Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy

General Surgery During Pregnancy and Gynecologic Emergencies

Nonobstetrical surgical emergencies can occur throughout pregnancy but are often difficult to diagnose due to the physiologic and anatomical changes that occur during pregnancy. Medical providers should have insight into these changes and be familiar with options for the diagnosis and management of common nonobstetrical surgical emergencies, such as appendicitis, cholecystitis, and small bowel obstruction. Surgeons should also be aware of obstetrical emergencies, such as ectopic pregnancy and severe vaginal bleeding, which may be life threatening to mother and the fetus. Intraoperatively, surgeons should be familiar with minimally invasive approaches for surgical diseases and special anesthetic considerations for pregnant patients.

Laparoscopy in Pregnancy: A Comparative Review of National Guidelines

Gynecological and general surgical conditions requiring surgical management during pregnancy constitute a medical challenge, which often entails the collaboration of numerous medical specialties. In recent years, laparoscopy in pregnancy has been accepted as a safe alternative to open surgery. This has led gynecological societies to conduct studies and issue guidelines related to laparoscopy in pregnancy, with a view to assisting and guiding clinicians and surgeons. The aim of this study was to review and compare the recommendations from various published national guidelines on laparoscopy in pregnant women. To that end, a descriptive review of guidelines from the British Society for Gynaecological Endoscopy (BSGE), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the Society of Obstetricians and Gynaecologists of Canada (SOCG), and the Collège National des Gynécologues et Obstétriciens Français (CNGOF) was conducted. Regarding diagnosis, the SAGES and SOCG societies recommend ultrasound as the preferred and safe imaging technique during pregnancy. In terms of the optimal timing for laparoscopic intervention, BSGE and SAGES do not restrict the laparoscopic approach based on safety, depending on the gestation week, whereas SOCG and CNGOF propose early second trimester and first and second quarter of pregnancy respectively. There is an overall consensus regarding patient positioning, initial port placement, insufflation pressure during the operation, venous thromboembolic (VTE) prophylaxis, fetal heart monitoring, and tocolysis among the reviewed guidelines. Moreover, only the BSGE mentions the need for corticosteroids, magnesium sulfate, and anti-D prophylactic administration.

Laparoendoscopic single-site compared with conventional laparoscopic surgery for gynaecological acute abdomen in pregnant women

Objective

To estimate the safety and feasibility of laparoendoscopic single-site surgery (LESS) in pregnant patients with acute abdomen.

Methods

Baseline characteristics, surgical results, and obstetric and neonatal outcomes were retrospectively compared between single and multiport procedures in patients who underwent laparoscopic surgery during pregnancy between 2017 and 2021.

Results

Fifty-four pregnant patients were included: 26 who underwent LESS (salpingectomy, 11 cases/cystectomy, 15 cases) and 28 who underwent conventional laparoscopic surgeries (salpingectomy, 12 cases/cystectomy, 16 cases) during pregnancy. One patient in the single-port group required additional ports. No patients converted to laparotomy. In patients undergoing salpingectomy, the single-port group showed lower 8- and 24-h postoperative pain scores, shorter hospital stays, and lower Self-rating Anxiety Scale scores prior to discharge versus conventional laparoscopy. One patient experienced postoperative vaginal bleeding and a missed abortion during follow-up. In patients receiving cystectomy, 8- and 24-h pain scores, postoperative hospital stay, and anxiety scores were lower in the single-port versus multiport group. Other outcomes were comparable between the groups.

Conclusion

The feasibility and efficacy of laparoscopic surgery during pregnancy is similar between single- or multiport routes, however, the single-port route may be associated with less postoperative pain, shorter hospital stay, and lower anxiety.

Surgical and obstetrical outcomes after laparoscopic appendectomy during pregnancy: a case-matched analysis

PURPOSE

Laparoscopic appendectomy (LA) for acute appendicitis (AA) remains controversial during pregnancy. We aimed to determine surgical and obstetrical outcomes of LA in pregnant women.

METHODS

Pregnant women who underwent LA for AA (G1) between 2006 and 2019 were included and matched by gender, age, white blood cells, ASA score, and presence of peritonitis in a 1:2 ratio with non-pregnant women who had undergone LA (G2). Demographics and surgical outcomes were compared between groups. Preterm delivery and fetal loss rate were also analyzed.

RESULTS

From a total of 2009 LA, 18 (0.9%) were included in G1 and 36 (1.8%) in G2. There were no intraoperative complications or converted surgeries. Length of hospital stay was longer in G1 (G1: 2.6 vs G2: 1.4 days, p < 0.01). There was no difference in overall morbidity and readmission rates. Fetal loss and preterm delivery rates were both 11%.

CONCLUSION

LA in pregnant women has similar intraoperative and postoperative outcomes as those achieved in non-pregnant patients. In addition, the laparoscopic approach does not seem to jeopardize obstetrical outcomes.

Adnexal masses in pregnancy: An updated review

Adnexal masses in pregnancy are not commonly encountered. The majority of these masses are discovered incidentally during routine follow-up. However, some of these masses become symptomatic due to their size, location, and impingement of adjacent structures. Several diagnostic modalities can be utilized for the detection of adnexal masses with different sensitivity and specificity rates. The differential diagnosis of adnexal masses discovered during pregnancy is broad and includes both benign and malignant lesions. The management of such lesions has been a subject of debate for years with no consensus regarding the best management plan. Tumor size, site, and the trimester of mass detection are all crucial in management. In this account, we review adnexal masses discovered in pregnancy, the diagnostic modalities utilized for detecting these lesions, their differential diagnosis, and management strategies.

Adnexal Masses in Pregnancy

Importance

Adnexal masses are identified in approximately 0.05% to 2.4% of pregnancies, and more recent data note a higher incidence due to widespread use of antenatal ultrasound. Whereas most adnexal masses are benign, approximately 1% to 6% are malignant. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

Objective

The aim of this study was to review imaging modalities for evaluating adnexal masses in pregnancy and imaging characteristics that differentiate benign and malignant masses, examine various types of adnexal masses, and understand complications of and explore management options for adnexal masses in pregnancy.

Evidence Acquisition

This was a literature review using primarily PubMed and Google Scholar.

Results

Ultrasound can distinguish between simple-appearing benign ovarian cysts and masses with more complex features that can be associated with malignancy. Radiologic information can help guide physicians toward recommending conservative management with observation or surgical removal during pregnancy to facilitate diagnosis and treatment. The risks of expectant management of an adnexal mass during pregnancy include rupture, torsion, need for emergent surgery, labor obstruction, and progression of malignancy. Historically, surgical removal was performed more routinely to avoid such complications in pregnancy; however, increasing knowledge has directed management toward conservative measures for benign masses. Surgical removal of adnexal masses is increasingly performed via minimally invasive techniques including laparoscopy and robotic surgery due to a decreased risk of surgical complications compared with laparotomy.

Conclusions and Relevance

Adnexal masses are increasingly identified in pregnancy because of the use of antenatal ultrasound. Clear and specific guidelines exist to help differentiate between benign and malignant masses. This is important for management as benign masses can usually be conservatively managed, whereas malignant masses require excision for diagnosis and treatment. A multidisciplinary approach, including referral to gynecologic oncology, should be used for masses with complex features associated with malignancy. Proper diagnosis and management of adnexal masses in pregnancy are an important skill for obstetricians.

A 27-Year-Old Primigravida with a Right Renal Cell Carcinoma Removed at 30 Weeks of Gestation by Robot-Assisted Retroperitoneoscopic Partial Nephrectomy

BACKGROUND Large renal tumors during pregnancy are rare findings (0.07-0.1%). Current guidelines recommend surgical removal. This surgery should be carefully planned in an interdisciplinary team and involves special risks for mother and fetus. This report describes a case of a 27-year-old primigravida woman with a right renal cell carcinoma involving the lower pole of the kidney, which was removed at 30 weeks of gestation by robot-assisted retroperitoneoscopic partial nephrectomy (RARPN). CASE REPORT The patient was referred by the treating obstetrician with a newly diagnosed right lower pole renal mass of 6×4 cm in greatest diameter extending deeply into the parenchyma. No metastasis or enlarged lymph nodes were described in subsequent magnetic resonance tomography. Clinical and laboratory examinations documented a healthy mother and fetus. A right-sided RARPN was advised and planned by an interdisciplinary team of treating physicians (gynecologists, oncologists, and urologists). The surgery was conducted under general anesthesia with an obstetrician on stand-by. Surgery was performed without any complications (operation time 95 min, renal-ischemia time 15 min, and negligible blood loss) and histopathology confirmed the diagnosis of a chromophobe renal cell carcinoma. Further follow-up consultations showed regular wound healing and normal progression of pregnancy, and the patient gave birth to a healthy child at term. Follow-up examinations of the patient were uneventful. CONCLUSIONS This case shows that RARPN can be a safe and effective surgical procedure for partial nephrectomy during pregnancy, where surgery is performed in a specialist center and by an interdisciplinary experienced surgical team. It seems to offer advantages and better risk profile over the laparoscopic approach.

Evaluation of safety and foeto-maternal outcome following non-obstetric surgery in pregnancy: a retrospective single-site Australian study

BACKGROUND

Existing data on safety of non-obstetric surgery during pregnancy appear limited and conflicting. This study aimed to assess perinatal outcomes and complications in pregnant women undergoing non-obstetric surgeries.

METHODS

A single-site Australian study was performed utilizing a 10-year data (2009-2018) collected retrospectively. Descriptive statistics were used to summarize the characteristics of the study population. Statistical analyses between groups were conducted by independent t-test or Mann-Whitney (for means between groups) and by chi-squared/Fisher's exact test (for categorical variables).

RESULTS

A total of 108 pregnant women underwent non-obstetric surgery, with an increasing trend in annual numbers since 2014. The majority of women (91%) underwent surgeries as an emergency procedure, and under general anaesthesia (69.8%). Procedures during the first trimester comprised 45%, making it the most common trimester for non-obstetric surgeries. The most common cause for surgery arose in the gastrointestinal/digestive tract (39%). Overall perinatal complication rate was 19% with the rate of miscarriage/foetal loss, preterm birth and intrauterine growth restriction/small for gestational age being 4.7%, 10.4% and 3.8%, respectively. A total of 46 patients underwent intra-abdominal surgery. The most common surgery in the laparoscopy group was appendicectomy (56%), whereas adnexal pathology (54%) contributed to the majority of laparotomies. Subgroup comparison showed no significant difference in perinatal outcomes except for caesarean delivery rate (24% versus 67% for laparoscopy versus open, respectively (P = 0.04)).

CONCLUSION

With an overall perinatal complication rate of 19%, the rate of adverse perinatal outcomes following non-obstetric surgery during pregnancy in our study was low and comparable to those of the general population.

Surgical Management of Adnexal Masses in Pregnancy: A Systematic Review and Meta-analysis

OBJECTIVE

The incidence of adnexal masses in pregnancy is 1% to 6%. Although surgery is often indicated, there are no definitive management guidelines. We aimed to investigate the optimal approach to surgical management of adnexal masses in pregnancy on the basis of a meta-analysis of previous studies.

DATA SOURCES

We performed a systematic review using MEDLINE, Embase, Cochrane Library, and Clinicaltrials.gov from inception to July 17, 2020.

METHODS OF STUDY SELECTION

There were no restrictions on study type, language, or publication date. Comparative and noncomparative retrospective studies that reviewed operative techniques used in surgery of adnexal masses in pregnancy were included. Meta-analyses were performed to assess outcomes. This study was registered in the International Prospective Register of Systematic Reviews (CRD42019129709).

TABULATION, INTEGRATION, AND RESULTS

Comparative studies were identified for laparoscopy vs laparotomy and elective vs emergent surgery (11 and 4, respectively). Elective surgery is defined as a scheduled antepartum procedure. For laparoscopy vs laparotomy, the mean maternal ages and gestational ages at time of surgery were similar (27.8 years vs 27.7 years, p = .85; 16.2 weeks in laparoscopy vs 15.4 weeks in laparotomy, p = .59). Mass size was larger in those undergoing laparotomy (mean 8.8 cm vs 7.8 cm, p = .03). The most common pathologic condition was dermoid cyst (36%), and the risk of discovering a malignant tumor was 1%. Laparoscopy was not associated with a statistically increased risk of spontaneous abortion (SAB) or preterm delivery (PTD) (odds ratio [OR] 1.53; 95% confidence interval [CI], 0.67-3.52; p = .31 and OR 0.95; 95% CI, 0.47-1.89; p = .88, respectively). The mean length of hospital stay was 2.5 days after laparoscopy vs 5.3 days after laparotomy (p <.001). The decrease in estimated blood loss in laparoscopy was not statistically significant (94.0 mL in laparotomy vs 54.0 mL in laparoscopy, p = .06). Operative times were similar in laparoscopy and laparotomy (80.0 minutes vs 72.5 minutes, p = .09). Elective surgery was associated with a decreased risk of PTD (OR 0.13; 95% CI, 0.04-0.48; p = .05). Noncomparative studies were identified for laparoscopy and laparotomy. Laparotomy had more SABs and PTDs than laparoscopy (pooled proportion = 0.02 vs 0.07 and pooled proportion = 0.02 vs 0.14, respectively).

CONCLUSION

Laparoscopy for the surgical management of adnexal masses in pregnancy is associated with shorter length of hospital stay and similar risk of SAB or PTD. Elective surgery is associated with a decreased risk of PTD.

Association of laparoscopy and laparotomy with adverse fetal outcomes: a retrospective population-based case-control study

BACKGROUND

This study aimed to evaluate fetal adverse outcomes of laparoscopy and laparotomy in pregnant women to determine the safety of these surgical approaches.

METHODS

This was a retrospective nationwide case-control study of women who became pregnant for the first time between 2000 and 2012 in Taiwan. The case (with adverse fetal outcomes) and control groups comprised 208,604 and 417,124 participants, respectively. Participants who underwent appendectomy, cholecystectomy, ovarian cystectomy, or myomectomy were treated with either laparoscopy or laparotomy. A conditional logistic regression model was used to calculate the odds ratios (ORs) for adverse fetal outcomes.

RESULTS

The laparotomy and laparoscopy groups comprised 632 and 536 patients, respectively. Women who underwent laparoscopy had a significantly higher risk of adverse fetal outcomes (adjusted OR [AOR] = 2.33; 95% CI 1.66-2.99) than those who underwent laparotomy. Adverse fetal outcomes were found to be significantly associated with laparoscopy among women aged 20-39 years (AOR = 2.30; 95% CI 1.70-3.31). Regarding surgical indication, unlike laparotomy, laparoscopic cholecystectomy and appendectomy were not associated with adverse fetal outcomes. However, laparoscopic myomectomy and ovarian surgeries were associated with a higher incidence of adverse fetal outcomes than the laparotomy group (AOR = 2.29 [95% CI 1.57-3.35, p < 0.0001] and AOR = 2.52 [95% CI 1.58-4.04, p = 0.0001], respectively).

CONCLUSIONS

Pregnant women who underwent laparoscopic surgery experienced significantly more adverse fetal outcomes than those who underwent laparotomy. Therefore, pregnant women undergoing either laparotomy or laparoscopy should be informed of the risk of adverse fetal outcomes.

Obstetrical outcomes following laparoscopy during pregnancy: a retrospective case-control study

PURPOSE

To evaluate pregnancy outcome of patients who undergo laparoscopy during pregnancy.

METHODS

A retrospective case-control study, conducted in a single university-affiliated tertiary care medical center, comparing pregnancy outcomes of women who underwent laparoscopy during pregnancy to women without operations during pregnancy. The study group (n = 232) included all pregnant women who underwent a single laparoscopic surgery during pregnancy (4-28 weeks of gestation) which culminated in delivery between 2006 and 2017; this study group was matched to a control group (n = 463) without surgical intervention during pregnancy, in a 2:1 ratio by maternal age, parity, and multiple gestation.

RESULTS

The main pregnancy outcomes included preterm birth, cesarean section, small for gestational age (≤ 10 percentile), and Apgar score of less than 7 in 5 min. Laparoscopy during pregnancy was associated with an increased risk for cesarean section (32.3% vs. 24.6%, adjusted OR = 1.9, CI 1.2-3.1, p = 0.011). We found no difference between the groups with regard to other outcomes, including rates of preterm birth (12.1% vs. 10.4%, adjusted OR = 1.3, CI 0.64-2.72, p = 0.451). In a subgroup analysis of the study group, various perioperative parameters such as operation duration, hospitalization length, and others, did not correlate with adverse pregnancy outcome.

CONCLUSIONS

Laparoscopy during pregnancy may be associated with an increased rate of cesarean section. We did not find an increase in any other pregnancy or neonatal complication. Different perioperative parameters did not appear to predict adverse pregnancy outcome.

Adnexal masses in pregnancy: an updated review on diagnosis and treatment

Adnexal masses are not common in pregnancy. They are often discovered incidentally during routine ultrasound examinations. In general, 24%-40% of the cases are benign tumors; up to 8% are malignant tumors. Adnexal masses are usually asymptomatic, but sometimes can be responsible for abdominal or pelvic pain. Transvaginal and transabdominal ultrasound is essential to define the morphology of pelvic masses and to distinguish between benign and malignant cases. Magnetic resonance imaging can be a complementary examination when ultrasound findings are equivocal and a useful additional examination to better define tissue planes and relations with other organs. Patient counseling can be challenging because there is no clear consensus on the management of adnexal masses during pregnancy. Treatment options consist of observational management (in case of asymptomatic women with reassuring instrumental findings) or surgery (via laparoscopy or laparotomy). Surgery can be offered as a primary tool when cancer is suspected or when acute complications such as ovarian torsion occur.

Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)

Non-obstetric surgery during pregnancy is required in 0.75-2% of pregnancies. Physiologic changes during pregnancy, both hormonal and anatomic, can have interactions with surgery and anesthesia. Indication, timing as well as risks of anesthesia and surgery should be considered in surgical decision making. The health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and neonatologist, is mandatory. Delay in diagnosis and treatment carry risks of complications in all septic visceral indications. Considerations should be individualized.

Pregnancy-preserving Laparoendoscopic Single-site Surgery for Gynecologic Disease: A Case Series

STUDY OBJECTIVE

The study objective was to assess the feasibility of laparoendoscopic single-site surgery (LESS) for the management of nonobstetric, gynecologic disease processes in pregnant patients.

DESIGN

A retrospective case series of 13 pregnant women aged 21 to 42 years who underwent LESS for various gynecologic pathology. If able to be contacted, the patients were followed up until the delivery of the fetus.

SETTING

The surgeries were performed in a single institution between January 2015 and June 2019.

PATIENTS

The patients were selected if a laparoscopic intervention was indicated.

INTERVENTIONS

The cases included 6 ovarian cystectomies and 2 salpingo-oophorectomies for adnexal masses; 1 myomectomy for a degenerated myoma; 1 salpingectomy for a heterotopic pregnancy; 2 cerclage placements for recurrent pregnancy loss and cervical insufficiency; and 1 paratubal cystectomy. The patients underwent LESS through a 2.5-cm umbilical incision. The masses were exteriorized using a laparoscopic specimen retrieval bag, with the exception of 2 large adnexal masses, which were aspirated at the incision site, exteriorized after content drainage, and cystectomies performed extracorporeally. The fascial incision was repaired with a permanent suture.

MEASUREMENTS AND MAIN RESULTS

Various data were collected from patients, including age, surgical and obstetric history, gestational age at surgery, and ultrasonic imaging results. The outcomes measured were operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring before and after surgery, pathologic findings, conversions, intraoperative complications, and pregnancy outcomes. Eight cases were performed in the first trimester, 4 in the second trimester, and 1 in the third trimester, with the surgeries lasting between 45 minutes and 298 minutes. The blood loss ranged from 5 mL to 300 mL, and postoperative symptoms of mild pelvic or abdominal pain were reported. There were 2 conversions to traditional multiport laparoscopic surgery for the 2 cerclage cases, and there were no open surgery conversions or intraoperative complications. The fetal heart rate ranged between 130 beats per minute and 167 beats per minute postoperatively. Of the 9 patients who were able to be contacted for follow-up, all had successful deliveries. One patient was healthy at 31 weeks and 5 days without complication at the time of her last follow-up.

CONCLUSION

LESS may be performed by experienced surgeons on gravid patients in any trimester for adnexal masses, myomas, heterotopic pregnancy, and cervical incompetence. Future multiple-center studies may provide further evidence that LESS is a feasible and safe option for gynecologic surgery during pregnancy.

Nonobstetric Surgery During Pregnancy

One percent to 2% of pregnant women undergo nonobstetric surgery during pregnancy. Historically, there has been a reluctance to operate on pregnant women based on concerns for teratogenesis, pregnancy loss, or preterm birth. However, a careful review of published data suggests four major flaws affecting much of the available literature. Many studies contain outcomes data from past years in which diagnostic testing, surgical technique, and perioperative maternal-fetal care were so different from current experience as to make these data of limited utility today. This issue is further compounded by a tendency to combine experience from vastly disparate types of surgery into a single report. In addition, reports in nonobstetric journals often focus on maternal outcomes and contain insufficient detail regarding perinatal outcomes to allow distinction between complications associated with surgical disease and those attributable to surgery itself. Finally, most series are either uncontrolled or use the general population of pregnant women as controls rather than women with surgical disease who are managed nonsurgically. Consideration of these factors as well as our own extensive experience suggests that when the risks of maternal hypotension or hypoxia are minimal, or can be adequately mitigated, indicated surgery during any trimester does not appear to subject either the mother or fetus to risks significantly beyond those associated with the disease itself or the complications of surgery in nonpregnant individuals. In some cases, reluctance to operate during pregnancy becomes a self-fulfilling prophecy in which delay in surgery contributes to adverse perinatal outcomes traditionally attributed to surgery itself.

Obstetric and non-obstetric surgery during pregnancy: A 20-year Danish population-based prevalence study

OBJECTIVES

Population-based studies on use of non-obstetric and obstetric surgical procedures during pregnancy are sparse. Therefore, our objective was to estimate the prevalence of surgery during pregnancy, including potential time trends, overall and by trimester and describe the characteristics of pregnant women undergoing surgery.

DESIGN

This study is a large nationwide cohort study.

SETTING

From administrative and medical databases, we obtained information about all pregnancies ending in a live birth, a stillbirth or an abortion (spontaneous and induced) in Denmark during 1996-2015. Procedures (excluding caesarean sections) conducted during pregnancy were categorised as a non-obstetric or obstetric surgery and further divided into laparoscopic or non-laparoscopic procedures.

MAIN OUTCOME MEASURE

Main outcome measure is prevalence of surgery during pregnancy.

RESULTS

We included 1 687 176 pregnancies of which 108 502 (6.4%) received 117 424 surgical procedures. The prevalence of non-obstetric surgery was almost stable (1.5% in 1996-1999 to 1.6% in 2012-2015), whereas non-obstetric abdominal or gynaecological laparoscopic procedures increased from 0.5% to 0.8%. For appendectomies, the proportion of laparoscopic surgery increased from 4.2% to 79.2% during the study period. In 49 pregnancies, surgery for internal herniation was conducted in 2012-2015 versus none in 1996-1999. The prevalence of obstetric surgery, excluding invasive diagnostic tests, increased from 0.2% to 0.8%. High multiplicity, smoking, increasing age, body mass index (BMI) and parity were factors associated with a high prevalence of surgery during pregnancy.

CONCLUSIONS

The increase in the prevalence of laparoscopic surgery during pregnancy may reflect a decreased restraint concerning conductance of these surgical procedures during pregnancy. The increasing proportion of laparoscopic procedures complies with clinical recommendations, and the prevalence of surgery during pregnancy varied by multiplicity, smoking status, parity, age and BMI.

Laparoscopic appendectomy versus open appendectomy for suspected appendicitis during pregnancy: a systematic review and updated meta-analysis

BACKGROUND

Recently, laparoscopic appendectomies (LAs) have been widely performed instead of open appendectomies (OAs) during pregnancy. However, concerns about the safety of LA during pregnancy remain. This systematic review and meta-analysis aimed to evaluate the current evidence relating to the safety of LA versus OA for suspected appendicitis during pregnancy.

METHODS

Comprehensive literature searches were conducted using the PubMed, EMBASE, and Cochrane Library databases to identify articles describing LA versus OA in pregnancy, without restrictions regarding the publication date. The primary endpoints were fetal loss and preterm delivery.

RESULTS

After screening 801 studies, 22 comparative cohort studies were included in the analysis, which involved 4694 women, of whom 905 underwent LAs and 3789 underwent OAs. Fetal loss was significantly higher among those who underwent LAs compared with those who underwent OAs, and the pooled odds ratio (OR) was 1.72 (95% confidence interval [CI]: 1.22-2.42) without heterogeneity. The sensitivity analysis showed that the effect size was influenced by one of the studies, because its removal resulted in there being no significant difference between LA and OA with respect to the risk of fetal loss (OR 1.163, 95% CI: 0.68-1.99; P = 0.581). A significant difference was not evident between LA and OA with respect to preterm delivery (OR 0.76, 95% CI: 0.51-1.15), a result that did not change following the sensitivity analysis. The patients who underwent LA had shorter hospital stays (mean difference - 1.01, 95% CI: -1.61--0.41) and a lower wound infection risk (OR 0.40, 95% CI: 0.21-0.76) compared with those who underwent OA.

CONCLUSION

It is not reasonable to conclude that LA in pregnant women might be associated with a greater risk of fetal loss. The difference between LA and OA with respect to preterm delivery was not significant.

Laparoscopy versus open surgery for adnexal masses in pregnancy: a meta-analytic review

PURPOSE

The objective of this meta-analysis is to investigate and compare the pregnancy outcomes of laparoscopy and open surgery in the treatment of ovarian tumors during pregnancy.

METHODS

Search was conducted using MEDLINE, EMBASE, and Cochrane Databases from January 1990 to November 2018. A broad search strategy was used to identify studies comparing laparoscopy and open surgery in pregnancy. Inclusion criteria included comparative studies with the quantitative outcome data on gravida. Two authors independently reviewed and assessed for the quality of included studies according to the Newcastle-Ottawa Scale. Data were extracted for fetal loss, preterm delivery, duration of surgery, blood loss and length of hospital stay.

RESULTS

Nine retrospective trials were identified involving 985 patients. No statistical significance was found in fetal loss between laparoscopy and open surgery (P value = 0.334). The pooled estimate for preterm labor statistically significantly decreased for laparoscopy group (P value = 0.014). Reduced operative blood loss was found in laparoscopy group by 83.81 ml (P value = 0.015). Duration of operation may be longer in the laparoscopy group, but without statistical significance (P value = 0.346). Length of hospital stay was shorter in the laparoscopy group with reduction of 1.95 days (P value < 0.001).

CONCLUSIONS

The available low-grade evidence suggests that laparoscopic surgery might be a feasible alternative for pregnant women with adnexal masses.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Meta-analysis comparing the safety of laparoscopic and open surgical approaches for suspected adnexal mass during the second trimester

BACKGROUND

The safety of laparoscopic surgery during the second trimester of pregnancy remains a controversial subject.

OBJECTIVES

To compare the safety of laparoscopic surgery and laparotomy for suspected adnexal mass during the second trimester.

SEARCH STRATEGY

Articles published in any language prior to April 31, 2016, were retrieved from PubMed, Scopus, EMBSCO, and the Cochrane Library using keywords including pregnant, adnexal mass, laparoscopy, laparotomy, pregnancy outcomes, and surgical outcomes.

SELECTION CRITERIA

Randomized and non-randomized controlled trials reporting at least one obstetric or surgical outcome were included if they compared laparoscopic surgery and laparotomy for adnexal masses during the second trimester.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two reviewers. Homogeneous data were pooled using a fixed effects model and heterogeneous data were qualitatively analyzed.

MAIN RESULTS

Four comparative effectiveness studies including a total of 240 patients were identified. Laparoscopic surgery was associated with a reduced risk of post-operative adverse events (relative risk 0.20, 95% confidence interval 0.06-0.72); no difference was recorded in the risk of post-operative spontaneous abortion (P=0.26) or threatened spontaneous abortion (P=0.13).

CONCLUSIONS

Laparoscopic surgery could be preferable to laparotomy for suspected adnexal mass during the second trimester of pregnancy.

Could laparoscopic appendectomy in pregnant women affect obstetric outcomes? A multicenter study

PURPOSE

The purpose of this study was to compare the perioperative and obstetric outcomes of pregnant women between laparoscopic surgery and open surgery and to evaluate the predictive factors for overall obstetric outcomes.

METHODS

We retrospectively reviewed the medical records of pregnant women who underwent appendectomy between January 2008 and June 2015 at six hospitals affiliated to Hallym University.

RESULTS

Eighty patients were evaluated. Twenty-four underwent laparoscopic appendectomy (LA) and 56 underwent open appendectomy (OA). There were no significant differences in the patients' characteristics and gestational age at surgery between the two groups. Operation time, time to flatus, and time to soft food intake were similar in both groups. The length of stay was shorter in the LA group than in the OA group (5.1 vs 8.1 days, P = 0.044). Gestational age at delivery, birth weight, and delivery type were similar in both groups. There was no significant difference in overall obstetric poor outcome (20.8 vs 14.3 %, P = 0.516), including preterm delivery (8.3 vs 7.1 %, P = 1.000) and fetal loss (12.5 vs 7.1 %, P = 0.350). Multivariable analysis revealed that fever >38 °C (P = 0.022) and maternal age (P = 0.044) were independent predictors for the overall poor outcomes.

CONCLUSIONS

LA was associated with shorter length of stay compared with OA, but perioperative and obstetric outcomes were similar with both procedures. LA can be safely performed in pregnant women in any trimester.

[Laparoscopic splenectomy in immune thrombocytopenic purpura in pregnant women]

The paper describes 4 cases of laparoscopic splenectomy in pregnant women with immune thrombocytopenic purpura. No complications of surgery were noted in all the patients. The postoperative period was marked by sustained clinical and hematological remission that made it possible to discontinue prednisolone therapy and to ensure an uncomplicated course of pregnancy and labor.

Laparoscopic surgery in pregnancy

Each year, roughly 2% of pregnant women will undergo non-obstetrical abdominal surgery. Appendicitis, symptomatic cholelithiasis and adnexal masses are some of the common diagnoses encountered. Pregnancy poses challenges in the diagnosis and surgical management of these conditions for several reasons. Since the 1990’s, laparoscopic surgery has gained popularity and in the past few years has become the standard of care for pregnant women with surgical pathologies. The advantages of laparoscopic surgery include shorter hospital stay, lower rates of wound infection, and decreased time to bowel function. This brief review discusses key points in laparoscopic surgery during pregnancy and highlights studies comparing laparoscopic and open approaches in common surgical conditions during pregnancy.

Investigation and Management of Adnexal Masses in Pregnancy

Adnexal masses can be found in 0.19 to 8.8% of all pregnancies. Most masses are functional and asymptomatic and up to 70% resolve spontaneously in the second trimester. The main predictors of persistence are the size (>5 cm) and the imagiological morphocomplexity. Those that persist carry a low risk of malignancy (0 to 10%). Most malignant masses are diagnosed at early stages and more than 50% are borderline epithelial neoplasms. Ultrasound is the preferred method to stratify the risk of complications and malignancy, allowing medical approach planning. Pregnancy and some gestational disorders may modify the levels of tumor markers, whereby their interpretation during pregnancy should be cautious. Large masses are at increased risk of torsion, rupture, and dystocia. When surgery is indicated, laparoscopy is a safe technique and should ideally be carried out in the second trimester of pregnancy.

Laparoscopic surgery for treating adnexal masses during the first trimester of pregnancy

OBJECTIVE:

To evaluate the feasibility and safety of laparoscopic surgery for treating adnexal masses during the first trimester of pregnancy.

STUDY DESIGN:

An observational study of a prospective collection of data of all pregnant women who underwent laparoscopic surgery for adnexal masses during the first trimester of pregnancy between January 1999 and November 2012 at the Obstetrics and Gynecology Department of the Italian Hospital of Buenos Aires, Buenos Aires, Argentina was performed.

RESULTS:

A total of 13 women were included. The median (range) gestational age at the moment of surgical procedure was 7 weeks (range: 5-12 weeks). The main indication of surgery was cyst torsion in four cases (30.7%) and rupture of ovarian cysts in four cases (30.7%). Other indications included persistent ovarian cyst in three patients (23%) and heterotopic pregnancy in two cases (15.3%). Neither surgical complications nor spontaneous abortions occurred in any of the cases and the post-operative period was uneventful in all the cases. No cases of intrauterine growth retardation, preterm delivery, congenital defects, or neonatal complications were registered.

CONCLUSION:

The treatment of complicated adnexal masses by laparoscopic surgery during the first trimester of pregnancy appears to be a safe procedure both for the mother and for the foetus. Additional research on a larger number of cases is still needed to support these conclusions.

Adnexal masses in the premenopausal patient

Practitioners may frequently encounter adnexal masses in premenopausal women. Adnexal masses can represent a wide variety of etiologies, and therefore they can represent a diagnostic dilemma. When an adnexal mass is found the initial work up must focus on identifying acute pathology followed by determining the risk of a malignancy. Pelvic ultrasound remains the mainstay for evaluation of adnexal masses in premenopausal patients. If ultrasounds findings are indeterminate magnetic resonance imaging (MRI) is the next imaging modality of choice. The evaluation for malignancy should include serum marker screening. Aspiration of adnexal masses is generally avoided, due to the lack of therapeutic benefit and risk of seeding a tumor. When ultrasound findings are suggestive of benign disease, conservative management, including repeat imaging, should be considered. If the clinical suspicion for malignancy is high referral to a gynecologic oncologist is warranted. In other patients whom the evaluation of their adnexal mass remains unclear surgical excision with care not to disrupt the integrity of the mass should be performed for pathologic diagnosis.

Abdominal surgery in pregnancy--an interdisciplinary challenge

BACKGROUND

Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach.

METHOD

This review is based on pertinent articles retrieved by a selective search in the PubMed database.

RESULTS

The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth.

CONCLUSION

Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.

Comparative analysis of laparoscopy versus laparotomy in the management of ovarian cyst during pregnancy

AIM

The aim of the present study was to evaluate the surgical and obstetric results of laparoscopy versus laparotomy in the management of ovarian cyst during pregnancy.

MATERIAL AND METHODS

Sixty-nine eligible patients who met our criteria were randomly divided into the laparoscopy group (n = 33) and the laparotomy group (n = 36). The two groups were compared for their surgical and obstetric outcomes and the extent of pelvic adhesion discovered in later cesarean section (CS).

RESULTS

The laparoscopy group had less blood loss (43 ± 15 vs 51 ± 13 mL, P = 0.02), shorter postoperative hospital stay (2.9 ± 0.5 vs 5.8 ± 0.6 days, P < 0.001), and lower postoperative pain score (2.7 ± 1.2 vs 5.9 ± 1.5, P < 0.001) compared with the laparotomy group. The operative time, neonates' Apgar scores and birthweights between the two groups showed no significant differences (P > 0.05). Sixteen patients in the laparoscopy group, and 15 patients in the laparotomy group underwent cesarean section. The filmy and dense type adhesion rate was significantly different between the laparoscopy group and the laparotomy group (6.25% vs 53.3%, and 0% vs 20%, respectively).

CONCLUSIONS

The present results suggest that laparoscopy is a better choice than laparotomy for ovarian cyst during pregnancy, with less blood loss, less postoperative pain and less postoperative hospital stay. It offers a faster recovery, results in less pelvic adhesion and does not affect the fetus; however, studies encompassing larger numbers of cases are needed.

Management of pregnant patients undergoing general surgical procedures

Pregnant patients have a 0.2% to 0.75% chance of developing a medical condition that requires a general surgical intervention during pregnancy. To safely and appropriately care for patients, surgeons must be cognizant of the maternal physiologic changes in pregnancy as well as of the unique risk to both mothers and fetuses of diagnostic modalities, anesthetic care, operative intervention, and postoperative management. Surgeons can be assured that, if these risks are understood and considered, operating during pregnancy, even in the abdomen, can be safely undertaken.

Laparoscopic tumorectomy for a primary ovarian leiomyoma during pregnancy: A case report

Few reports have explored laparoscopic adnexal tumorectomy as a treatment for large and symptomatic ovarian leiomyomas during pregnancy. The current study presents the case of a patient with a large and symptomatic ovarian leiomyoma at 14 weeks of pregnancy. A laparoscopic adnexal tumorectomy was performed without complications. The laparoscopic management of large primary ovarian leiomyoma during pregnancy has not been reported in literature. Therefore, laparoscopy may be considered as a minimally invasive and feasible alternative to laparotomy for the treatment of large ovarian solid tumors during pregnancy, resulting in reduced postoperative pain, a smaller scar and shorter recovery time. By contrast, with respect to the ovarian solid tumor, surgery prior to gestation is advised, even for tumors of <3 cm in diameter, due to the probability of rapid growth of the tumor during pregnancy.

Surgical intervention for adnexal masses during pregnancy

We aimed to evaluate the influence of surgical intervention on gestational and neonatal outcomes in women who underwent elective surgery in the second trimester of gestation because of an adnexal mass. We retrospectively reviewed the hospital records of women who underwent elective surgery for adnexal masses in the second trimester of gestation between 2006 and 2012. The ages of the women ranged between 17 and 33 years. Eight women underwent a laparotomy, and one woman, who aborted on the day of the operation, underwent a laparoscopy. Dermoid cysts, cystadenoma and borderline ovarian tumours were present in four, two and two of the women, respectively. Eight women had no complications after surgery and delivered healthy newborns at term. We concluded that elective surgery on an adnexal mass in the second trimester of gestation is safe for both the mother and the fetus.

Diagnosis and management of adnexal masses in pregnancy

Widespread use of ultrasound in early pregnancy has led to the detection of incidental adnexal masses more frequently. This article reviews the diagnosis and management options for adnexal masses in pregnancy. The availability of high-resolution ultrasound has made observation to be a viable option in some cases. However, for those masses suspicious of malignancy, at risk of torsion, rupture, or clinically symptomatic, surgical treatment is warranted. Laparoscopy has been successfully used in pregnancy and is safe in experienced and trained hands in properly equipped units.

Cystically degenerated leiomyoma of the rectosigmoid managed laparoscopically at 13 weeks of gestation

The safety of laparoscopic management of adnexal masses in pregnancy has been documented. Herein we report laparoscopic removal during pregnancy of a cystically degenerated leiomyoma of the sigmoid colon, which had been mistaken for an adnexal mass. When smooth muscle gastrointestinal tumors are observed, it is important that they be characterized with appropriate markers so that postoperative treatment can be individualized to the patient.

Laparoscopy in pregnancy and the pediatric patient

Minimally invasive surgery is now standard of care for many procedures in pediatric gynecology. Laparoscopy has been well documented to produce faster recovery,decreased postoperative pain, and because of smaller incisions, a better cosmetic result. These are important when considering an active pediatric patient. Although a laparoscopic approach to endometriosis, adnexal masses, and ovarian torsion are well supported in the literature in the pediatric patient, more data are needed with regard to SILS in younger patients. Laparoscopy seems to be a better approach to oopheropexy in children undergoing radiation, and in resection of certain mullerian anomalies; however, the numbers are low.Similarly in pregnant patients, laparoscopy provides for shorter recovery times,decrease analgesic use and shorter hospital stays. Concerns about poor fetal outcomes in surgery during pregnancy for non gynecologic problems have been brought to light; however, the evidence indicates that these outcomes can be attributed to the nature of the underlying disease and not the surgical approach. With regard to pneumoperitoneum the effect of CO2 insufflation on fetal physiology and long-term outcomes remains unclear, and will continue to be an issue of controversy until larger studies are published.With both the pediatric and pregnant populations, laparoscopic complications can be diminished when performed by skilled surgeons with strict adherence to good technical principles. The advantages of laparoscopy are great, and this approach should be considered in pediatric and pregnant patients.

Suspicion of acute appendicitis in the third trimester of pregnancy: pros and cons of a laparoscopic procedure

This review suggests that diagnostic laparoscopy during the third trimester of pregnancy is a logical strategy to minimize maternal and fetal risk when acute appendicitis is suspected.

The presentation of acute appendicitis during pregnancy may cause diagnostic and therapeutic difficulty. Delay in diagnosis may lead to increased maternal and fetal risk. Therefore, an aggressive surgical approach is mandatory, even though this may result in an increased number of appendectomies for normal appendices. Diagnostic laparoscopy, followed by laparoscopic appendectomy in case of inflammation, seems a logical strategy. We present the case of a 36-week pregnant woman who presented with suspicion of acute appendicitis. The pro and cons of a laparoscopic approach in the third trimester of pregnancy are discussed as is its safety by reviewing the literature.