1. LAPAROSCOPY IN
PREGNANCY
Dr. Maya Menon
Prof and HOD,
Dept. Of Obstetrics and Gynecology
ESIC medical College and hospital,
KK Nagar, Chennai
2. STATISTICS
• Non obstetric abdominal surgeries during pregnancy – 0.5 - 2%
• Appendicectomy in pregnancy – 6.5%
• Cholecystectomy in pregnancy – 2.7%
• Symptomatic benign adnexal tumors (>5cm) managed during pregnancy – 0.05%
• BSGE + RCOG based guidelines framed for laparoscopy in pregnancy
• Pregnancy should not be a reason to delay urgent surgery.
Ref- RCOG. Royal College of Obstetricians and Gynaecologists, British Society of Gynaecological Endoscopy. Management
of Suspected Ovarian Masses in Premenopausal Women. Green-top Guideline No 62. London: RCOG; 2011.
3. PHYSIOLOGICAL CHANGES IN PREGNANCY
• GIT – Anatomical alterations, hence alteration in the location of abdominal
pain in conditions like appendicitis
Poor LES tone in pregnancy
• CVS and HEMATOLOGICAL CHANGES – Increased CO and blood volume,
physiological anemia of pregnancy, supine hypotension
syndrome, increased WBC count, hypercoagulable state of pregnancy
• RS – Decreased residual volume, increased minute ventilation and oxygen
consumption, edema hence difficulty in airway management
• Urinary system – Hydroureter, Increased risk of UTI
4.
5. EFFECTS OF PNEUMOPERITONEUM IN
PREGNANCY
• Pneumoperitoneum during laparoscopy increases intra
abdominal pressure decreases venous return and decreases
cardiac output
• Reverse Trendelenberg's position - cardiac index decreases
6. TECHNICAL CONSIDERATIONS IN LAP
BEYOND 20 WEEKS OF PREGNANCY
• Expertise in the technique-decision between open/lap should depend upon the
expertise, infrastructure, background history, gestation and women's preference
• Lack of expertise – open surgery is better to avoid maternal and fetal complications
• Appropriate neonatal facilities in the unit where laparoscopy is performed
• Multidisciplinary approach (obstetricians, surgeons, neonatologists and
anesthetists)
7. • In pregnancy beyond 20 weeks chances of Veress needle
and trocar perforation injuries are more
• Any surgery in pregnancy is associated with maternal and fetal
risks. Non-urgent surgery should be postponed until after
pregnancy.
• SAFE IN FIRST ,SECOND AND EARLY THIRD TRIMESTER
(UPTO 31 WEEKS) OF PREGNANCY
8. LAP vs OPEN SURGERY
• Both laparoscopic and open routes are acceptable, depending
on circumstances since maternal and fetal outcomes are equally
acceptable.
• Lack of expertise – open surgery is better to avoid maternal and
fetal complications
9. ANESTHETIC CONCERNS
• Risk of aspiration pneumonitis beyond 16 weeks of pregnancy - delayed gastric
emptying , reduced lower esophageal sphincter tone and increased pressure from
the gravid uterus
• GA preferred and ET intubation , LMA not recommended
• Antacid prophylaxis
• Elective nasogastric tube insertion
• Experienced obstetric anesthetist
10. • Modern anesthetic agents, muscle relaxants and opioids are non –
teratogenic when used in therapeutic doses
• Avoid maternal hypotension
• End tidal CO2 levels to monitor maternal CO2 levels
(ETCO2 -surrogate marker for arterial CO2)
11. PRE REQUISITES
• POSITIONING - Left lateral tilt while manoeuvering into the Trendelenberg or reverse
Trendelenberg's position
• INSTRUMENTS
30 degree laparoscope
Bipolar electrocautery to be used to minimize "stray " current going through the
fetus
Standard specimen endoscopy retrieval bag
12. PRE REQUISITES
• INTRA ABDOMINAL PRESSURE CHECK 12 – 15 mm of Hg depending on the visual access
• FHR before and after the surgery, impossible during the surgery due to
pneumoperitoneum
• TOCOLYSIS - No routine tocolysis required. If anticipated preterm labor due to acute
infections – Tocolysis + AN corticosteroids + Mg SO4 for neuroprotection
Anti-D administration is not deemed necessary according to guidelines since
laparoscopic surgery is not included in the list of potentially sensitizing events.
13. TOP TIPS
1.Ensure that an experienced surgeon and anesthetist are present
2. Give antacid prophylaxis
3. Consider nasogastric tube insertion
4. Apply a left lateral tile to avoid aortocaval compression
5. Perform any change of position slowly
14. 6. Consider using Hasson’s entry (supra-umbilical incision)
7. Consider Palmer’s point entry
8.NO TOUCH approach (do not touch the uterus )
9. Consider the use of ultrasound to facilitate entry
10. Use operating pressures of 10–12 mmHg
11. Auscultate the fetal heart prior to and after surgery
15. PORTS
• The location of the primary port will depend on the level of the uterine fundus.
• The uterine size should be determined by palpation or ultrasound. In very obese women
transabdominal ultrasound and obstetric guidance may be required.
• Clinicians should choose their primary port location including umbilical, supra-umbilical /
sub-xiphoid and Palmers’ point (left upper quadrant in the mid- clavicular line) according
to uterine size, location of pathology and operator experience
• In the late second and early third trimester primary port sites could include 1-2cm below
costal margin in the left (Palmers’ point) or right mid-clavicular line or 3-6 cm above the
umbilicus in the midline
Ref- RCOG. Royal College of Obstetricians and Gynaecologists. Preventing Entry-related Gynaecological Laparoscopic Injuries. Green-
top Guideline No 49. London: RCOG; 2008.
16. • Secondary port placement will be dictated by uterine size,
pathology and operative approach.
• There are limited degrees of freedom in laparoscopic surgery and
the added obstacle due to the size of the pregnant uterus.
• Ipsilateral port placement may circumvent this obstacle.
Ref-RCOG. Royal College of Obstetricians and Gynaecologists. Preventing Entry-related
Gynaecological Laparoscopic Injuries. Green-top Guideline No 49. London: RCOG; 2008.
17.
18. LAPAROSCOPIC TECHNIQUES IN PREGNANCY
BEYOND 20 WEEKS
HASSON’S TECHNIQUE
• The benefits of the Hasson technique may include reducing the risk of uterine trauma and
spillage of contents of ovarian cysts.
• Blunt ended trocar under direct vision
• Horizontal 10mm incision at the umbilicus
• Langenbeck retractor to facilitate access to deeper layers of the anterior abdominal wall
• Umbilical stalk exposed and linea alba incised
• Peritoneum opened under direct vision
• Ensure no adherent bowel loops
• Pneumoperitoneum created – initially 20 mm of Hg later 12 mm HG maintained and 360
degree check performed
Ball E, Waters N, Cooper N, Talati C, Mallick R, Rabas S, et al. Evidence-based guideline on laparoscopy in pregnancy: commissioned
by the British Society for Gynaecological Endoscopy (BSGE), endorsed by the Royal College of Obstetricians and Gynaecologists
(RCOG). Facts Views Vis ObGyn 2019;11:5–25.
24. PALMER'S ENTRY
• Clinical examination to rule out splenomegaly
• NG tube aspiration of gastric contents and stomach decompressed
• Small incision in the left MCL , 2-3 cm below the costal margin and Veress
needle inserted perpendicularly
• Palmer's and pressure profile tests to ensure intraperitoneal placement
• Pneumoperitoneum 20 mm Hg initially followed by 12 mm Hg to
be maintained
• Incision is increased to 5-10mm to allow trocar insertion
Ball E, Waters N, Cooper N, Talati C, Mallick R, Rabas S, et al. Evidence-based guideline on laparoscopy in pregnancy:
commissioned by the British Society for Gynaecological Endoscopy (BSGE), endorsed by the Royal College of Obstetricians and
Gynaecologists (RCOG). Facts Views Vis ObGyn 2019;11:5–25.
27. APPENDICITIS DURING PREGNANCY
• Incidence lower than in non-pregnant state
• Anatomical shift of the appendix can mislead the clinician
• Generalized peritonitis, maternal sepsis ,SIRS, miscarriage, preterm labor and still
birth
• Compared to open appendicectomy no increased maternal or fetal complications-
Lap / open appendicectomy depending on the expertise
• Timely surgical intervention is important in order avoid the risk of perforation and
subsequent sepsis.
28. Pregnant women who had conservative treatment for appendicitis had a
higher incidence of preterm labor and miscarriages than pregnant
women who did not have appendicitis.
First lap appendicectomy in pregnancy – Scheiber in 1990
29. GALL BLADDER DISEASE (Symptomatic
gallstones and acute cholecystitis)
• Gall bladder symptoms are exaggerated in pregnancy due to pregnancy
related gall bladder sludge
• A conservative approach to gallbladder disease (symptomatic gallstones and
acute cholecystitis) in pregnancy is associated with higher maternal
morbidity than surgery.
• Clinicians should be vigilant about complications of gallbladder disease such
as gallstone pancreatitis, since this may be associated with a high risk of fetal
mortality.
• In pregnant women with biliary colic, supportive care will lead to resolution
of symptoms in most cases. Complicated gallstone disease requires a more
proactive approach.
30. OVARIAN CYSTS AND MASSES
• Most common ovarian tumor during pregnancy - DERMOID CYST
• Women with asymptomatic simple cysts may be managed conservatively in
pregnancy provided that symptoms are absent or acceptable to the woman.
• Women with large, non-twisted symptomatic cysts who wish to avoid surgery may
be offered aspiration under ultrasound guidance during pregnancy, with definitive
cystectomy after delivery if required.
• The risk of torsion of ovarian cysts requiring emergency surgery in pregnancy is low
and in most cases, surgery may be delayed until the woman becomes symptomatic,
with good fetal outcomes.
31. • Cyst aspiration with or without concurrent cystectomy may be a safe
alternative.
• The incidence of adnexal mass in pregnancy is 2% and currently,
conservative treatment is usually advised for cystic lesions <6 cm in size
• Surgery is warranted is cases of suspected adnexal torsion in pregnancy
because infarction increases the risk of miscarriage, preterm labor,
peritonitis and death
32. ADVANTAGES OVER OPEN SURGERIES
•Faster recovery
•Shorter hospital stay
•Lower rate of wound infection in pregnant women.
33. COMPLICATIONS
• Uterine perforation
• Infections
• Still birth, miscarriages
• Lacerations to the fetus and the placenta
• Preterm labor due to uterine manipulations
• CO2 toxicity in the mother and fetus
• Respiratory compromise
• Uterine rupture in the future
34. COMPLICATIONS
• Increased risk of vascular and organ trauma
• Hemorrhage and herniation at the port site
• The risk of hernia formation is 1-2% in incisions greater than 10 mm,
therefore the fascia should be closed.
• Increased risk of bleeding due to increased vascularity of the uterus
• Risk of venous thrombo-embolism and hence thromboprophylaxis as per
RCOG GTG
• Fetal complications – Risks related to anesthetic agents (almost nil ) / risks
related to reduced uteroplacental blood flow
35. POST OPERATIVE CARE
• Antibiotics should be used if there is an infective process. The choice of
antibiotic should be based upon local anti-microbial guidance and drug
safety in pregnancy.
• In the case of elective surgery for adnexal masses, antibiotics would
not be routinely required.
• Good analgesia, adequate rehydration to maintain euvolemia and
measures to prevent postoperative nausea and vomiting should be
integrated into maternal postoperative care.
36. TAKE HOME MESSAGE
• Laparoscopic procedures can be carried out in first, second till early third trimester
• Hasson’s technique for port entry is safe
• No touch technique while operating
• Pregnancy should not be a hinderance for laparoscopic procedures in acute
abdominal emergencies
• Expertise and multimodality approach
• Consider physiological alterations in pregnancy and pneumoperitoneum related
changes.
• Informed consent explaining the risks for mother and baby
