaining hemodynamics.[15] Placing the patient in the left lateral position allows for offloading of the uterus and maintenance of maternal venous return and cardiac output, thereby also maintaining uteroplacental perfusion.[44] This is especially important at the 16-week gestational mark and can be accomplished via padding under the left side or left lateral rotation of the table.[37]

Techniques. Both the open Hasson and the Veress needle techniques have been described for gaining access to the peritoneum. The concern with using a blind entry revolves around the possibility of inadvertently puncturing the gravid uterus, an event that has been described in the literature.[45,46] In this case, however, the point of access was at the umbilicus, which may not be ideal when considering the alterations in anatomic location of abdominal organs during pregnancy. Studies have reported safe entry via both techniques when port placement was appropriately altered to compensate for the enlarged uterus.[15,37,45] Many now advocate for access via the left subcostal region to reduce the risk for intra-abdominal organ injury. No differences in complication rates have been found between a Hasson or Veress needle entry.[15,37,38]

Fetal monitoring. The fetal heart rate should be assessed both pre- and postoperatively as determined by consultation with obstetrical colleagues.[15,38] No evidence exists to support the use of prophylactic tocolytics; these should only be used when clinical signs of preterm labor are present.[15,38,47] Glucocorticoids, likewise, should only be administered as determined by consultation with obstetrical colleagues in the appropriate clinical setting.

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