A review of laparoscopy for non-obstetric–related surgery during pregnancy

Emergent Laparoscopic Removal of a Perforating Intrauterine Device During Pregnancy Under Regional Anesthesia

STUDY OBJECTIVES

To describe and demonstrate a technique for laparoscopic removal of a perforating intrauterine device (IUD) during pregnancy, and to provide tips to facilitate safe laparoscopic surgery during pregnancy.

DESIGN

Video presentation of the technique for laparoscopic removal of a perforating IUD in a pregnant woman.

SETTING

Department of Neuroscience, Reproductive Sciences, and Dentistry, University of Naples Federico II, Naples, Italy.

INTERVENTION

A 30-year-old woman, gravida 3, para 2, with a copper T IUD (Nova T 380; Bayer, Leverkusen, Germany) perforating the left adnexa presented to the emergency room complaining of left lower quadrant pain. The patient had the IUD inserted by her gynecologist 3 months before the onset of the symptoms. Ultrasound revealed a 6-week intrauterine pregnancy with the presence of fetal cardiac activity along with the IUD perforating the left adnexa. The patient returned at 11 weeks of gestation complaining of worsening abdominal pain and excruciating left lower quadrant pain. She was scheduled for laparoscopic excision of the perforating IUD [1-3]. Considering her pregnancy, laparoscopy under regional anesthesia was performed in the minimal Trendelenburg position at 12 degrees, through open laparoscopic access [4]. Intra-abdominal pressure of 8 mmHg and ultrasound energy to cut and coagulate, avoiding monopolar/bipolar energy owing to the presence of a copper IUD, were used. The IUD and tube were extracted in an endobag through umbilical access, under a 5-mm, 0-degree telescope in left lateral access [5]. The procedure was carried out uneventfully, and the IUD was removed. Fetal viability was confirmed after the procedure. At the time of this report, the patient was in the 23rd week of gestation, and the pregnancy was progressing without any problems.

CONCLUSION

Laparoscopic removal of perforated IUD during pregnancy under regional anesthesia is a feasible and safe option that should be considered when needed.

Maternal and preterm fetal sheep responses to dexmedetomidine

BACKGROUND

The α(2) adrenergic receptor agonist dexmedetomidine has some unique pharmacologic properties that could benefit pregnant patients (and their fetuses) when they require sedation, analgesia, and/or anesthesia during pregnancy. The purpose of the present study was to delineate maternal and fetal responses to an intravenous infusion of dexmedetomidine.

METHODS

This study was conducted on surgically-recovered preterm sheep instrumented for physiologic recording and blood sampling. Maternal and fetal cardiovascular and blood gas parameters and fetal cerebral oxygenation levels were recorded before, during, and after 3h of dexmedetomidine infusion to the ewe at a rate of 1 μg/kg/h.

RESULTS

Drug infusion produced overt sedation but no apparent respiratory depression as evidenced by stable maternal arterial blood gases; fetal blood gases were also stable. The one blood parameter to change was serum glucose, By the end of the 3-h infusion, glucose increased from 49±10 to 104±33mg/dL in the ewe and from 22±3 to 48±16mg/dL in the fetus; it declined post-drug exposure but remained elevated compared to the starting levels (maternal, 63±12mg/dL, P=0.0497; and fetal, 24±4mg/dL, P=0.012). With respect to cardiovascular status, dexmedetomidine produced a decrease in maternal blood pressure and heart rate with fluctuations in uterine blood flow but had no discernable effect on fetal heart rate or mean arterial pressure. Likewise, maternal drug infusion had no effect on fetal cerebral oxygenation, as measured by in utero near-infrared spectroscopy.

CONCLUSIONS

Using a clinically-relevant dosing regimen, intravenous infusion of dexmedetomidine produced significant maternal sedation without altering fetal physiologic status. Results from this initial acute assessment support the conduct of further studies to determine if dexmedetomidine has clinical utility for sedation and pain control during pregnancy.

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.

Laparotomy versus laparoscopy for the treatment of adnexal masses during pregnancy

BACKGROUND

Laparoscopy has been highlighted as an effective surgical modality for diverse pelvic organ diseases. However, its surgical and obstetric efficacy has not been fully confirmed in pregnant women because of the absence of a large comparative study. The objective of this study was to compare outcomes between laparotomy and laparoscopic surgery for adnexal masses during pregnancy.

METHODS

A retrospective analysis of 262 pregnant women who underwent laparotomy or laparoscopic surgery for adnexal masses between 2000 and 2009 was performed.

RESULTS

Of the 262 women, 174 (66.4%) underwent laparotomy and 88 (33.6%) underwent laparoscopic surgery for adnexal masses. The laparoscopy group had a significantly shorter mean operative time (60.7 ± 27.1 vs 69.7 ± 24.4 min, P = 0.002) and mean hospital stay (4.7 ± 1.7 vs 6.6 ± 1.3 days, P < 0.001) than the laparotomy group. In multivariate analysis, there was no significant difference between laparoscopy and laparotomy group in obstetric outcomes, including preterm delivery and miscarriage rate, after adjusting for confounding factors, such as gestational age at surgery, emergency surgery and mass size.

CONCLUSIONS

The laparoscopic approach appears to offer a suitable alternative to laparotomy, which, in our setting, was associated with shorter operative times and hospital stays than laparotomy.

Inclusion of a nitric oxide congener in the insufflation gas repletes S-nitrosohemoglobin and stabilizes physiologic status during prolonged carbon dioxide pneumoperitoneum

A method to maintain organ blood flow during laparoscopic surgery has not been developed. Here we determined if ethyl nitrite, an S-nitrosylating agent that would maintain nitric oxide bioactivity (the major regulator of tissue perfusion), might be an effective intervention to preserve physiologic status during prolonged pneumoperitoneum. The study was conducted on appropriately anesthetized adult swine; the period of pneumoperitoneum was 240 minutes. Cohorts consisted of an anesthesia control group and groups insufflated with CO2 alone or CO2 containing fixed amounts of ethyl nitrite (1-300 ppm). Insufflation with CO2 alone produced declines in splanchnic organ blood flows and it reduced circulating levels of S-nitrosohemoglobin (i.e., nitric oxide bioactivity); these reductions were obviated by ethyl nitrite. In a specific example, preservation of kidney blood flow with ethyl nitrite kept serum creatinine and blood urea nitrogen concentrations constant whereas in the CO2 alone group both increased as kidney blood flow declined. The data indicate ethyl nitrite can effectively attenuate insufflation-induced decreases in organ blood flow and nitric oxide bioactivity leading to reductions in markers of acute tissue injury. This simple intervention provides a method for controlling a major source of laparoscopic-related morbidity and mortality: tissue ischemia and altered postoperative organ function.

Maternal and fetal near-term sheep cytokine responses to carbon dioxide pneumoperitoneum

It is known that carbon dioxide (CO2) pneumoperitoneum induces fetal acidosis in pregnant ewes. Our aim was to determine changes of the levels of maternal and fetal cytokines interleukin-6, interleukin-8, and tumor necrosis factor alpha after CO2 pneumoperitoneum in pregnant ewes. Eight ewes with singleton pregnancies of 120 to 140 days gestation were anesthetized and intubated. Insufflation produced modest but significant maternal arterial hypercapnia (an increase of 10.7 mm Hg; P<0.001) and acidosis (a decrease in mean pH of 0.1.04; P=0.0005). Fetal pCO2 was increased by 15.3 mm Hg on average and pH was decreased by 0.11 U on average immediately after desufflation (both P<0.001). No significant difference was observed in the concentration of cytokine in the maternal or fetal blood samples. These results suggest that respiratory acidosis does not lead to the elevation of cytokines in pregnant ewes and fetuses, which may contribute to premature labor.

Laparoscopic versus open appendicectomy in pregnancy: a systematic review

BACKGROUND

Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnant women. The benefits of a laparoscopic over an open approach to appendicectomy are well established in the non-pregnant population. Data on the optimal surgical approach to acute appendicitis in pregnant women are conflicting.

METHODS

A systematic review of reported cases of laparoscopic appendicectomy (LA) in pregnancy over the period 1990 to 2007. Twenty-eight articles documenting 637 cases of LA in pregnancy were included. Data on pregnancy outcome, patient characteristics, operative technique and peri-operative complications were analysed.

RESULTS

The rate of fetal loss following LA in pregnancy approaches 6% and is significantly higher than that following open appendicectomy. Fetal loss was highest in cases of complicated appendicitis. Incidence of preterm delivery appears lower in the LA group although this complication is likely to be under-reported in a significant proportion of cases. Trimester at the time of LA does not appear to influence complication rates. The negative appendicectomy rate in this series was 27%, which is higher than in the non-pregnant population. Complication rates following LA with negative appendicitis are as high as with simple appendicitis. Rates of entry-related complications were 2.8% in the Veress needle group and 0% in the Hasson open entry group. The overall rate of conversion to laparotomy was 1%. No difference was found in the preterm delivery rate between women who received prophylactic tocolysis and those who were not tocolysed.

CONCLUSIONS

Laparoscopic appendicectomy in pregnancy is associated with a low rate of intra-operative complications in all trimesters. However, LA in pregnancy is associated with a significantly higher rate of fetal loss compared to open appendicectomy. Rates of preterm delivery appear similar or slightly better following a laparoscopic approach. Open appendicectomy would appear to be the safer option for pregnant women for whom surgical intervention is indicated.

Laparoscopic procedures during pregnancy and the risks of anesthesia: what does an obstetrician need to know?

BACKGROUND

Nonobstetric surgery may be necessary during any stage of gestation.

METHODS

The purpose of this article is to review the current recommendations (using Medline search for the relevant publications) for the perioperative anesthetic management of pregnant women undergoing laparoscopy for indications unrelated to pregnancy.

RESULTS

The current estimates of the incidence of nonobstetric surgery in pregnancy range from 1% to 2%. Laparoscopy is the most common surgical procedure performed in the first trimester of pregnancy, whereas appendectomy is the most common procedure performed during the remainder of pregnancy.

CONCLUSIONS

In the past pregnancy was considered as an absolute contraindication to laparoscopy. However, recent years have brought an extensive experience with this technique during gestation.

A Description of the Preterm Fetal Sheep Systemic and Central Responses to Maternal General Anesthesia

BACKGROUND

The second trimester is recommended as the optimal time to conduct a surgical procedure on pregnant patients, even though the fetal responses to anesthesia at this age are not known. Here we assessed the responses of preterm fetal sheep to a standard anesthetic regimen of midazolam, thiopental, and isoflurane.

METHODS

Variables were monitored in previously instrumented preterm pregnant sheep before, during, and after 4 h of general anesthesia. Isoflurane produced moderate fetal hypotension and bradycardia, whereas extubation was accompanied by increases in fetal heart rate and mean arterial blood pressure.

RESULTS

We observed an initial increase in fetal Sao2 followed by a gradual decline to baseline. Within the fetal brain, oxygenated hemoglobin changed by <10% (nonsignificant) and deoxygenated hemoglobin and total hemoglobin varied by <5%. Overall, although O2 levels within the preterm fetal brain were not independently enhanced by isoflurane (as occurs in the older fetus and in the adult), they did remain constant even as fetal mean arterial pressure decreased by more than 20%. By extension, we failed to identify changes in cerebral oxygenation that could be construed as injurious.

CONCLUSION

Any adverse preterm fetal response to maternal surgery should not be attributed solely to the actions of general anesthesia upon the fetus.

The safety of anaesthetics in pregnant women

Each year, a significant number of pregnant women undergo surgery and anaesthesia for indications unrelated to pregnancy. Estimates of the incidence of non-obstetric surgery in pregnancy, which may be required at any gestational age, and for a number of indications, range from 1.0 to 2%. The diagnosis of any medical condition requiring surgery in pregnancy often raises questions about the safety of anaesthesia in these patients. This controversy is primarily attributed to the lay press speculations that surgery and anaesthesia in pregnancy may pose hazards to the mother and fetus. Despite these concerns, the safety of non-obstetric surgery and anaesthesia in pregnancy is well-documented for nearly every operative procedure. The timing and indications for surgery seem critical to the maternal and fetal outcome. Laparoscopy is the most common surgical procedure performed in the first trimester of pregnancy, whereas appendectomy is the most common procedure performed during the remainder of pregnancy.

Long-term behavioral assessment of guinea pigs following neonatal pneumoperitoneum

BACKGROUND

Using guinea pigs, we previously demonstrated that pneumoperitoneum during pregnancy produces behavioral deficits in the offspring. In the current study, the purpose was to determine if CO(2) pneumoperitoneum during the early postnatal period also produced behavioral anomalies.

METHODS

Following delivery, guinea pig pups were randomly assigned to one of three treatment groups: CO(2) pneumoperitoneum (P), laparotomy (L), or isolation control (I). Surgeries were performed on postnatal day (PND) 5 under isoflurane anesthesia; control pups were isolated from the dams for an equivalent period of time. On PNDs 10, 20, 40, and 60, behavior was assessed by monitoring locomotor and exploratory activity.

RESULTS

A total of 29 animals were studied. We observed no immediate morbidity or mortality and the manipulations did not appear to affect postnatal growth. On PND 10, pups in group P exhibited lower levels of locomotor activity compared to L and I neonates, but this difference resolved as the animals got older. Histologic assessment of the adult offspring brains revealed no evidence of neurologic injury.

CONCLUSION

These data suggest that unlike insufflation during pregnancy, neonatal pneumoperitoneum does not produce behavioral deficits.

Laparoscopic Appendectomy after 30 Weeks Pregnancy: Report of Two Cases and Description of Technique

Appendicitis and pregnancy are both common conditions, and when they co-exist, both the general surgeon and obstetrician are presented with unique challenges. Acute appendicitis is the most common cause of the acute abdomen during pregnancy, effecting 0.1–0.3 per cent of pregnancies each year. With an estimated 4 million deliveries per year in the United States, there are potentially as many as 12,000 cases of acute appendicitis to be managed by the general surgeon during pregnancy (Eur J Surg 1992;158:603–6; Curr Surg 2003;60:164–73). Laparoscopic appendectomy has become a routine procedure and is now widely performed in North America. Although laparoscopic appendectomy has been discussed during pregnancy, limited data is available on the role of laparoscopic appendectomy in the third trimester of pregnancy. In fact, some authors have advocated a gestational age of 26–28 weeks to be the upper gestational limit for successful completion of laparoscopic surgery (Obstet Gynecol Surg 2001;56:50–9). In this paper, we present two recent cases of successful laparoscopic appendectomy during late pregnancy without immediate complication to mother or fetus and a description of our operative technique.