Laparoscopic surgery in pregnancy

INTRODUCTION — The advantages of laparoscopic surgery are similar for pregnant and nonpregnant women; nevertheless, this procedure had been avoided during pregnancy because of concerns that it may be harmful to the fetus. Potential concerns include:

●The rise in intraabdominal pressure during pneumoperitoneum could decrease utero-placental blood flow and result in fetal hypoxia.

●Fetal acidosis could develop from absorption of carbon dioxide (CO₂).

●The fetus could be injured directly or indirectly if the uterus is perforated by a trocar or Veress needle.

●Uterine perforation may result in preterm premature rupture of the membranes and preterm delivery.

However, multiple case reports and case series describing the safe performance of laparoscopic procedures in pregnant patients have been published, resulting in a paradigm shift [1-5]. Appendicitis, gallbladder disease, mesenteric cysts, and adnexal masses/torsion have been successfully managed laparoscopically during pregnancy. More advanced laparoscopic procedures, such as radical nephrectomy, splenectomy, adrenalectomy, retroperitoneal lymphadenectomy, and ventral hernia repair, have also been reported in gravid patients [6-9].

This topic will discuss issues specific to laparoscopic surgery during pregnancy. Discussions of laparoscopic surgery in the general population and specific laparoscopic procedures can be found separately (refer to individual topic reviews).

In this topic, when discussing study results, we will use the gender terms as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transmasculine and gender-expansive individuals.

SAFETY

Maternal — For pregnant women who require surgery, laparoscopy appears to be associated with less risk than laparotomy [10-17]. In a retrospective study of nearly 2000 pregnant women that compared open and laparoscopic appendectomy and cholecystectomy, laparoscopic surgery was associated with shorter operative times, shorter length of stay, and fewer complications compared with open surgery [4]. In a national cohort study of nearly 20,000 women undergoing appendectomy or cholecystectomy during pregnancy, open surgery was associated with a threefold increased risk of postoperative obstetric complications, including preterm delivery, preterm labor without preterm delivery, and miscarriage, when compared with laparoscopy [18].

Fetal — Prospective studies evaluating the safety of laparoscopy in human pregnancy are lacking, but multiple case series have reported laparoscopic procedures in all trimesters of pregnancy with minimal morbidity to the fetus and mother. The best available outcome data were derived from retrospective studies. A report from Swedish health registries [2] compared the outcome of 2181 laparoscopies performed on pregnant patients prior to 20 weeks of gestation with the outcome of 1522 laparotomies performed in a similar population. There were no significant differences between groups in any measured outcome: birth weight, gestational duration, intrauterine growth restriction, congenital malformations, stillbirths, or neonatal deaths. No adverse long-term effects have been reported, but data are sparse.

Multiple maternal physiologic changes during laparoscopic surgery can impact the fetus. Pneumoperitoneum can alter maternal hemodynamics, arterial oxygenation, and acid-base balance as a result of CO₂ absorption. Pressure on uteroplacental vessels can decrease uterine blood flow, while upward displacement of the diaphragm further reduces maternal residual lung volume and functional residual capacity. Hemodynamic changes include a decrease in cardiac index and increases in mean arterial pressure and systemic vascular resistance [19].

Animal models have been used to evaluate the maternal and fetal effects of increased intraabdominal pressures associated with CO₂ pneumoperitoneum. The following studies illustrate some of the findings from this work:

●In a gravid baboon model, one group found that there were no adverse maternal or fetal effects during laparoscopy with an intraabdominal pressure (IAP) of 10 mmHg; however, at a pressure of 20 mmHg, maternal respiratory acidosis was noted despite an increase in the ventilatory rate [20]. The maternal hypercarbia resulted from absorption of CO₂ from the abdominal cavity. Fetal Doppler flow studies after the procedure were similar to baseline measurements.

●In a gravid ewe model, another group found that laparoscopy with an IAP of 20 mmHg decreased maternal placental blood flow by 61 percent [21]. However, after one hour at this IAP, fetoplacental perfusion, pH, and blood gas tension did not deteriorate further.

●In another gravid ewe model, CO₂ pneumoperitoneum caused fetal tachycardia, hypertension, and hypercarbia, most likely as a result of fetal CO₂ absorption [22]. These changes were reversed by inducing mild maternal respiratory alkalosis, which promoted fetal to maternal diffusion of CO₂; the changes did not occur when nitrous oxide was used to create the pneumoperitoneum.

●A fourth study showed that gravid ewes who were insufflated with carbon dioxide for 60 minutes at a pressure of 15 mmHg developed progressive fetal hypotension and bradycardia [23]. After deflation of the pneumoperitoneum, uterine blood flow returned to normal, and the fetal partial pressure of carbon dioxide and pH changes resolved within one hour. However, fetal oxygen saturation and content remained depressed, and fetal cardiovascular status continued to decline during the two-hour postinsufflation period.

Fetal loss — While studies of laparoscopic appendectomy during pregnancy have raised the concern that laparoscopy may be associated with higher rates of fetal loss or preterm delivery, limitations of these studies and meta-analysis include retrospective design and lack of adjustment for confounders such as patient age, duration of pregnancy, complications of appendicitis, surgeon skill, time period in which laparoscopy was performed, and clinical setting [24-26]. In the 2012 meta-analysis of 11 studies that included 3415 women, the risk of fetal loss was greater for laparoscopic versus open appendectomy in pregnant women (pooled relative risk 1.91, 95% CI 1.31-2.77) [25]. However, the largest study to date, which included nearly 20,000 women undergoing either appendectomy or cholecystectomy, open surgery was associated with a higher risk of adverse obstetric outcome, including miscarriage, when compared with laparoscopic surgery [18]. We counsel women undergoing laparoscopic surgery that data from the largest study indicate that the laparoscopic route is safer than the open approach, but the overall body of evidence is mixed.

Anesthetic drugs — Potential effects of anesthetic drugs in pregnancy are reviewed separately.

INDICATIONS — Once the need for surgery has been determined, the surgical approach (laparotomy or laparoscopy) is based on the skills of the surgeon and the availability of the appropriate staff and equipment.

The indications for laparoscopic treatment of acute abdominal processes and benefits of the laparoscopic approach are the same in pregnant and nonpregnant patients [5]. Hemodynamic instability is a contraindication to using a laparoscopic approach. Laparotomy is often preferred to laparoscopy in the presence of a large solid ovarian mass on preoperative ultrasonography, and when the patient has had multiple prior surgeries and/or a history of adhesive disease.

See individual topic reviews on laparoscopic management of specific disorders, such as:

●(See "Acute appendicitis in pregnancy", section on 'Surgical approach'.)

●(See "Gallstone diseases in pregnancy", section on 'Laparoscopic cholecystectomy'.)

BENEFITS — The benefits of laparoscopy during pregnancy are similar to those in nonpregnant patients: less postoperative pain, less postoperative ileus, reduction in adhesion formation, shorter hospital stay, and faster return to usual activities [27].

There may also be specific benefits during pregnancy. As an example, there is often less uterine manipulation intraoperatively during laparoscopic procedures than during laparotomy [28]. In addition, avoidance of a large abdominal scar while the uterus is enlarging results in a better cosmetic outcome and less postoperative discomfort (lower narcotic requirements, better respiratory effort) [28,29]. The laparoscopic approach may provide better exposure than laparotomy because of optical magnification, lighting, and other technical factors.

TIMING — Laparoscopy can be performed in any trimester [5]; however, as with other types of surgery performed during pregnancy, the optimal time to operate is the early second trimester. (See "Anesthesia for nonobstetric surgery during pregnancy".)

When surgery is required during the third trimester, the enlarged uterus can interfere with adequate visualization. However, successful laparoscopic management of appendicitis, cholecystitis, intussusception, and an adnexal mass has been described in the third trimester, as late as 34 weeks of gestation [10,30-35]. Whether a laparoscopic procedure is feasible in the third trimester depends upon individual clinical factors (eg, the disorder being treated, body habitus, size of the uterus, comorbid medical and obstetric conditions). There is no absolute maximum gestational age for performing laparoscopy; we will perform these procedures in the early third trimester if we feel that it is technically possible and clinically appropriate.

Although procedures performed in the first trimester should be easier technically, introducing a potential teratogen during organogenesis is a concern. In addition, it is preferable to perform surgery after the period when spontaneous miscarriages are likely to occur. However, in some cases, surgery cannot be delayed from the first to the second trimester. In cases of suspected ovarian torsion, for example, prompt surgical intervention is indicated.

PROCEDURE — Prior to initiating the procedure, an oro- or naso-gastric tube is inserted into the stomach to prevent perforation of a distended stomach, and to reduce the risk of aspiration of gastric contents. A Foley catheter is placed in the bladder.

Thromboprophylaxis — There are no data from randomized trials on the use of unfractionated or low molecular weight heparin or intermittent pneumatic compression for venous thromboembolism prophylaxis in pregnant patients undergoing laparoscopy.

The Society of American Gastrointestinal and Endoscopic Surgeons recommends placing pneumatic compression devices on the lower limbs of pregnant women undergoing laparoscopic procedures for surgical problems [5].

The 2012 American College of Chest Physicians (ACCP) clinical practice guideline on prevention and treatment of thrombosis recommends mechanical or pharmacologic thromboprophylaxis for pregnant patients undergoing surgery [36]. For laparoscopic procedure (gynecologic or general surgical) likely to take >45 minutes, use of low molecular weight heparin is suggested; mechanical thromboprophylaxis is a reasonable alternative for shorter procedures.

Prophylactic tocolysis — There is no evidence to support the use of prophylactic tocolytics or glucocorticoids. However, these drugs may be indicated in management of threatened preterm delivery. (See "Inhibition of acute preterm labor" and "Antenatal corticosteroid therapy for reduction of neonatal respiratory morbidity and mortality from preterm delivery".)

Patient position — Depending on the planned procedure, the patient is placed in the supine or low lithotomy position with a leftward tilt (after 16 weeks of gestation) to avoid significant compression of the aorta and inferior vena cava. Left lateral rotation of the operating table may also help to displace the uterus adequately [30]. However, such positioning may make the surgical procedure more difficult because the gravid uterus may block the surgeon's view, such as with a left adnexal mass. In these cases, we utilize a hand-assist port to dislodge the adnexa from behind the uterus and bring it into operative view. The patient can temporarily be taken out of left lateral tilt to facilitate this manipulation. After a pneumoperitoneum has been created, the patient's position can be adjusted further to allow gravity to aid with visualization. As an example, varying degrees of Trendelenburg position can move the intestines cephalad and thus improve visualization for procedures in the pelvis. The amount of Trendelenburg position that a pregnant woman will tolerate depends on the patient's habitus, co-morbid risk factors, and gestational age of the pregnancy. Left-sided rotation of 30 degrees with chest and thigh restraining straps improves visualization of the appendix and gall bladder during laparoscopic appendectomy and cholecystectomy in the third trimester [37,38]. These positions displace the gravid uterus off of the inferior vena cava, in addition to exposing the right paracolic gutter.

Trocar placement/insertion — While all patients undergoing laparoscopy are at risk of trocar injury, the gravid uterus makes trocar insertion and creation of a pneumoperitoneum more difficult and potentially more hazardous. Inadvertent placement of a Veress needle through the umbilicus into the pregnant uterus has been described [39].

Supraumbilical primary trocar placement is a common practice; we suggest positioning the port at least 6 cm above the uterine fundus and elevating the abdominal wall (figure 1) [40]. This placement provides an adequate distance between the tip of the laparoscope and the uterus to allow optimal visualization and instrumentation. With increasing gestational age, use of the subxiphoid, left upper quadrant, or right upper quadrant insertion points also helps to avoid the enlarged uterus. Lateral displacement of the uterus during trocar insertion may also decrease the risk of uterine and fetal injury.

Both the Hasson (open) technique and the Veress needle technique have been used for establishing a pneumoperitoneum in pregnant patients [5]. The Veress needle technique requires a blind entry with its attendant risk of uterine/fetal injury, especially when inserted through the umbilicus [39]. A blind approach, however, was successfully used in a series of 10 third trimester procedures in which the Veress needle was inserted in the mid-clavicular line, 1 to 2 cm below the costal margin in either the left or right upper quadrants [30]. Some surgeons recommend an open technique for trocar insertion because of greater assurance of safety [33,40-42]. Given the feasibility of both methods, individual surgeons should use the technique with which they have the most experience and comfort.

Our preferred entry technique is use of a Veress needle inserted in the left-upper quadrant. As discussed above, gastric decompression with an orogastric tube prior to placement of the needle decreases the risk of gastric injury. The needle should be angled approximately 15 degrees caudad to minimize risk of liver, gastric, and splenic injury [43]. The uterus is gently manually displaced toward the right during placement in order to avoid uterine injury.

A sponge stick may be placed in the vagina and used to exert gentle cephalad pressure on the uterus, if necessary. Transcervical instruments should NOT be used to manipulate the uterus.

Laparoendoscopic single-site surgery (LESS), also referred to as single port laparoscopy, utilizes a single skin incision, through which a port with multiple operating channels is introduced. There are a few reports of use of LESS in pregnant women [44-47]. Further study is needed before LESS techniques can be recommended for use in the pregnant population.

Pneumoperitoneum — Even though intraabdominal pressure needs to be sufficient to allow for adequate visualization, maintenance of a low pressure is mandatory, given the possible adverse effects of increased intraabdominal CO₂ pressures on the hemodynamic and respiratory physiology of the gravid patient. Intraabdominal pressure between 8 to 12 mmHg and not exceeding 15 mmHg should be maintained [29,39].

Gasless laparoscopy may be a safer alternative to the traditional CO₂ pneumoperitoneum, but specialized abdominal wall lifting devices are often necessary for a completely gasless procedure [48,49]. Other techniques have been described that can decrease intraabdominal pressures using a combination of pneumoperitoneum and abdominal wall retraction [50]. We perform laparoscopy with a CO₂ pneumoperitoneum, but we try to operate as efficiently as possible to minimize operative time and any potential maternal/fetal morbidity.

Several large studies found measurement of end-tidal carbon dioxide pressure (capnography) was adequate for intraoperative CO₂ monitoring in pregnant women; routine blood gas monitoring was unnecessary [10,31,51]. We recommend keeping the end-tidal CO₂ at 32 to 34 mmHg, as respiratory acidosis has not been reported at this level [52,53].

A study of eight pregnant women from 17 to 30 weeks of gestation undergoing laparoscopic cholecystectomy under general anesthesia measured changes in arterial to end-tidal carbon dioxide pressure difference (PaCO₂-PetCO₂) before, during, and after CO₂ pneumoperitoneum [54]. There were no significant differences in either mean PaCO₂-PetCO₂ or PaCO₂ and pH during the various phases of laparoscopy, demonstrating that capnography is adequate to guide ventilation. Respiratory acidosis did not occur when end tidal CO₂ was maintained at 32 mmHg.

Fetal assessment — Fetal heart rate should be confirmed and documented before and after the procedure, and is usually done with a hand-held Doppler device (eg, Doptone). Due to the pneumoperitoneum, transabdominal fetal monitoring is usually not possible during laparoscopy in the second trimester. If fetal monitoring is necessary during the procedure, transabdominal fetal monitoring may be possible through the left abdominal wall with the patient in a steep leftward tilt [37]. Another option is transvaginal ultrasound assessment of the fetal heart rate.

If maternal acidosis is suspected and confirmed, it can be reversed by immediately hyperventilating the mother and decreasing intraabdominal pressure. These measures can help to resuscitate the fetus by improving placental blood flow and fetal oxygenation [51]. (See "Anesthesia for nonobstetric surgery during pregnancy".)

POSTOPERATIVE CARE — Fetal heart rate and uterine activity should be monitored in the recovery room, as appropriate for gestational age. Opioids and antiemetics can be used, as needed, to control postoperative pain and nausea. Nonsteroidal anti-inflammatory drugs should be avoided, especially after 32 weeks of gestation, because they may cause premature closure of the fetal ductus arteriosus. Cesarean delivery is performed for standard obstetric indications; the presence of a recent abdominal incision does not preclude pushing in the second stage of labor.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Laparoscopic and robotic surgery".)

SUMMARY AND RECOMMENDATIONS

●Safety – Laparoscopic surgery can be performed safely and effectively in pregnant women. (See 'Safety' above.)

●Gestational age – The procedure has been performed as late as 34 weeks of gestation, but the optimal time is the early second trimester. (See 'Timing' above.)

●Surgical positioning – Pregnant patients are placed in the left lateral recumbent position to minimize uterine compression of the vena cava and the aorta. (See 'Patient position' above.)

●Thromboprophylaxis – We suggest use of pneumatic compression devices for low-risk pregnant women undergoing short laparoscopic procedures for surgical problems, and low molecular weight heparin for procedures >45 minutes (Grade 2C). (See 'Thromboprophylaxis' above.)

●Abdominal entry and port placement – There is no evidence that open procedures are safer than blind procedures. Modification of port sites is necessary when the uterus is significantly enlarged. (See 'Trocar placement/insertion' above.)

●Intraabdominal pressure – We suggest intraabdominal pressure be maintained between 8 to 12 mmHg and not exceed 15 mmHg (Grade 2C). Maintaining intraabdominal pressure at this level helps to avoid a decrease in placental blood flow. (See 'Pneumoperitoneum' above and 'Safety' above.)

●Maternal carbon dioxide levels – We suggest keeping the end-tidal carbon dioxide at 32 to 34 mmHg, as respiratory acidosis is unlikely at this level (Grade 2C). If maternal acidosis is suspected or confirmed, then immediate hyperventilation of the mother and decreasing the intraabdominal pressure may improve placental perfusion. (See 'Fetal assessment' above.)