Laparoscopic Surgery in Pregnancy: Precautions and Complications

INTRODUCTION
Since the advent of laparoscopic surgery in the 1980s,
laparoscopic surgery has been popularized by surgeons
throughouttheworld.However,routinelaparoscopicsurgery
has been slow to catch the pregnant patient. Treatment of
surgical disease in the gravid patient requires a unique and
careful approach where safety of both the mother and the
fetus are considered.
During pregnancy, due to the physiological changes
that take place in the mother and considering the presence
of a living fetus in utero, surgical conditions are handled
with a lot of care and cautions. In past, pregnancy was
considered to be absolutely contraindicated for laparoscopic
intervention, but with better understanding of physiology
of pregnancy and improved anesthetic and laparoscopic
techniques, emergency laparoscopic procedures such as
diagnostic laparoscopy for pain abdomen, appendicectomy,
splenectomy, pheochromocytoma, and cholecystectomy are
feasible in pregnancy. Lachman et al. have already reported
300 laparoscopic procedures during pregnancy.
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 intra-abdominal pressure during pneumo-
peritoneum could decrease uteroplacental 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. Appendicitis, gallbladder disease,
mesenteric cysts, and adnexal masses/torsion have been
successfully managed laparoscopically during pregnancy.
More advanced laparoscopic procedures, such as radical
Fig. 1: Anatomical changes inside abdominal
cavity during pregnancy.
Laparoscopic Surgery in
Pregnancy: Precautions
and Complications
nephrectomy, splenectomy, adrenalectomy, retroperitoneal
lymphadenectomy, and ventral hernia repair, have also been
reported in gravid patients.
The responsibility of caring for two patients during
one operation and the concern over potential harm to
the unborn fetus due to the pneumoperitoneum and/or
instrumentation are factors that have played a role in the
delay of adapting laparoscopic surgery to the pregnant
patient (Fig. 1). However, recent evidence suggests that not
only is laparoscopic surgery safe in the pregnant patient in
all three trimesters, but it is also often preferable.
During pregnancy, usually all surgical procedures
are avoided to minimize various risks of anesthesia and
Prof. Dr. R. K. Mishra

418 SECTION 3: Laparoscopic Gynecological Procedures
Fig. 2: Proper evaluation of patient is necessary to evaluate
pathophysiological changes.
procedure to mother and fetus. At times, emergency surgical
conditions make it absolutely necessary for intervention.
Withincreasingprogressinminimalaccesssurgerymoreand
more surgeons have found the skill and interest to perform
the emergency procedures laparoscopically. Laparoscopy
was first done in pregnancy for diagnosis and evaluation.
The first laparoscopic appendicectomy in pregnancy was
performed by Scheiber in 1990. The first laparoscopic
cholecystectomy in laparoscopy was first done in pregnancy
for diagnosis and evaluation of acute abdominal pain in
1980.
However, surgical intervention in pregnant ladies
needs special consideration of well-being of both mother
and fetus; if intrauterine viable fetus is present, and in
cases of ectopic pregnancy or heterotrophic pregnancy,
the pathophysiological changes brought about during
pregnancy should be considered for the safety of patient
(Fig. 2). Furthermore, with advancement of pregnancy
laparoscopic diagnosis and procedures become more
challengingly difficult as the gravid uterus displaces the
organs and becomes completely an abdominal organ.
Up-to-date the data on laparoscopic procedures during
pregnancy are still limited, but with growing ability of
minimal access surgeons, the recent accumulating data
shows that laparoscopic procedures such as diagnostic
laparoscopy, adnexal surgery, appendicectomy, splen-
ectomy, cholecystectomy, and management of ectopic and
heterotrophic pregnancies are relatively safe and effective
during pregnancy, if certain precautions are taken. But of
course like all surgical procedures in pregnancy, there is an
increased risk of certain complications with laparoscopic
intervention in pregnancy.
PHYSIOLOGICAL CHANGES IN PREGNANCY
Almost all the organ systems undergo physiological changes
in pregnancy. These changes should be considered during
operative procedures in pregnancy.
Gastrointestinal System
Due to enlarged gravid uterus, stomach is pushed toward
diaphragm and assumes a more horizontal position. The
viscera,suchastransverse,ascending,anddescendingcolon,
are displaced, so location of abdominal pain and tenderness,
especially in condition such as appendicitis, is altered. The
hormonally-induced decrease lower esophageal sphincter
tone causes gastroesophageal regurgitation which places the
pregnant lady at higher risk of aspiration, so nasogastric tube
suction and careful airway management is necessary for all
pregnant patients undergoing laparoscopy.
Cardiovascular and Hematological Changes
Cardiac output and blood volume increase by 30–40%, but
as RBC volume does not expand by same ratio, this results
in physiological anemia, especially noticed in the second
trimester. After 20 weeks’ gestation, the gravid uterus
compresses the aorta and inferior vena cava and may cause
supine hypotension syndrome; so during surgery, the
patient should be positioned in lateral recumbent position to
avoid vena caval compression. A vasomotor block caused by
spinal anesthesia produces more severe hypotension than
in nonpregnant individuals. During pregnancy, WBC count
increases to 12,000–14,900/mm.
A hypercoagulable state is physiologically developed
in pregnancy due to increase in fibrinogen and other
coagulation factors such as factor VII, factor VIII, factor IX,
and factor X. Thus, the risk of thromboembolism increases
in pregnancy.
Respiratory System
Due to enlarging gravid uterus, gradually the chest
movements are restricted. There is an increase in minute
ventilation and oxygen consumption and decrease in
residual volume, also mixed venous oxygen content
and functional reserve capacity also decreases so the
patient is prone to hypoxemia and hypocapnia. PaCO2 of
28–32 mm Hg, pH of 7.44, and decreased bicarbonate levels
are detected due to chronic respiratory alkalosis which has
to be maintained during pregnancy. The patient gains more
weight during pregnancy and there is more edema in soft
tissues of neck, so the anesthetist may face more difficulties
in airway management.
Urinary System
Hydroureter, decreased urethral peristalsis, and bladder
expansion increase incidence of urinary tract infection.
There is an increased retention of water and electrolytes.

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CHAPTER 32: Laparoscopic Surgery in Pregnancy: Precautions and Complications
Other Changes
In addition to the respiratory changes, there are mild
hematologic abnormalities in the pregnant patient. Levels of
fibrinogen, factor VII, and factor XII are increased, whereas
there are decreased levels of antithrombin III, all of which
result in an increased risk of venous thromboembolism.
When considering the acute abdomen in a pregnant
patient, making the correct diagnosis may often be difficult.
Nausea and vomiting, leukocytosis, low-grade fever, mild
hypotension, and anorexia are common. The gravid uterus
pushes the abdominal contents cephalad, displacing organs
andinhibitingthemigrationoftheomentum,causingaltered
landmarks and often distorting the clinical picture. During
the second and third trimesters, the gravid uterus may cause
decreased gastric motility and may lead to an increased risk
of gastroesophageal reflux disease (GERD) and aspiration as
well.
FETAL CONSIDERATION
Fetus is a hidden patient in the womb of the pregnant
mother and its health should be considered by surgeon and
anesthetist both. It is important to:

■ Maintain uteroplacental blood flow and oxygenation.
Decreased uteroplacental blood flow may be due to
maternal hypotension or increase in uterine artery
resistance.

■ Maternal hypoxia causes fetal hypoxia and metabolic
acidosis and in long-term; it may be fatal to infant, so it
should be prevented.

■ Avoid teratogenic drugs during anesthesia. Cocaine is
known to have teratogenic effect so products containing
cocaine should be avoided. Diazepam and nitrous oxide
areconsideredsafeduringanesthesiaasnoteratogenicity
was detected clinically.

■ Avoid preterm labor. Try to manipulate uterus minimum
as possible. Although, there is an increased incidence of
spontaneous abortion, premature delivery, and low birth
weight following anesthesia but in emergency situations
operation is unavoidable.
EFFECTS OF PNEUMOPERITONEUM IN
PREGNANCY DURING LAPAROSCOPIC
PROCEDURE
In pregnant patient, the pneumoperitoneum increases
the intra-abdominal pressure and this causes decreased
inferior vena caval return to the heart, hence decreased
cardiac output. With reverse Trendelenburg position,
decreased cardiac output is even worsened, cardiac index
decreases, and when this is combined with mothers hypoxia
can cause fetal death. Increased intra-abdominal pressure
also leads to decreased uterine blood flow and increased
intrauterine pressure; these may, in turn cause fetal
hypoxia and may lead to fetal death. Pneumoperitoneum
decreases the diaphragmatic movement; in pregnant lady,
already the movement of diaphragm is decreased due to
bulky uterus, this further decreases the movement due
to pneumoperitoneum causing increased peak airway
pressure, decreased functional reserve capacity, increased
ventilation–perfusion mismatch, decreased thoracic cavity
compliance, and increased pleural pressure.
The use of CO2 for causing pneumoperitoneum leads
to hypercarbia and further hypoxemia. The CO2 absorbs
across the peritoneum and leads to respiratory acidosis in
the patient and her fetus. If pCO2 increases above 40 mm Hg,
decreased removal of CO2 occurs leading to fetal acidosis.
Fetal tachycardia and hypotension may develop as a result
of fetal hypocarbia. This can be corrected by maintaining
mild maternal respiratory alkalosis, by hyperventilating the
mother during surgery. Monitoring maternal arterial blood
gases is better than monitoring PaCO2 during laparoscopic
procedures.
N2O as the gas for pneumo-peritonization will not cause
fetal respiratory acidosis, but it is highly combustible.
CRITERIA FOR PATIENT SELECTION
A safe laparoscopic procedure can be performed in all the
three trimesters of pregnancy from 2 to 31 weeks.
During the first trimester, there is increase risk of
abortion up to 12% also risk of teratogenesis increases in first
trimester. In the third trimester, there is a 40% risk of preterm
labor and 30% risk of premature birth. Also the visualization
in laparoscopic procedure is decreased due to enlarged
uterus.
Therefore, second trimester is considered as the safest
time for laparoscopic surgery in pregnancy. The risk of
abortion is not increased, no risk of teratogenesis, and risk of
preterm labor is only 5% in second trimester.
ADVANTAGES OF LAPAROSCOPY IN
PREGNANCY

■ Short hospital stay

■ Early return to normal activities

■ Small incision, so rapid postoperative recovery and less
incision complications such as hernia, postoperative
wound infection and pain

■ Less uterine manipulation and hence decreased uterine
irritability and fetal loss
Risks of Laparoscopy in Pregnancy

■ More chance of uterine injury during port entry as uterus
becomes an abdominal organ after first trimester (Fig. 3)

■ Problems associated with pneumo-peritonization as
discussed already

Fig. 3: Injury of pregnant uterus.
SAGES (Society of American Gastrointestinal
Endoscopic Surgery) Recommendations

■ Obstetrical consultation should be obtained pre-
operatively.

■ Whenpossible,operativeinterventionshouldbedeferred
until the second trimester, when fetal risk is lowest.

■ Pneumoperitoneum enhances lower extremity venous
stasis already present in the gravid patient and pregnancy
induces a hypercoagulable state. Therefore, pneumatic
compression devices should be utilized whenever
possible.

■ Fetal and uterine status, as maternal end tidal CO2 and/
or arterial blood gases, should be monitored.

■ The uterus should be protected with a lead shield if
intraoperative cholangiography is a possibility.

■ Fluoroscopy should be utilized selectively.

■ Given the enlarged gravid uterus, abdominal access
should be attained using an open technique.

■ Dependent positioning should be utilized to shift the
uterus away from the inferior vena cava.

■ Pneumoperitoneum pressures should be kept at
10 mm Hg.

■ Further studies into methods that increase the safety of
laparoscopy in pregnant patient should be done.
DISCUSSION
Advances in laparoscopic surgery have led to development
of methods to perform abdominal surgery and reduce
morbidity using minimal access surgery techniques. In 1999,
Lachman et al. reported on a series of pregnant women
undergoing 518 surgical procedures. Cholecystectomy
(45%) is the most common procedures performed
during pregnancy followed by adnexal surgery (34%) and
appendicectomy (15%).
Operative procedures are postponed in pregnant patient
until after delivery, but in acute emergency conditions even
if the patient is pregnant, operation should be performed.
According to the recent studies done, the second
trimester is ideal for laparoscopic intervention.
Most cases reported and small series indicate that
laparoscopy can be safely performed during pregnancy. The
incidence of prematurity and intrauterine growth restriction
was reported to be higher in the open surgical group too.
Two recent studies suggest that there is no difference
in fetal outcome for patient with singleton pregnancies
undergoing laparoscopy or laparotomy. In one study, the
resultant children born after laparoscopic surgery was
performed on their mother during their intrauterine life,
were monitored and no evidence of developmental or
physical abnormality was detected during the study period.
Despite the growing clinical experience suggesting that
laparoscopy is as safe as laparotomy in pregnancy, more
long-term clinical studies are required.

■ CO2 absorption causes increased CO2 pressure and
decreased arterial pH

■ Risk of exposure to intra-abdominal smoke including
carbon monoxide generated by electrosurgery and laser
Strategies for Safe Laparoscopic
Surgery in Pregnancy

■ Surgery should be done in second trimester.

■ If patient presents in late third trimester, surgery should
be postponed if possible until after delivery.

■ Nasogastric incubation is a must in all cases, as there is a
high risk of aspiration into the lungs.

■ Patient can be placed in dorsal lithotomy position in
the first-half of pregnancy, but in second-half to prevent
inferior vena cava compression patient is ideally placed
in lateral recumbent position.

■ Hypotensionshouldbeavoided;properfluidreplacement
should be done.

■ Ideal method for commencing pneumoperitoneum
is open Hasson trocar method. Placement of trocar
depends on the size of gravid uterus.

■ Tocolysis is indicated if signs of uterine irritability are
present.

■ Decrease operation time by using adequate number of
ports, and using the most experienced surgeons.

■ Maternal hyperventilation to maintain end-tidal CO2
pressure at 32 mm Hg

■ Lower CO2 insufflations pressure of <12 mm Hg should
be used to avoid fetal acidosis.

■ Electrocautery should be used with care; the smokes
containing carbon monoxide should be evacuated
promptly to avoid toxic effect to fetus.

■ Entry of all instruments must be under direct vision; care
should be taken to avoid injury to the gravid uterus.

■ All specimens should be removed with endobag to avoid
spillage.

■ Manipulators should never be fixed to vagina or cervix.

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CHAPTER 32: Laparoscopic Surgery in Pregnancy: Precautions and Complications
CONCLUSION
A laparoscopic access to pathology in pregnancy has
many benefits for the patient, but it is important that the
surgeon and anesthetist both have an immense knowledge
of maternal fetal physiology. An experienced surgeon can
continue to perform laparoscopy safely in all trimesters
by without significant increases in either maternal or fetal
morbidity or mortality. Further controlled clinical studies are
needed to clarify many other unknown issues, and revision
may be necessary as new data appear.
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