The document discusses the use of laparoscopy in pregnancy, detailing its history, types, indications, advantages over open surgery, and safety considerations. It highlights guidelines for implementation, complications, risks associated with procedures, and presents case studies illustrating practical applications. Laparoscopy is emphasized as a minimal access approach that can be effectively performed during any trimester, with specific precautions to ensure maternal and fetal safety.

1. LAPAROSCOPY IN PREGNANCY
IAGE VARANASI, INDIA,
HOTEL TAJ GANGES,
17TH MARCH, 2024.
DR. NIRANJAN CHAVAN
Prof. & HOU,
LTMMC & GH, MUMBAI.

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
President, MOGS (2022-2023)
Joint Treasurer, FOGSI (2021-2025)
Organising Secretary, AICOG Mumbai 2025
Treasurer, AFG (2023-2024)
Member Oncology Committee, SAFOG (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
77 publications in International and National Journals with 189 Citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-
2022)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Member, Oncology Committee AOFOG (2013-2015)
Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Managing Committee IAGE (2013-17), (2018-20), (2022-2023)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery
(AMAS) at LTMGH (2018-19)
DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP,
DIPLOMA IN ENDOSCOPY (USA)

4. LET’S GO BACK TO HISTORY
• Georg Kelling of Germany, performed
the first laparoscopic procedure in dogs,
and, in 1910, Hans Christian
Jacobaeus of Sweden performed the first
laparoscopic operation in humans.

5. • In 1975, Tarasconi, from the Department of
Ob-Gyn of the University of Passo Fundo
Medical School (Brazil), started his
experience with organ resection by
laparoscopy (Salpingectomy).
• This laparoscopic surgical procedure was
the first laparoscopic organ resection
reported in medical literature.

6. • In 1981, Semm, from the gynecological
clinic of Kiel University, Germany,
established several standard procedures
that were regularly performed, such
as ovariancyst enucleation, myomectomy
, treatment of ectopic pregnancy, and
finally laparoscopic-assisted
vaginal hysterectomy (also termed
cervical intra-fascial Semm
hysterectomy).

7. PEEKING INTO THE
WOMB!
• It is a minimal access procedure allowing endoscopic access
to peritoneal cavity after insufflation of gas to create space
between the anterior abdominal wall & viscera for safe
manipulation of instruments & organs.
TYPES
• Intraperitoneal
• Extraperitoneal
• Abdominal wall retraction (gasless laparoscopy)
• Hand assisted (Hassans technique)

8. OBSTETRIC INDICATION
• Ectopic pregnancy
• Heterotopic pregnancy
• Excision of Rudimentary Horn

9. GYNECOLOGICAL
INDICATION
• Adnexal mass
• Ovarian tumor
• Torsion

10. ADVANTAGES
LAPAROSCOPY VS OPEN
• Small abdominal incision
• Rapid postoperative recovery and
• Early mobilization
• Decreased risk of thromboembolism associated with pregnancy.
• Smaller scars.
• Fewer incisional hernias.

11. •Early return of gastrointestinal activity due to less manipulation of the
bowel during surgery, which may result in fewer postoperative
adhesions and intestinal obstruction.
•Decreased rate of fetal depression due to decreased pain and less
narcotic use.
•Shorter hospitalization time and prompt return to regular life

12. SAFETY
• A retrospective study performed by Swedish health registries on the
safety of laparoscopy during pregnancy compared the outcome of 2181
laparoscopies performed on pregnant patients before 20 weeks of
gestation with the outcome of 1522 laparotomies performed in a similar
population.
• The conclusion was that there were no significant differences in any
measured outcome between the two groups:
• Intrauterine growth restriction,
• Congenital malformations,
• Stillbirths, or neonatal deaths.
• No adverse long-term effects have been reported.

13. TIMING
• There is no absolute maximum gestational age for
performing laparoscopy, the operation can be
performed in any trimester.
• The optimal time to operate is the early second
trimester.
• Laparoscopy during the last trimester can be difficult
to perform due to the enlarged uterus which can
interfere with adequate visualization.

14. THROMBOPROPHYLAXIS
• In Laparoscopic procedure the duration of the
intervention is longer.
• The use of pneumoperitoneum contributes to venous
stasis and, possibly, thrombosis.
• Society of American Gastrointestinal and Endoscopic
Surgeons (SAGE in 2008), recommended placing
pneumatic compression devices on the lower limbs of
pregnant women undergoing laparoscopic procedures
for surgical problems.

15. PROPHYLACTIC
TOCOLYSIS
• There is no evidence to support the use of prophylactic
tocolytics or glucocorticoids.
• These drugs may be indicated in the management of
threatened preterm delivery in patients who are
presenting premature contractions.
• The use of monopolar electrocautery must be avoided
to minimize uterine contractility.

16. PREMEDICATION
1. NBM
2. NO ENEMA
3. Antibiotics
4. Written informed consent for SOS laparotomy
6. Anxiolytics/ Antiemetic/ H2 receptor antagonist/analgesic
7. DVT prophylaxis
Above all Informed Consent and explaining the
Complications

17. PATIENT POSITION
• Depending on the operation that is to be performed, the patient is placed in the
• Low lithotomy position with a leftward tilt (after 16 weeks of gestation) to avoid
significant compression of the gross abdominal vessels.

18. GUIDELINES FOR LAPAROSCOPY
American Gastrointestinal and Endoscopic Surgeons,
published in 2011, makes the following recommendation:
• Nasogastric intubation is a must in all cases as there is a
high risk of aspiration into the lungs.
• Patient Positioning: dorsal lithotomy position in the first
half of pregnancy, but in the second half lateral
recumbent position.
• Hypotension should be avoided; proper fluid
replacement should be done.
• Open Hasson trocar method

19. GUIDELINES FOR LAPAROSCOPY
• Pneumoperitoneum: Lower CO2 insufflation
pressure of < 12 mm Hg should be used to avoid
fetal acidosis.
• Trocars: VersaStep trocars or other non-bladed
trocars should be used under direct visualization.
• Instrument size: Laparoscopes as small as 3mm are
recommended.
• Bowel Retractor Fan: The upgraded 5-mm bowel
retractor fan has become indispensable in the larger
uterus.

20. • Laparoscopic Ports in Pregnancy: If the
uterus is <18 weeks, the initial trocar
placement is in the umbilicus, not infra-
umbilical. CO2 pneumoperitoneum is
obtained with the open placement of the
laparoscopic trocar that ranges from a 10-
mm to 3-mm diagnostic laparoscope.
• In pregnancies associated with a uterine size
≥18 weeks, the initial trocar is placed above
the navel with the lateral ports being placed
under direct visualization.

21. • Electrocautery should be used with care; the
smoke containing carbon monoxide should be
evacuated promptly to avoid toxic effects on the
fetus.
• All specimens should be removed with endobag
to avoid spillage.
• Tocolysis is indicated if signs of uterine
irritability are present.
• Venous Thromboembolic (VTE) Prophylaxis:
intermittent pneumatic compression devices or
intermittent electric calf stimulators should be
used to prevent stasis due to decreased venous
return.

22. 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.
• If fetal monitoring is necessary during the procedure,
transabdominal fetal monitoring may be possible
through the left abdominal wall.
• 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.

23. POST-OPERATIVE CARE
• A CTG (non-stress test) should be done in the
recovery room if the gestational age is
appropriate.
• Opioids, pain killers, and antiemetics can be
used to control pain and nausea.
• NSAID should be avoided, especially after 32
weeks of gestation.

24. COMPLICATIONS AND
RISKS
• Laparoscopy is not a risk–free
procedure.
• The risk of spontaneous abortion
is high, especially in the first
trimester.
• The risk correlated to anesthesia,
is directly proportional to the
duration of the intervention.

25. COMPLICATIONS
Intraoperative
Pneumoperitoneum
Gas
Extravasation
Positioning Nerve injury
Endobronchial intubation
Thermal injuries
s/c emphysema
Pneumothorax
pneumomediastinum
Hycercarbia
Gas embolism
Arrythmias
Hyper/hypotension

26. Postoperative
Pain
PONV
1. Visceral
2. Parietal – Port site infiltration
3. Shoulder tip- d/t residual co2 and HCO3
-
T/T-Complete CO2 de-sufflation
-Rt subdiaphragmatic LA infiltration
-NSAIDS / opioids,
COMPLICATIONS
Cause- CO2 insufflation
Bowel manipulation
Treatment -Propofol induction, hydration
NG tube
Ondansetron
Peri-operative O2 supplementation
Low dose dexamethasone

27. RISKS RELATED EXCLUSIVELY TO THE
LAPAROSCOPIC INTERVENTION
• Risk of penetration of the uterus by the Veress needle or the trocar
• Bleeding
• Uterine rupture
• Loss of amniotic fluid
• Direct fetal damage
• Creation of a pneumo-amnion
• Consequent spontaneous rupture of the membranes
• Fetal distress and
• Stillbirth

28. RISKS RELATED TO THE
PNEUMOPERITONEUM AND THE
INSUFFLATION OF CO2
• The increased intraabdominal pressure determines important alterations of
the materno-fetal hemodynamics.
• The reduction of the blood flow in the vena cava and the limitation of the
maternal diaphragm excursion can compromise uteroplacental perfusion.
• The greatest risk seems to be maternal acidosis, caused by CO2, and
consequent fetal hypoxia.

29. RISKS RELATED TO THE
ELECTROSURGERY
• Harmful potential of the gas developed in the abdomen because of the
use of laser and bipolar electrocautery during the laparoscopic procedures
seen.
• Increase in the levels of fetal carboxyhemoglobin in the peripheral blood
• Increase of the maternal intrabdominal concentration of CO2
• RECOMMENDATION: to minimize the harmful potential of the gases freed
in the peritoneal cavity through a suitable elimination of the CO by
ventilation at high concentrations of oxygen.

30. CASE 1
• 25 year, G4P3L3 patient was referred from
peripheral hospital i/v/o pain in abdomen
with 4 months of amenorrhea
• O/E-
• P/A- Soft, 28-30 weeks soft cystic mass
arising from pelvis, non-tender, freely
mobile
• P/V- findings confirmed.
• Uterus felt separate from the mass, 14-16
weeks size

31. INVESTIGATIONS
• USG - 13 x 8 x 6 cm left sided ovarian
Cystadenoma
• MRI- Benign 13 x 8x 6 cm left ovarian
Cystadenoma
• Ca-125- WNL

32. SURGERY
• Laparoscopic Cystectomy
• Ovarian cyst fluid aspiration done
• Around 300cc serous fluid was aspirated
• Patient withstood procedure well
• Immediate Post-op USG for FHS.

33. PERINATAL OUTCOME
• Patient had regular ANC visits
• Put on progesterone support
• And delivered full term 2.8 kg female child
normally

35. • 30 years old, married since 1 year, came with complaints of amenorrhea since 2
months, acute lower abdominal pain, and P/V spotting since 2 days.
• Urine Pregnancy Test: Positive
• Beta hCG: 5300mIU/ml
• On examination:
General condition fair
Pulse: 78/min
Blood Pressure: 120/80 mmHg
No pallor
CASE 2

36. • Per abdomen: Soft, no guarding, rigidity,
Minimal tenderness present
• Per Vaginal: Uterusnormal size
Right adnexal fullness present
Right forniceal tenderness
Cervical movement tenderness present
Left fornix non tender
Minimal spotting present

37. • Transvaginal Ultrasonography:
Uterus normal size
No intrauterine G-sac.
G-sac like structure noted in right adnexa, measuring
5*3cm. Right ovary not seen separately.
Showing ring of fire appearance on color Doppler.
Echogenic pulsating structure noted within G-sac.
No free fluid in pouch of douglas.

38. • Management:
Laparoscopic salphingostomy or salphingectomy.

40. • The greatest

41. THANK YOU!