Surg Endosc (1997) 11: 98–102
Surgical Endoscopy © Springer-Verlag New York Inc. 1997
The acute abdomen in the pregnant patient Is there a role for laparoscopy? A. T. Gurbuz,1,2 M. E. Peetz1 1 2
Department of Surgery, North Colorado Medical Center, 1801 16th Street, Greeley, CO 80631, USA Saint Joseph Hospital Medical Center, Denver, CO, USA
Received: 1 April 1996/Accepted 15 July 1996
Abstract Background: The acute abdomen in the pregnant patient poses a difficult diagnostic and therapeutic challenge to the surgeon. Appendicitis, cholecystitis, and bowel obstruction account for the majority of the abdominal pain syndromes which require surgical intervention. Laparoscopy is being used increasingly in the diagnosis and operative management of these disorders. Methods: We examine our experience over the last 3 years with 47 women who developed significant abdominal pain during pregnancy. Thirty-four patients had symptomatic gallstone disease, nine had appendicitis, two had incarcerated inguinal hernias, and two had pelvic masses. Twentytwo patients with biliary colic and two patients with acute cholecystitis were managed conservatively during pregnancy. Twenty-three of these underwent laparoscopic cholecystectomy in the postpartum period. A total of 23 women required surgical intervention during pregnancy and 15 underwent a variety of laparoscopic procedures. Ten patients underwent laparoscopic cholecystectomy, and five had laparoscopic appendectomy. The remaining five patients had open appendectomy. Among the 15 laparoscopic procedures, four were performed in the first trimester, seven were performed in the second trimester, and four were performed in the third trimester. Results: Laparoscopy didn’t result in increased maternal morbidity. There were no congenital malformations, fetal losses, or premature deliveries in the pregnant patients who underwent laparoscopy. Conclusions: Laparoscopy can be a useful means of diagnosis and in addition a therapeutic tool in selected pregnant patients with abdominal pain. Close maternal and fetal monitoring is essential during and after the procedure. Laparoscopic cholecystectomy is safe and can be performed Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 13–17 March 1996 Correspondence to: A. T. Gurbuz, Memphis Health Sciences Center, University of Tennessee, 956 Count Avenue A-318, Memphis, TN 38163, USA
without additional risk to the fetus for those who require surgical intervention during pregnancy. Key words: Pelvioscopy — Laparoscopy — Pregnancy — Symptomatic cholelithiasis — Appendicitis
Abdominal pain is a common complaint during pregnancy. It is reported by nearly all pregnant females at some time during the course of gestation. Pregnancy-related causes,— namely, nonpathological physiological changes, ectopic pregnancy, and placental abruption make up the majority of abdominal pain syndromes. Fortunately general surgical emergencies are less common. Among those, appendicitis is number 1 in frequency, followed by intestinal obstruction and cholecystitis [19]. The pregnant patient presents several diagnostic and therapeutic difficulties. Some of the signs and symptoms of acute abdomen such as nausea, vomiting, and anorexia may simply be pregnancy induced. Anatomical changes due to enlarging uterus and displacement of the organs away from the anterior abdominal wall may distort the clinical picture. The uterus can also inhibit the migration of omentum to the area of inflammation. The leukocytic response due to infection may be attributed to pregnancy-induced leukocytosis [28]. The surgeon not only has to take care of the mother but also has to ensure fetal well-being. Delay in diagnosis and treatment of the surgical abdomen in the pregnant patient because of the fear of unnecessary laparotomy contributes to the high complication rate in this patient population. As written by Balber in his 1908 paper, ‘‘the mortality of appendicitis complicating pregnancy is the mortality of delay’’ [2]. Early diagnosis with aggressive treatment is therefore essential for a successful pregnancy and fetal outcome.
Materials and methods During the period from October 1992 to September 1995, 47 pregnant females were treated for abdominal pain of surgical etiology; 23 patients underwent various surgical procedures during pregnancy: ten had laparoscopic cholecystectomies, five had laparoscopic appendectomies, four had
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Fig. 1. Placement of ports for a laparoscopic cholecystectomy in a 6-month-pregnant female. Fig. 2. The port sites for laparoscopic appendectomy in the early stages of gestation. Fig. 3. Position of appendix vermiformis in different stages of gestation and port sites for laparoscopic appendectomy at or after 6th month of pregnancy.
open appendectomies, two had incarcerating inguinal hernia repairs, and two were explored for pelvic masses. General inhalational anesthesia with end-tidal CO2 monitoring was employed routinely. Sequential compression stockings were placed on all patients, Foley catheters were placed in the appendectomy and pelvioscopy group, and orogastric tubes were placed in the cholecystectomy group. Patients were rotated to the left to displace the uterus from the inferior vena cava. The peritoneal cavity was entered with the open method (Hasson technique) in all patients and the blunt-tip trocar was inserted into the abdomen under direct vision. CO2 was insufflated to a pressure of no more than 12 mmHg. Fetal heart rate monitoring was employed in all patients. Intraoperative cholangiograms were performed using fluoroscopy and adequate fetal shielding with lead aprons. Laparoscopic cholecystectomy was performed with the standard fourport technique (Fig. 1). The periumbilical port was placed above the uterine fundus; placement was modified according to stage of pregnancy. The patients that underwent laparoscopic cholecystectomy had an average age of 29.1 (range 21–40); eight were multigravidas and two were nullipara. At the time of surgery two patients were in the first trimester (7, 9 weeks), seven were in the second trimester (12, 14, 15, 18, 21, 22, 22 weeks), and one was in the last trimester (27 weeks) of pregnancy. The average fetal age was 16.8 weeks. Four of the ten patients had acute cholecystitis unresponsive to conservative medical management; six were operated on a semielective basis for recurrent episodes of biliary colic interfering with mother’s nutritional status. The patients with biliary colic had an average of 3.2 attacks (2–4) per patient. All four patients with acute cholecystitis had only one attack. Abdominal ultrasound was used for diagnosis in all patients. Leukocytosis (WBC count 12,000–18,000) was observed in four; mild elevations in liver enzymes were observed in six patients. Two patients had elevated bilirubin levels (>1.5 mg/dl); no patients had an elevated amylase. Intraoperative cholangiograms were performed in two patients because of elevated bilirubin (>1.5 mg/dl) and liver enzymes (twice the normal range) with or without demonstration of a dilated common bile duct (>5 mm) with abdominal ultrasound examination preoperatively. Twenty-two pregnant patients with biliary colic and two patients with acute cholecystitis were managed conservatively during the same period. Symptoms started in the first trimester in one patient, in the second trimester in four patients, and in the third trimester in 19 patients. Nineteen patients had only one attack, one had two attacks, and two had three attacks of biliary colic. Both patients with acute cholecystitis had only one single attack. Diagnosis was verified with abdominal ultrasound, and cholelithiasis was demonstrated in all 24 patients. There was ultrasound evidence of
acute cholecystitis (gallbladder wall thickening and pericholecystic fluid) in two patients. All patients were given intravenous fluids and an intravenous second-generation cephalosporin. Appendectomies were performed in nine patients. The patients had an average age of 24.5 (range 21–27). Appendectomy was performed laparoscopically in five patients and four patients had open appendectomies. The mean gestational age was 26 weeks (9, 11, 28, 30, 32 weeks) in the laparoscopic group and 17 weeks (11, 14, 22, 24 weeks) in the open group. All patients had right lower quadrant pain, eight had elevated WBC count (>12,000), and seven were febrile (99.6°F). Laparoscopic appendectomy was performed with three ports. The first port was placed in the periumbilical area and the second port was placed laterally in the right upper abdomen. The insertion site of the suprapubic port was modified according to the stage of the gestation. In the early stages of the pregnancy (less then 3 months) it was placed in the lower midline under direct vision between umbilicus and pubic symphysis above the uterine fundus (Fig. 2). In the more advanced stages of gestation the third port was placed in the right upper quadrant between the first two ports but in a more cranial location (Fig. 3). The periumbilical port was again placed above the uterine fundus. The upward and lateral displacement of appendix with advancing gestational age makes visualization of this organ easier through the right upper abdominal approach (Fig. 3). Appendectomy was performed with the help of endolaparoscopic stapling instruments. The appendix was placed in a plastic bag prior to extraction from the peritoneal cavity. Two patients underwent laparoscopy for lower abdominal–pelvic pain. Abdominopelvic ultrasound demonstrated pelvic masses in both patients. The first patient was in the first trimester (8 weeks) and the second patient was in the early second trimester (13 weeks) of gestation. A three-port exploratory laparoscopy is performed with placement of one periumbilical and right and left midabdominal ports placed on the midclavicular line. Simple ovarian cyst aspiration was performed with resolution of the cysts in both cases.
Results Twenty-three pregnant patients had a variety of surgical procedures. Fifteen of these procedures were completed with laparoscopy. Of these 15 laparoscopic procedures, four were performed in the first trimester, seven were performed in the second trimester, and four were performed in the third trimester.
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Ten patients underwent laparoscopic cholecystectomies. The average operating time was 68 min (52–102 min). All patients were tolerating regular diet on the 1st postoperative day except one patient who stayed in the hospital for 3 days because of prolonged nausea. None of the patients were given narcotics after discharge, which limited the narcotic use for analgesia to less than 2 days. There was no maternal morbidity or mortality. Eight patients were discharged home on day 1, one patient on day 2, and one patient on day 3 following surgery. Average hospital stay was 1.3 days. Patients were fully ambulatory on the 1st day following surgery. Pathological examination showed severe acute cholecystitis in four specimens and chronic cholecystitis in six specimens. All pregnancies were followed to term and resulted with delivery of healthy babies. Twenty-four patients were followed conservatively for symptomatic cholelithiasis. There was one spontaneous abortion due to fulminant acute cholecystitis and sepsis. This patient’s condition worsened rapidly over several hours and she went on to have an abortion while she was being prepared for surgery. The average hospital stay was 3 days. All patients were followed to term and delivered healthy babies; 23 patients underwent standard laparoscopic cholecystectomy with intraoperative cholangiograms after completion of pregnancy. The procedures were performed in the first 8 weeks of delivery in 14 patients and after 8 weeks of delivery in nine patients. The mean operative time was 68.2 min (54–109 min) and average postoperative hospital stay was 1.3 days. One patient developed mild postoperative pancreatitis (peak serum amylase 420 IU/ml) probably due to reflux of radiologic contrast medium into the pancreatic duct at the time of intraoperative cholangiogram. She was discharged home on the 3rd postoperative day after resolution of abdominal pain and hyperamylasemia. Pathological examination of specimens confirmed chronic cholecystitis in 23 and acute cholecystitis in one patient. Nine patients were operated for right lower abdominal pain and various combinations of leukocytosis and fever. Five had appendectomy via laparoscopy while four had open appendectomies. Mean operating time was 64 min in the laparoscopic group and 58 min in the open group. Average hospital stay was 1.2 days in the laparoscopic group and 1.8 days in the open group. Pathology confirmed the diagnosis of acute appendicitis in seven specimens, and no appendicial inflammation was found in two specimens. All patients were followed to term and all nine of them delivered healthy babies. Two patients underwent pelvioscopy for ovarian cysts. Mean operating time was 47 min. Both patients had simple ovarian cysts. Mean hospital stay was 2 days. Pregnancy resulted with delivery of healthy babies in both patients. Overall, there was no maternal morbidity related to the laparoscopic surgery. Laparoscopy did not result in premature labor or spontaneous abortion.
Discussion Abdominal pain of surgical etiology is relatively uncommon during pregnancy. The surgeon is faced with the dilemma of choosing between unnecessary operation and increased maternal morbidity or fetal loss due to delay in diagnosis and
treatment. The change in the signs and symptoms of common acute abdominal disease due to pregnancy-induced alteration in the anatomy and physiology adds further to the confusion and causes a delay in diagnosis. Acute appendicitis is the most common nonobstetrical abdominal emergency requiring surgery during pregnancy. The incidence is one in 1,500 pregnancies and is evenly distributed throughout the trimesters. Perforation occurs in 10% of these cases and almost one-third of the removed appendices are normal pathologically. Fetal loss is reported in 1.5% of pregnancies with uncomplicated appendicitis, but the risk increases to 35% if rupture of the appendix has occurred [19]. The incidence of cholecystectomy is reported to be between three and eight per 10,000 pregnancies [14]. The incidence of spontaneous abortion is 5% with uncomplicated cholecystectomy but increases to 60% with associated pancreatitis [7]. The management of symptomatic gallstone disease during pregnancy is still controversial, although most agree that the initial treatment should be conservative [13]. If this proves unsuccessful with recurrent severe biliary colic, cholecystectomy should be performed. Surgery should also be considered for patients with acute severe cholecystitis rather early during the course, especially if the condition has not improved rapidly with conservative treatment or has deteriorated with medical management. Laparoscopy has added a new perspective to the diagnosis and treatment of a variety of abdominal and pelvic diseases. Owing to the success of laparoscopy in the nonpregnant patient, indications are now extending to the pregnant patient population as well. Once an absolute contraindication in pregnancy [11], laparoscopy has been safely used in the last several years for the treatment of abdominopelvic pathology during pregnancy. In the series of Mazze and Kallen it constituted the largest number of surgical procedures performed during the first trimester [20]. Laparoscopy is also helpful in defining the etiology of abdominal pain, therefore avoiding the delay in diagnosis [30]. The pregnant patient would benefit even more from the advantages of laparoscopic surgery—namely, easier postoperative ambulation, minimal postoperative pain, a lesser narcotic requirement, and an earlier ability to tolerate food in the postoperative course. Average hospital stay is shortened to less than 3 days in most patients. This is significantly shorter than the average hospitalization of 14 days for symptomatic gallstone disease during pregnancy reported earlier [8]. There are a total of 47 reported cases of laparoscopic procedures performed during pregnancy in the literature [1, 4–6, 9, 10, 12, 17–19, 21–23, 25–27, 29, 31–33]. Forty of these are cholecystectomies, six are appendectomies, and one is a laparoscopic ovarian cystectomy. The majority of the procedures were performed in the second trimester. Indications for cholecystectomy were biliary colic unresponsive to conservative treatment in 35 patients, progressive weight loss in two patients, acute cholecystitis in two patients and acute gallstone pancreatitis in one patient. Indications for appendectomy were right lower quadrant abdominal pain in all cases. The open technique (Hasson) was preferred for entry into the peritoneal cavity in 29 procedures, whereas the Veress needle was used in 18 cases. Four patients were in the first trimester, 39 patients were in second trimester, and three patients were in the third trimester.
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Cholangiograms were obtained in 13 of 40 cholecystectomies. Perioperative fetal monitoring was employed in 30 cases and tocolytic therapy was instituted in two patients prophylactically. No intra- or postoperative complications are described. Twenty-seven of 47 women were followed to term with delivery of healthy babies. One infant developed hyaline membrane disease shortly after birth. The remaining 20 women were reported to be continuing uncomplicated gestation. The enlarged uterus and the fetus are two points of concern during laparoscopy in a pregnant patient. The fundus of the uterus is at the pelvic brim by 12 weeks and reaches the umbilicus by the 20th week of gestation. Thus, there is a chance of injuring the uterus, the overlying enlarged uterine vessels, or the fetus during blind attempts of insufflation using the Veress needle, which has been previously reported [3]. This can potentially result in uterine insufflation and CO2 embolism. Others have recommended inserting the Veress needle through the seventh intercostal space on the left side [24] or using the umbilicus as the point of entry but aiming the needle toward the right upper quadrant to prevent uterine puncture. An alternative technique of abdominal wall lifting is also described [9]. Opening the abdominal wall in layers and inserting the blunt trocar under direct vision—therefore, the Hasson technique—should be the preferred method of entry. The gravid uterus can also interfere with the visualization and instrumentation during the procedure. Minimal manipulation of the uterus is essential. Pushing, pulling, or retracting the uterus should be avoided. Placement of trocars should be modified according to the height of the uterus. The periumbilical port has to be moved cranially after the 20th week. Preexisting high intraabdominal pressure due to the pregnant uterus and its contents may cause difficulty in insufflation and in achieving an adequate pneumoperitoneum in the advanced stages of pregnancy. The latest gestational age at which one can perform laparoscopy safely is uncertain. There may not be enough room in the upper abdomen to accommodate the instruments, and exposure of the lower abdomen and pelvis may be difficult in the late third trimester. Although initial reports had recommended that laparoscopy be performed during the second trimester only [21], laparoscopic cholecystectomy has been reported during the 25th, 28th, [10], and 31st weeks [23] of gestation. We also performed a laparoscopic appendectomy in the 32nd week of pregnancy. Each patient requires an individualized judgment by the operating surgeon as to the feasibility of laparoscopy. The potential untoward effects of intraperitoneal CO2 and high intraperitoneal pressures are another point of concern. The fetus absorbs CO2 from maternal blood and through the uterine circulation [15]. It is known that CO2 pneumoperitoneum causes an acute but mild hypercarbia and respiratory acidosis in the mother. Since the pH of the fetal blood parallels the mother’s pH, a slight acidosis is also detected in the fetus. Fortunately, the fetal acidosis is partially reversible with maternal hyperventilation. Despite the changes in the arterial CO2 and pH, the fetal PO2 changes only minimally. It has also been demonstrated that there is a significant lag time between development of maternal acidosis and increase in the end-tidal CO2 values [16]. Therefore, close hemodynamic monitoring of the mother
with capnography and preferably an arterial line is necessary. Considering the high pressures generated by the uterus at term, intraabdominal pressures up to 15 mmHg should not be harmful to the fetus. No significant hemodynamic effect of increased intraabdominal pressure is demonstrated in the pregnant ewe model if CO2 is replaced with N2O [16]. Fetal heart-tone monitoring should be an essential part of the procedure. The demonstration of fetal bradycardia or tachycardia should result in immediate exsufflation. Again, close communication with the obstetrician is necessary, especially in the late second and the third trimester of pregnancy in case of premature labor. The presence of an experienced obstetrics nurse in the operating room at the time of fetal monitoring would also be helpful. To minimize possible damage to the fetus during the organogenesis period, the first trimester should not be chosen for elective or semielective procedures. Similarly, abdominal operations and general anesthesia can cause premature labor in the third trimester. Thus, it would be safer to defer any elective procedure to the second trimester when the organogenesis is complete and the uterus is not big enough to impair the visual field. If the mother can be carried to term with conservative management, these risks will be eliminated. The indications for intraoperative cholangiography are not different from the nonpregnant patient—namely, an elevated serum bilirubin (1.5 mg/dl), a dilated common bile duct on the preoperative ultrasound (>8 mm), or gallstone pancreatitis. For the patients in whom laparoscopic cholecystectomy and laparoscopic appendectomy were performed, results from the literature and our patients show no spontaneous abortions despite the reported abortion rate of 5% with open cholecystectomy in the literature [7]. Conclusions Laparoscopy can be utilized in the pregnant patient for diagnosis and treatment of selective abdominal emergencies. The procedure has to be carefully planned and conducted by an experienced laparoscopic surgeon. Close monitoring of the mother and the fetus is essential. Modifications of the port placement and surgical technique are required to prevent injury to the gravid uterus and the fetus. Laparoscopy in the pregnant patient does not result in fetal loss. Laparoscopic procedures do not increase maternal morbidity and actually may decrease hospital stay and recovery time compared to open procedures.
References 1. Arvidsson D, Gerdin E (1991) Laparoscopic cholecytectomy in pregnancy. Surg Laparosc Endosc 1: 193–194 2. Balber EA (1908) Perforative appendicitis complicating pregnancy. JAMA 51: 1310–1313 3. Barnett MB, Lui DTY (1974) Complications of laparoscopy during early pregnancy. Br Med J 23: 328 4. Bennett TL, Estes N (1993) Laparoscopic cholecystectomy in the second trimester of pregnancy. J Reprod Med 38: 833–834 5. Camitalo JB, Lynch D (1994) Laparoscopic cholecystectomy in the pregnant patient. Surg Laparosc Endosc 4: 268–271 6. Constantino GN, Vincent GJ, Mukalian GG, Kliefoth WL (1994) Lap-
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7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
aroscopic cholecystectomy in pregnancy. J Laparendosc Surg 4: 161– 164 Dixon NP, Green J, Rogers A, Rubin L (1983) Fetal loss after cholecystectomy during pregnancy. Can Med Assoc J 88: 576–577 Dixon NP, Faddis DM, Silberman H (1987) Aggressive management of cholecystitus during pregnancy. Am J Surg 154: 292–294 Edelman DS (1994) Alternative laparoscopic technique for cholecystectomy during pregnancy. Surg Endosc 8: 794–796 Elerding SC (1993) Laparoscopic cholecystectomy in pregnancy. Am J Surg 165: 625–627 Gadacz TR, Talamini MA (1991) Traditional versus laparoscopic cholecystectomy. Am J Surg 161: 336–338 Hart RO, Tamadon A, Fitzgibbons RJ, Fleming A (1993) Open laparoscopic cholecystectomy during pregnancy. Surg Laparosc Endosc 3: 13–16 Hiatt JR, Hiatt JG, Williams RA, Klein SR (1986) Biliary disease in pregnancy: a strategy for surgical management. Am J Surg 151: 263– 265 Hill LM, Johnson CE, Lee RA (1975) Cholecystectomy in pregnancy. Obstet Gynecol 46: 291–293 Hunter JG (1992) 1991 Scientific session and postgraduate course: advances in laparoscopic general surgery. Surg Endosc 6: 47–56 Hunter JG, Swanstrom L, Thornburg K (1995) Carbon dioxide pneumoperitoneum induces fetal acidosis in a pregnant ewe model. Surg Endosc 9: 272–279 Iarfati MD, Yarnell R, Schwaitzberg SD (1995) Gasless laparoscopic cholecystectomy in pregnancy. J Laparendosc Surg 5: 127–130 Jackson SJ, Sigman HH (1993) Laparoscopic cholecystectomy in pregnancy. J Laparendosc Surg 3: 35–39 Kammerer WS (1979) Non-obstetric surgery during pregnancy. Med Clin North Am 63: 1157–1163 Mazze RI, Kallen B (1989) Reproductive outcome after anesthesia and operation during pregnancy. Am J Obstet Gynecol 161: 1178–1185
21. Morrell DG, Mullins JR, Harrison PB (1992) Laparoscopic cholecystectomy during pregnancy in symptomatic patients. Surgery 112: 856– 859 22. Nezhat F, Nezhat C (1991) Laparoscopic ovarian cystectomy during pregnancy. J Laparendosc Surg 1: 161–164 23. Pucci RO, Seed RW (1991) Case report of a laparoscopic cholecystectomy in the third trimesterof pregnancy. Am J Ostet Gynecol 165: 401–402 24. Reich H, Hunter JG (1992) Is it safe to perform laparoscopic appendectomy during pregnancy? Laparosc Focus 1: 11–12 25. Schorr RT (1993) Laparoscopic cholecystectomy and pregnancy. J Laparendosc Surg 3: 291–293 26. Schreiber JH (1990) Laparoscopic appendectomy in pregnancy. Surg Endosc 4: 100 27. Shaked G, Twena M, Charuzzi I (1994) Laparoscopic cholecystectomy for empyema of gallbladder during pregnancy. Surg Laparosc Endosc 4: 65–76 28. Smoleniec J, James D (1990) General surgical problems in pregnancy. Br J Surg 77: 1203–1204 29. Soper NJ, Hunter JG, Petrie RH (1992) Laparoscopic cholecystectomy during pregnancy. Surg Endosc 6: 115–117 30. Spirtos NM, Eienkop SM, Spirtos TW, Poliakin RI, Hibbard LT (1987) Laparoscopy—a diagnostic aid in cases of suspected appendicitis. Am J Obstet Gynecol 156: 90–94 31. Weber AM, Bloom GP, Allan TR, Curry SL (1991) Laparoscopic cholecystectomy during pregnancy. Obstet Gynecol 78: 958–959 32. Williams JK, Rosenmurgy AS, Albrink MH, Parsons MT, Stock S (1995) Laparoscopic cholecystectomy in pregnancy: a case report. J Reprod Med 40: 243–245 33. Wilson RB, McKenzie RJ, Fisher JW (1994) Laparoscopic cholecystectomy in pregnancy: two case reports. Aust NZ J Surg 64: 647–649
Surgical Endoscopy © Springer-Verlag New York Inc. 1997
The acute abdomen in the pregnant patient Is there a role for laparoscopy? A. T. Gurbuz,1,2 M. E. Peetz1 1 2
Department of Surgery, North Colorado Medical Center, 1801 16th Street, Greeley, CO 80631, USA Saint Joseph Hospital Medical Center, Denver, CO, USA
Received: 1 April 1996/Accepted 15 July 1996
Abstract Background: The acute abdomen in the pregnant patient poses a difficult diagnostic and therapeutic challenge to the surgeon. Appendicitis, cholecystitis, and bowel obstruction account for the majority of the abdominal pain syndromes which require surgical intervention. Laparoscopy is being used increasingly in the diagnosis and operative management of these disorders. Methods: We examine our experience over the last 3 years with 47 women who developed significant abdominal pain during pregnancy. Thirty-four patients had symptomatic gallstone disease, nine had appendicitis, two had incarcerated inguinal hernias, and two had pelvic masses. Twentytwo patients with biliary colic and two patients with acute cholecystitis were managed conservatively during pregnancy. Twenty-three of these underwent laparoscopic cholecystectomy in the postpartum period. A total of 23 women required surgical intervention during pregnancy and 15 underwent a variety of laparoscopic procedures. Ten patients underwent laparoscopic cholecystectomy, and five had laparoscopic appendectomy. The remaining five patients had open appendectomy. Among the 15 laparoscopic procedures, four were performed in the first trimester, seven were performed in the second trimester, and four were performed in the third trimester. Results: Laparoscopy didn’t result in increased maternal morbidity. There were no congenital malformations, fetal losses, or premature deliveries in the pregnant patients who underwent laparoscopy. Conclusions: Laparoscopy can be a useful means of diagnosis and in addition a therapeutic tool in selected pregnant patients with abdominal pain. Close maternal and fetal monitoring is essential during and after the procedure. Laparoscopic cholecystectomy is safe and can be performed Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 13–17 March 1996 Correspondence to: A. T. Gurbuz, Memphis Health Sciences Center, University of Tennessee, 956 Count Avenue A-318, Memphis, TN 38163, USA
without additional risk to the fetus for those who require surgical intervention during pregnancy. Key words: Pelvioscopy — Laparoscopy — Pregnancy — Symptomatic cholelithiasis — Appendicitis
Abdominal pain is a common complaint during pregnancy. It is reported by nearly all pregnant females at some time during the course of gestation. Pregnancy-related causes,— namely, nonpathological physiological changes, ectopic pregnancy, and placental abruption make up the majority of abdominal pain syndromes. Fortunately general surgical emergencies are less common. Among those, appendicitis is number 1 in frequency, followed by intestinal obstruction and cholecystitis [19]. The pregnant patient presents several diagnostic and therapeutic difficulties. Some of the signs and symptoms of acute abdomen such as nausea, vomiting, and anorexia may simply be pregnancy induced. Anatomical changes due to enlarging uterus and displacement of the organs away from the anterior abdominal wall may distort the clinical picture. The uterus can also inhibit the migration of omentum to the area of inflammation. The leukocytic response due to infection may be attributed to pregnancy-induced leukocytosis [28]. The surgeon not only has to take care of the mother but also has to ensure fetal well-being. Delay in diagnosis and treatment of the surgical abdomen in the pregnant patient because of the fear of unnecessary laparotomy contributes to the high complication rate in this patient population. As written by Balber in his 1908 paper, ‘‘the mortality of appendicitis complicating pregnancy is the mortality of delay’’ [2]. Early diagnosis with aggressive treatment is therefore essential for a successful pregnancy and fetal outcome.
Materials and methods During the period from October 1992 to September 1995, 47 pregnant females were treated for abdominal pain of surgical etiology; 23 patients underwent various surgical procedures during pregnancy: ten had laparoscopic cholecystectomies, five had laparoscopic appendectomies, four had
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Fig. 1. Placement of ports for a laparoscopic cholecystectomy in a 6-month-pregnant female. Fig. 2. The port sites for laparoscopic appendectomy in the early stages of gestation. Fig. 3. Position of appendix vermiformis in different stages of gestation and port sites for laparoscopic appendectomy at or after 6th month of pregnancy.
open appendectomies, two had incarcerating inguinal hernia repairs, and two were explored for pelvic masses. General inhalational anesthesia with end-tidal CO2 monitoring was employed routinely. Sequential compression stockings were placed on all patients, Foley catheters were placed in the appendectomy and pelvioscopy group, and orogastric tubes were placed in the cholecystectomy group. Patients were rotated to the left to displace the uterus from the inferior vena cava. The peritoneal cavity was entered with the open method (Hasson technique) in all patients and the blunt-tip trocar was inserted into the abdomen under direct vision. CO2 was insufflated to a pressure of no more than 12 mmHg. Fetal heart rate monitoring was employed in all patients. Intraoperative cholangiograms were performed using fluoroscopy and adequate fetal shielding with lead aprons. Laparoscopic cholecystectomy was performed with the standard fourport technique (Fig. 1). The periumbilical port was placed above the uterine fundus; placement was modified according to stage of pregnancy. The patients that underwent laparoscopic cholecystectomy had an average age of 29.1 (range 21–40); eight were multigravidas and two were nullipara. At the time of surgery two patients were in the first trimester (7, 9 weeks), seven were in the second trimester (12, 14, 15, 18, 21, 22, 22 weeks), and one was in the last trimester (27 weeks) of pregnancy. The average fetal age was 16.8 weeks. Four of the ten patients had acute cholecystitis unresponsive to conservative medical management; six were operated on a semielective basis for recurrent episodes of biliary colic interfering with mother’s nutritional status. The patients with biliary colic had an average of 3.2 attacks (2–4) per patient. All four patients with acute cholecystitis had only one attack. Abdominal ultrasound was used for diagnosis in all patients. Leukocytosis (WBC count 12,000–18,000) was observed in four; mild elevations in liver enzymes were observed in six patients. Two patients had elevated bilirubin levels (>1.5 mg/dl); no patients had an elevated amylase. Intraoperative cholangiograms were performed in two patients because of elevated bilirubin (>1.5 mg/dl) and liver enzymes (twice the normal range) with or without demonstration of a dilated common bile duct (>5 mm) with abdominal ultrasound examination preoperatively. Twenty-two pregnant patients with biliary colic and two patients with acute cholecystitis were managed conservatively during the same period. Symptoms started in the first trimester in one patient, in the second trimester in four patients, and in the third trimester in 19 patients. Nineteen patients had only one attack, one had two attacks, and two had three attacks of biliary colic. Both patients with acute cholecystitis had only one single attack. Diagnosis was verified with abdominal ultrasound, and cholelithiasis was demonstrated in all 24 patients. There was ultrasound evidence of
acute cholecystitis (gallbladder wall thickening and pericholecystic fluid) in two patients. All patients were given intravenous fluids and an intravenous second-generation cephalosporin. Appendectomies were performed in nine patients. The patients had an average age of 24.5 (range 21–27). Appendectomy was performed laparoscopically in five patients and four patients had open appendectomies. The mean gestational age was 26 weeks (9, 11, 28, 30, 32 weeks) in the laparoscopic group and 17 weeks (11, 14, 22, 24 weeks) in the open group. All patients had right lower quadrant pain, eight had elevated WBC count (>12,000), and seven were febrile (99.6°F). Laparoscopic appendectomy was performed with three ports. The first port was placed in the periumbilical area and the second port was placed laterally in the right upper abdomen. The insertion site of the suprapubic port was modified according to the stage of the gestation. In the early stages of the pregnancy (less then 3 months) it was placed in the lower midline under direct vision between umbilicus and pubic symphysis above the uterine fundus (Fig. 2). In the more advanced stages of gestation the third port was placed in the right upper quadrant between the first two ports but in a more cranial location (Fig. 3). The periumbilical port was again placed above the uterine fundus. The upward and lateral displacement of appendix with advancing gestational age makes visualization of this organ easier through the right upper abdominal approach (Fig. 3). Appendectomy was performed with the help of endolaparoscopic stapling instruments. The appendix was placed in a plastic bag prior to extraction from the peritoneal cavity. Two patients underwent laparoscopy for lower abdominal–pelvic pain. Abdominopelvic ultrasound demonstrated pelvic masses in both patients. The first patient was in the first trimester (8 weeks) and the second patient was in the early second trimester (13 weeks) of gestation. A three-port exploratory laparoscopy is performed with placement of one periumbilical and right and left midabdominal ports placed on the midclavicular line. Simple ovarian cyst aspiration was performed with resolution of the cysts in both cases.
Results Twenty-three pregnant patients had a variety of surgical procedures. Fifteen of these procedures were completed with laparoscopy. Of these 15 laparoscopic procedures, four were performed in the first trimester, seven were performed in the second trimester, and four were performed in the third trimester.
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Ten patients underwent laparoscopic cholecystectomies. The average operating time was 68 min (52–102 min). All patients were tolerating regular diet on the 1st postoperative day except one patient who stayed in the hospital for 3 days because of prolonged nausea. None of the patients were given narcotics after discharge, which limited the narcotic use for analgesia to less than 2 days. There was no maternal morbidity or mortality. Eight patients were discharged home on day 1, one patient on day 2, and one patient on day 3 following surgery. Average hospital stay was 1.3 days. Patients were fully ambulatory on the 1st day following surgery. Pathological examination showed severe acute cholecystitis in four specimens and chronic cholecystitis in six specimens. All pregnancies were followed to term and resulted with delivery of healthy babies. Twenty-four patients were followed conservatively for symptomatic cholelithiasis. There was one spontaneous abortion due to fulminant acute cholecystitis and sepsis. This patient’s condition worsened rapidly over several hours and she went on to have an abortion while she was being prepared for surgery. The average hospital stay was 3 days. All patients were followed to term and delivered healthy babies; 23 patients underwent standard laparoscopic cholecystectomy with intraoperative cholangiograms after completion of pregnancy. The procedures were performed in the first 8 weeks of delivery in 14 patients and after 8 weeks of delivery in nine patients. The mean operative time was 68.2 min (54–109 min) and average postoperative hospital stay was 1.3 days. One patient developed mild postoperative pancreatitis (peak serum amylase 420 IU/ml) probably due to reflux of radiologic contrast medium into the pancreatic duct at the time of intraoperative cholangiogram. She was discharged home on the 3rd postoperative day after resolution of abdominal pain and hyperamylasemia. Pathological examination of specimens confirmed chronic cholecystitis in 23 and acute cholecystitis in one patient. Nine patients were operated for right lower abdominal pain and various combinations of leukocytosis and fever. Five had appendectomy via laparoscopy while four had open appendectomies. Mean operating time was 64 min in the laparoscopic group and 58 min in the open group. Average hospital stay was 1.2 days in the laparoscopic group and 1.8 days in the open group. Pathology confirmed the diagnosis of acute appendicitis in seven specimens, and no appendicial inflammation was found in two specimens. All patients were followed to term and all nine of them delivered healthy babies. Two patients underwent pelvioscopy for ovarian cysts. Mean operating time was 47 min. Both patients had simple ovarian cysts. Mean hospital stay was 2 days. Pregnancy resulted with delivery of healthy babies in both patients. Overall, there was no maternal morbidity related to the laparoscopic surgery. Laparoscopy did not result in premature labor or spontaneous abortion.
Discussion Abdominal pain of surgical etiology is relatively uncommon during pregnancy. The surgeon is faced with the dilemma of choosing between unnecessary operation and increased maternal morbidity or fetal loss due to delay in diagnosis and
treatment. The change in the signs and symptoms of common acute abdominal disease due to pregnancy-induced alteration in the anatomy and physiology adds further to the confusion and causes a delay in diagnosis. Acute appendicitis is the most common nonobstetrical abdominal emergency requiring surgery during pregnancy. The incidence is one in 1,500 pregnancies and is evenly distributed throughout the trimesters. Perforation occurs in 10% of these cases and almost one-third of the removed appendices are normal pathologically. Fetal loss is reported in 1.5% of pregnancies with uncomplicated appendicitis, but the risk increases to 35% if rupture of the appendix has occurred [19]. The incidence of cholecystectomy is reported to be between three and eight per 10,000 pregnancies [14]. The incidence of spontaneous abortion is 5% with uncomplicated cholecystectomy but increases to 60% with associated pancreatitis [7]. The management of symptomatic gallstone disease during pregnancy is still controversial, although most agree that the initial treatment should be conservative [13]. If this proves unsuccessful with recurrent severe biliary colic, cholecystectomy should be performed. Surgery should also be considered for patients with acute severe cholecystitis rather early during the course, especially if the condition has not improved rapidly with conservative treatment or has deteriorated with medical management. Laparoscopy has added a new perspective to the diagnosis and treatment of a variety of abdominal and pelvic diseases. Owing to the success of laparoscopy in the nonpregnant patient, indications are now extending to the pregnant patient population as well. Once an absolute contraindication in pregnancy [11], laparoscopy has been safely used in the last several years for the treatment of abdominopelvic pathology during pregnancy. In the series of Mazze and Kallen it constituted the largest number of surgical procedures performed during the first trimester [20]. Laparoscopy is also helpful in defining the etiology of abdominal pain, therefore avoiding the delay in diagnosis [30]. The pregnant patient would benefit even more from the advantages of laparoscopic surgery—namely, easier postoperative ambulation, minimal postoperative pain, a lesser narcotic requirement, and an earlier ability to tolerate food in the postoperative course. Average hospital stay is shortened to less than 3 days in most patients. This is significantly shorter than the average hospitalization of 14 days for symptomatic gallstone disease during pregnancy reported earlier [8]. There are a total of 47 reported cases of laparoscopic procedures performed during pregnancy in the literature [1, 4–6, 9, 10, 12, 17–19, 21–23, 25–27, 29, 31–33]. Forty of these are cholecystectomies, six are appendectomies, and one is a laparoscopic ovarian cystectomy. The majority of the procedures were performed in the second trimester. Indications for cholecystectomy were biliary colic unresponsive to conservative treatment in 35 patients, progressive weight loss in two patients, acute cholecystitis in two patients and acute gallstone pancreatitis in one patient. Indications for appendectomy were right lower quadrant abdominal pain in all cases. The open technique (Hasson) was preferred for entry into the peritoneal cavity in 29 procedures, whereas the Veress needle was used in 18 cases. Four patients were in the first trimester, 39 patients were in second trimester, and three patients were in the third trimester.
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Cholangiograms were obtained in 13 of 40 cholecystectomies. Perioperative fetal monitoring was employed in 30 cases and tocolytic therapy was instituted in two patients prophylactically. No intra- or postoperative complications are described. Twenty-seven of 47 women were followed to term with delivery of healthy babies. One infant developed hyaline membrane disease shortly after birth. The remaining 20 women were reported to be continuing uncomplicated gestation. The enlarged uterus and the fetus are two points of concern during laparoscopy in a pregnant patient. The fundus of the uterus is at the pelvic brim by 12 weeks and reaches the umbilicus by the 20th week of gestation. Thus, there is a chance of injuring the uterus, the overlying enlarged uterine vessels, or the fetus during blind attempts of insufflation using the Veress needle, which has been previously reported [3]. This can potentially result in uterine insufflation and CO2 embolism. Others have recommended inserting the Veress needle through the seventh intercostal space on the left side [24] or using the umbilicus as the point of entry but aiming the needle toward the right upper quadrant to prevent uterine puncture. An alternative technique of abdominal wall lifting is also described [9]. Opening the abdominal wall in layers and inserting the blunt trocar under direct vision—therefore, the Hasson technique—should be the preferred method of entry. The gravid uterus can also interfere with the visualization and instrumentation during the procedure. Minimal manipulation of the uterus is essential. Pushing, pulling, or retracting the uterus should be avoided. Placement of trocars should be modified according to the height of the uterus. The periumbilical port has to be moved cranially after the 20th week. Preexisting high intraabdominal pressure due to the pregnant uterus and its contents may cause difficulty in insufflation and in achieving an adequate pneumoperitoneum in the advanced stages of pregnancy. The latest gestational age at which one can perform laparoscopy safely is uncertain. There may not be enough room in the upper abdomen to accommodate the instruments, and exposure of the lower abdomen and pelvis may be difficult in the late third trimester. Although initial reports had recommended that laparoscopy be performed during the second trimester only [21], laparoscopic cholecystectomy has been reported during the 25th, 28th, [10], and 31st weeks [23] of gestation. We also performed a laparoscopic appendectomy in the 32nd week of pregnancy. Each patient requires an individualized judgment by the operating surgeon as to the feasibility of laparoscopy. The potential untoward effects of intraperitoneal CO2 and high intraperitoneal pressures are another point of concern. The fetus absorbs CO2 from maternal blood and through the uterine circulation [15]. It is known that CO2 pneumoperitoneum causes an acute but mild hypercarbia and respiratory acidosis in the mother. Since the pH of the fetal blood parallels the mother’s pH, a slight acidosis is also detected in the fetus. Fortunately, the fetal acidosis is partially reversible with maternal hyperventilation. Despite the changes in the arterial CO2 and pH, the fetal PO2 changes only minimally. It has also been demonstrated that there is a significant lag time between development of maternal acidosis and increase in the end-tidal CO2 values [16]. Therefore, close hemodynamic monitoring of the mother
with capnography and preferably an arterial line is necessary. Considering the high pressures generated by the uterus at term, intraabdominal pressures up to 15 mmHg should not be harmful to the fetus. No significant hemodynamic effect of increased intraabdominal pressure is demonstrated in the pregnant ewe model if CO2 is replaced with N2O [16]. Fetal heart-tone monitoring should be an essential part of the procedure. The demonstration of fetal bradycardia or tachycardia should result in immediate exsufflation. Again, close communication with the obstetrician is necessary, especially in the late second and the third trimester of pregnancy in case of premature labor. The presence of an experienced obstetrics nurse in the operating room at the time of fetal monitoring would also be helpful. To minimize possible damage to the fetus during the organogenesis period, the first trimester should not be chosen for elective or semielective procedures. Similarly, abdominal operations and general anesthesia can cause premature labor in the third trimester. Thus, it would be safer to defer any elective procedure to the second trimester when the organogenesis is complete and the uterus is not big enough to impair the visual field. If the mother can be carried to term with conservative management, these risks will be eliminated. The indications for intraoperative cholangiography are not different from the nonpregnant patient—namely, an elevated serum bilirubin (1.5 mg/dl), a dilated common bile duct on the preoperative ultrasound (>8 mm), or gallstone pancreatitis. For the patients in whom laparoscopic cholecystectomy and laparoscopic appendectomy were performed, results from the literature and our patients show no spontaneous abortions despite the reported abortion rate of 5% with open cholecystectomy in the literature [7]. Conclusions Laparoscopy can be utilized in the pregnant patient for diagnosis and treatment of selective abdominal emergencies. The procedure has to be carefully planned and conducted by an experienced laparoscopic surgeon. Close monitoring of the mother and the fetus is essential. Modifications of the port placement and surgical technique are required to prevent injury to the gravid uterus and the fetus. Laparoscopy in the pregnant patient does not result in fetal loss. Laparoscopic procedures do not increase maternal morbidity and actually may decrease hospital stay and recovery time compared to open procedures.
References 1. Arvidsson D, Gerdin E (1991) Laparoscopic cholecytectomy in pregnancy. Surg Laparosc Endosc 1: 193–194 2. Balber EA (1908) Perforative appendicitis complicating pregnancy. JAMA 51: 1310–1313 3. Barnett MB, Lui DTY (1974) Complications of laparoscopy during early pregnancy. Br Med J 23: 328 4. Bennett TL, Estes N (1993) Laparoscopic cholecystectomy in the second trimester of pregnancy. J Reprod Med 38: 833–834 5. Camitalo JB, Lynch D (1994) Laparoscopic cholecystectomy in the pregnant patient. Surg Laparosc Endosc 4: 268–271 6. Constantino GN, Vincent GJ, Mukalian GG, Kliefoth WL (1994) Lap-
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7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
aroscopic cholecystectomy in pregnancy. J Laparendosc Surg 4: 161– 164 Dixon NP, Green J, Rogers A, Rubin L (1983) Fetal loss after cholecystectomy during pregnancy. Can Med Assoc J 88: 576–577 Dixon NP, Faddis DM, Silberman H (1987) Aggressive management of cholecystitus during pregnancy. Am J Surg 154: 292–294 Edelman DS (1994) Alternative laparoscopic technique for cholecystectomy during pregnancy. Surg Endosc 8: 794–796 Elerding SC (1993) Laparoscopic cholecystectomy in pregnancy. Am J Surg 165: 625–627 Gadacz TR, Talamini MA (1991) Traditional versus laparoscopic cholecystectomy. Am J Surg 161: 336–338 Hart RO, Tamadon A, Fitzgibbons RJ, Fleming A (1993) Open laparoscopic cholecystectomy during pregnancy. Surg Laparosc Endosc 3: 13–16 Hiatt JR, Hiatt JG, Williams RA, Klein SR (1986) Biliary disease in pregnancy: a strategy for surgical management. Am J Surg 151: 263– 265 Hill LM, Johnson CE, Lee RA (1975) Cholecystectomy in pregnancy. Obstet Gynecol 46: 291–293 Hunter JG (1992) 1991 Scientific session and postgraduate course: advances in laparoscopic general surgery. Surg Endosc 6: 47–56 Hunter JG, Swanstrom L, Thornburg K (1995) Carbon dioxide pneumoperitoneum induces fetal acidosis in a pregnant ewe model. Surg Endosc 9: 272–279 Iarfati MD, Yarnell R, Schwaitzberg SD (1995) Gasless laparoscopic cholecystectomy in pregnancy. J Laparendosc Surg 5: 127–130 Jackson SJ, Sigman HH (1993) Laparoscopic cholecystectomy in pregnancy. J Laparendosc Surg 3: 35–39 Kammerer WS (1979) Non-obstetric surgery during pregnancy. Med Clin North Am 63: 1157–1163 Mazze RI, Kallen B (1989) Reproductive outcome after anesthesia and operation during pregnancy. Am J Obstet Gynecol 161: 1178–1185
21. Morrell DG, Mullins JR, Harrison PB (1992) Laparoscopic cholecystectomy during pregnancy in symptomatic patients. Surgery 112: 856– 859 22. Nezhat F, Nezhat C (1991) Laparoscopic ovarian cystectomy during pregnancy. J Laparendosc Surg 1: 161–164 23. Pucci RO, Seed RW (1991) Case report of a laparoscopic cholecystectomy in the third trimesterof pregnancy. Am J Ostet Gynecol 165: 401–402 24. Reich H, Hunter JG (1992) Is it safe to perform laparoscopic appendectomy during pregnancy? Laparosc Focus 1: 11–12 25. Schorr RT (1993) Laparoscopic cholecystectomy and pregnancy. J Laparendosc Surg 3: 291–293 26. Schreiber JH (1990) Laparoscopic appendectomy in pregnancy. Surg Endosc 4: 100 27. Shaked G, Twena M, Charuzzi I (1994) Laparoscopic cholecystectomy for empyema of gallbladder during pregnancy. Surg Laparosc Endosc 4: 65–76 28. Smoleniec J, James D (1990) General surgical problems in pregnancy. Br J Surg 77: 1203–1204 29. Soper NJ, Hunter JG, Petrie RH (1992) Laparoscopic cholecystectomy during pregnancy. Surg Endosc 6: 115–117 30. Spirtos NM, Eienkop SM, Spirtos TW, Poliakin RI, Hibbard LT (1987) Laparoscopy—a diagnostic aid in cases of suspected appendicitis. Am J Obstet Gynecol 156: 90–94 31. Weber AM, Bloom GP, Allan TR, Curry SL (1991) Laparoscopic cholecystectomy during pregnancy. Obstet Gynecol 78: 958–959 32. Williams JK, Rosenmurgy AS, Albrink MH, Parsons MT, Stock S (1995) Laparoscopic cholecystectomy in pregnancy: a case report. J Reprod Med 40: 243–245 33. Wilson RB, McKenzie RJ, Fisher JW (1994) Laparoscopic cholecystectomy in pregnancy: two case reports. Aust NZ J Surg 64: 647–649
