3 CME REVIEWARTICLE

Volume 56, Number 1

OBSTETRICAL AND GYNECOLOGICAL SURVEY
Copyright 2001
by Lippincott Williams & Wilkins, Inc.

CHIEF EDITORS NOTE: This article is the third of 36 that will be published in 2001 for which a total of up to 36 Category 1
CME credits can be earned. Instructions for how credits can be earned appear on the last page of the Table of Contents.

Laparoscopic Surgery During Pregnancy

Mohammad Fatum, MD* and Nathan Rojansky, MD
* Resident, Senior Lecturer, Department of Obstetrics & Gynecology, Hadassah Ein-Kerem Medical Center,
The Hebrew University Medical School, Jerusalem, Israel
In the last decade, operative laparoscopic procedures are performed increasingly in both gynecology and general surgery. The major advantages of this newer minimally invasive approach are:
decreased postoperative morbidity, less pain and decreased need for analgesics, early normal
bowel function, shorter hospital stay, and early return to normal activity. With the advancement of
laparoscopic surgery, its use during pregnancy is becoming more widely accepted. The most
commonly reported laparoscopic operation during pregnancy is laparoscopic cholecystectomy
(LC). Other laparoscopic procedures commonly performed during pregnancy include: management
of adnexal mass, ovarian torsion, ovarian cystectomy, appendectomy, and ectopic pregnancy.
The possible drawbacks of laparoscopic surgery during pregnancy may include injury of the
pregnant uterus and the technical difficulty of laparoscopic surgery due to the growing mass of the
gravid uterus. Also, the potential risk of decreased uterine blood flow secondary to the increase in
intraabdominal pressure and the possible risk of carbon dioxide absorption to both the mother and
fetus should be taken into account.
To date, data on laparoscopic surgery during pregnancy are insufficient to draw conclusions on
its safety and exact complication rate. This is due to the few cases reported and the lack of
prospective studies. Furthermore, there is a common tendency to underreport unsuccessful cases.
Finally, most reports in the literature come from centers and surgeons with special interest,
experience, and skills in laparoscopy, and their results may not reflect the real complication rates.
We have reviewed the pertinent English literature from the last decade. The cumulative experience
suggests that laparoscopic surgery may be performed safely during pregnancy, although more
studies are needed to establish its exact rate of adverse events.
Target Audience: Obstetricians & Gynecologists, Family Physicians
Learning Objectives: After completion of this article, the reader will be able to list the potential
complications of laparoscopic surgery during pregnancy and to outline management strategies to minimize complications of laparoscopic surgery during pregnancy.

frequently preformed without apparent increase in

the rate of complications. However, patient selection,
indications and contraindications are still being defined (2).
The major advantages of laparoscopic surgery during pregnancy are:

The new developments in operative laparoscopy in

gynecology and general surgery have greatly increased its use over the last decade. The minimally
invasive approach is used today in many procedures
that previously required open laparotomy (1). Although once considered an absolute contraindication,
laparoscopic surgery during pregnancy is now more

1. Small abdominal incisions result in rapid postoperative recovery and early mobilization, thus
minimizing the increased risk of thromboembolism associated with pregnancy.
2. Early return of gastrointestinal activity due to
less manipulation of the bowel during surgery,

Address for correspondence: Nathan Rojansky, MD, Department of Obstetrics and Gynecology, Hadassah Ein-Kerem Medical Center, PO Box 12000, Jerusalem il-91120, Israel. Email:
rojan@cc.huji.ac.il
The authors have disclosed no significant financial or other
relationship with any commercial entity.
50

Laparoscopic Surgery During Pregnancy Y CME Review Article

which may result in fewer postoperative adhesions and intestinal obstruction.

3. Smaller scars.
4. Fewer incisional hernias.
5. Decreased rate of fetal depression due to decreased pain and less narcotic use (2).
6. Shorter hospitalization time and prompt return
to regular life.
It seems that in comparison with laparotomy, laparoscopic procedure may be better tolerated, especially by the pregnant patient, due to the minimal
postoperative discomfort and the prevention of an
abdominal scar in the presence of a growing uterus.
This has led to enthusiasm for and acceptance of this
minimally invasive surgery during gestation in several gynecological and nongynecological procedures.
Some concern have been raised by several authors
that laparoscopy may hold an increased risk to the
fetus: 1) It may decrease uterine blood flow by increasing intraabdominal pressure; 2) it may cause
fetal hypotension and hypoxia because of decreased
maternal venous return and cardiac output, and/or 3)
although not proven in humans, it may cause fetal
acidosis by CO2 absorption.
During the last decade, more than a few case reports and retrospective studies have appeared, evaluating the safety and specific risks inherent to laparoscopy during pregnancy. No prospective controlled
studies have been reported yet. We have undertaken
to review the current English literature and summarize the commutative knowledge on this subject. A
MEDLINE search of the last 10 years was performed
using the keywords: laparoscopy, pregnancy. The
most commonly reported laparoscopic procedures
during pregnancy are laparoscopic cholecystectomy,
appendectomy, and management of adnexal masses
such as ovarian detorsion, ovarian cystectomy, and
ectopic pregnancy.
NONGYNECOLOGIC OPERATIONS
Nongynecologic surgery is required in approximately 2 of each 1000 pregnancies (3). The most
commonly preformed operations in pregnancy are
cholecystectomy and appendectomy, which occur in
0.05% and 0.10%, respectively. We found 37 case
reports and small series for a total of 176 patients
who underwent such procedures during gestation
(Tables 1 and 2). Since surgical treatment of the
pregnant patient has the added potential risk of injury
to two patientsthe mother and her fetusthe obstetrician or gynecologist should be involved in the
management of these patients.

51

Cholecystectomy
Pregnancy has been associated with an increased
incidence of cholelithiasis, and although most
women are asymptomatic, biliary colic occurs in
approximately 0.05% to 0.1% of pregnant women
(4). However, timing of surgery in the pregnant patient with biliary tract disease is a controversial issue.
Patients with obstructive jaundice, acute cholecystitis
unresponsive to medical management, or peritonitis
should undergo prompt operative intervention in any
trimester. Operations on patients with recurrent attacks of biliary colic should be deferred until the
postpartum period if possible. If symptoms are too
frequent and severe, or if they are associated with
gestational weight loss, then the second trimester is
the safest time to perform surgery.
During the second trimester, the miscarriage rate is
only 5.6% compared with 12% in the first trimester.
In addition, the rates of preterm labor are very low
during the second trimester, as compared with the
potential risk of 40% for premature delivery in the
third trimester. Finally, the potential risk of teratogenesis during the second trimester is very small and
the uterus is still of such proportion that do not
obliterate the operative field as might occur during
the third trimester.
In a retrospective case-control study, Curet et al.
(3) compared 16 pregnant patients who underwent
laparoscopic surgery with 18 control patients who
underwent open laparotomy during their first or second trimester (Tables 1 and 2). In the study group, 4
patients underwent appendectomy and 12 underwent
cholecystectomy. They also selected another 41 patients from a literature survey to make up a total of 57
cases in their series. There was no difference between
laparotomy and laparoscopy outcomes in their series.
Moreover, the incidences of obstetric complications
were in the range seen in pregnant patients who did
not have any surgery. None of the delivery complications observed was related to the type of surgery
the patient underwent or the method of access into
the abdominal cavity. These data suggest that laparoscopic surgery can be performed safely in the pregnant patient during both the first and second
trimester.
Gouldman et al. (4) reported eight laparoscopic
cholecystectomies performed in pregnant patients
(one during the first trimester and seven during the
second trimester). CO2 insufflation pressure was 12
mm Hg, and in seven patients, a Hasson trocar was
used, whereas a Veress needle was used in another
patient. No postoperative complications to mother or

52
TABLE 1

Obstetrical and Gynecological Survey

Cholecystectomy during pregnancy
Author

Week Trimesters*

Adamsen et al. (29)

Amos et al. (24)

2nd
2nd

Andreoli et al. (30)

2nd

Arvidsson and Gerdin (31)

Auabara and Sirinek (32)
Bennett and Estes (33)
Chandra et al. (34)
Comitalo and Lynch (35)
Conron et al. (36)

2nd
1st, 2nd, and 3rd
2nd
1st
2nd
1st and 2nd

Constantino et al. (37)

Csaba and Orban (38)
Curet et al. (3)

2nd
2nd
1st and 2nd

Edelman (39)
Eichenberg et al. (40)
Elderling (41)
Fabiani et al. (42)
Friedman and Friedman (43)

2nd
3rd
1st, 2nd, and 3rd
2nd
14 weeks

Geisler et al. (44)

2nd and 3rd

Gouldman et al. (4)

Gurbuz and Peetz (45)

Hart et al. (46)

Lafrati et al. (47)
Jackson and Sigman (48)
Lanzfame (49)
Martin et al. (50)
Morrell et al. (25)
OConnor et al. (51)

1st and 2nd

1st, 4 patients
2nd, 7 patients
3rd, 4 patients
1st and 2nd
2nd
2nd
2nd and 3rd
2nd
2nd and 3rd
1st and 2nd

Pucci et al. (19)

Rusher et al. (52)
Schorr (53)
Shaked et al. (54)
Soper et al. (55)
Steinbrook et al. (56)
Weber et al. (57)
Williams et al. (58)
Wilson et al. (59)
Wischner et al. (60)

3rd
2nd
2nd
1st
2nd
1st, 2nd, and 3rd
2nd
2nd
2nd
2nd

Type of Operation

Number of
Cases
2
4

5 appendectomies

1
20
1
1
4
12

Uneventful
2 fetal deaths
2 incomplete abortions
1 premature contraction
resolved with tocolysis.
No preterm labor
Uneventful
1 spontaneous abortion
Uneventful
Uneventful
Uneventful
2 spontaneous abortions

2
1
4
12
1
4
5
1
1

Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
1 preterm labor
Uneventful
Uneventful
Uneventful

Tocolysis started in 6 patients by attending ob

Uneventful
Uneventful
Uneventful

10

5 Chol

Chol, Append, and diagnostic

Append & Chol

ERCP, sphincterotomy, stone

extraction, & Chol
6 Chol, 2 Append, & 1 diagnostic

8
10
5

Append

Follow-up

3
1
1
5
3
5
10

1
1
2
1
5
10
1
1
2
6

Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful, except for 1
conversion to an open
surgery at 26 weeks of
gestation due to size of
the gravid uterus.
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful
Uneventful

* Number indicates trimester, unless actual number of weeks are specified.

The operation was a cholecystectomy (Chol) unless otherwise indicated.
Append appendectomy; ERCP endoscopic retrograde cholangiopancreatography.

fetus were observed. Eight patients delivered babies

who were full-term and healthy, with no perinatal
morbidity or mortality. The authors suggest that laparoscopic cholecystectomy in pregnancy can be safely

and effectively performed for symptomatic cholelithiasis, especially when symptoms are recurrent or
persistent. Reedy et al. (5) sent out a questionnaire to
all members of the Society of Laparoendoscopic

Laparoscopic Surgery During Pregnancy Y CME Review Article

TABLE 2

53

Appendectomy during pregnancy

Author

Trimester

Andreoli (30)

2nd

Conron (36)

1st and 2nd

Curet et al. (3)

1st and 2nd

Geisler (44)

2nd and 3rd

Gurbuz (45)

1st (4 patients)
2nd (7 patients)
3rd (4 patients)

Type of operation*
5 Append
5 Chol
Chol, Appendectomy, and
diagnostic
Append
Cholecystectomy
6 Chol, 2 Append, and 1
diagnostic
Chol
Append

Number of
cases
10
12
4
12
9
10
5

Follow-up
1 premature contractions resolved with
tocolytics. No preterm labor
2 spontaneous abortions
Uneventful
Uneventful
Tocolysis was begun in 6 patients at the
discretion of the attending obstetrician.
Uneventful
Uneventful

* Append appendectomy; Chol cholecystectomy.

Surgeons and obtained complete information on 413

laparoscopic cases. They reported 134 laparoscopic
procedures performed in the first trimester, 224 in the
second trimester, and 54 in the third trimester. Five
postoperative spontaneous abortions were reported in
134 cases performed in the first trimester. There were
no spontaneous abortions reported in the second trimester. The incidence of miscarriage was that reported to occur spontaneously. Three intraoperative
complications considered to be to related to laparoscopic surgery were:
1. The placement of a Veress needle inside a
22-weeks gestation uterus. This was identified
before insufflation of CO2 and the needle was
withdrawn and replaced and the procedure
completed. The patient continued her pregnancy uneventfully and delivered a healthy infant at term.
2. Enterotomy at an open laparoscopy.
3. Severe upper abdominal pain caused by CO2.
This report is important because it is the first that
addresses the clinical safety and complications of
laparoscopy in pregnancy. The authors concluded
that their data lend support to the assumption that
laparoscopy in pregnancy seems to be safe.
In another study of the same group, Reedy et al. (6)
analyzed 2,015,000 deliveries in Sweden from 1973
to 1993 and found a total of 2181 laparoscopies and
1522 laparotomies performed in singleton pregnancies between the 4th and 20th weeks of gestation. For
infants weighing 2500 gm in both laparoscopy and
laparotomy groups, there was an increased risk of
premature delivery before 37 weeks of gestation and
an increased incidence of growth restriction compared with the total population. However, the authors
could not determine whether this increased risk was
related to the anesthesia, surgical procedure, or the

complication of pregnancy that necessitated the surgical intervention. There was no difference between
laparoscopy and laparotomy in cumulative infant survival up to 1 year. No difference in the rate of
malformation among laparoscopy, laparotomy, and
the total population was found.

Appendectomy
Appendicitis in the pregnant patient can be difficult
to diagnose and cannot be clearly distinguished by
gastrointestinal tract symptoms, description or location of pain, or physical examination. In addition,
leukocytosis is common in pregnancy, and the count
can be as high as 16.0 109 per liter in the third
trimester. A negative exploration rate of 35% to 50%
is commonly seen for symptoms of appendicitis during
the third trimester of pregnancy. The morbidity and
mortality seen in the pregnant patient with appendicitis
usually comes from a delay in diagnosis and treatment.
Patients with suspected appendicitis should undergo
immediate exploration, no matter which trimester of
pregnancy the symptoms occur (3).

GYNECOLOGIC LAPAROSCOPIC
PROCEDURES
Only a few small series and case reports concerning laparoscopic surgery during pregnancy have been
reported. We have found 18 such reports encompassing 132 cases of endoscopic gynecologic procedures
during pregnancy (Tables 3 and 4). Although these
procedures are performed with increasing frequency
to date, the use of laparoscopy during pregnancy is
still uncommon. However, the limited data available
support its safety and efficacy during pregnancy.

54

Obstetrical and Gynecological Survey

Adnexal Torsion
Adnexal torsion is an emergency condition where
the adnexa rotate on its pedicle compromising its
blood supply. Early diagnostic and therapeutic laparoscopy is of importance in preserving the adnexa,
inasmuch as it avoids negative unnecessary laparotomy and offers definitive treatment (7) (Table 3).
Torsion of the adnexa has been described as a
complication of ovarian hyperstimulation syndrome
(OHSS). It has been found that 75% of patients with
OHSS complicated by torsion were pregnant. This
observation emphasizes the importance of applying a
minimally invasive therapeutic approach in these
cases (8, 9). Shalev et al. (1012) have advocated
laparoscopy for diagnosis and primary treatment of
torsion. They reported 41 patients, including 10 pregnant patients, successfully managed by laparoscopy.
All the pregnant patients had had a favorable outcome. Others have reported similar favorable results
(see Table 3). Wittich et al. (7) reported a case of
successful laparoscopic detorsion during the first trimester of pregnancy where acute appendicitis was
diagnosed initially. The authors noted that pregnancy
progressed normally to term. Garzarelli et al. (8)
reported two cases of a patient with an ovarian cyst
with adnexal torsion in the first trimester that were
treated by laparoscopic aspiration of the cysts and
unwinding of adnexa. Progression of pregnancy was
uneventful in both cases. Levy et al. (2) reported
three cases of laparoscopic unwinding of an hyperstimulated adnexa during the second trimester of
pregnancy. In these cases, ovaries were first aspirated
and then untwisted and placed in their anatomical
position. In one case, bleeding appeared after the
unwinding, which necessitated laparotomy and ligation of the bleeding vessel. The authors concluded
that laparoscopic treatment of ovarian torsion is a
TABLE 3

safe procedure if special precautions (see Discussion) are adhered to and it can be carried out in
advanced gestation. In their opinion, laparoscopic
surgery should not be considered an absolute contraindication even during advanced pregnancy, but
there are actually very few cases reported in the
second trimester and none in the third trimester. One
of the three patients delivered three viable healthy
premature babies in the 27th week of gestation,
whereas the other two cases delivered at term.
Morice et al. (13) reported on six pregnant women
with adnexal torsion that were treated laparoscopically during 6 to 13 weeks of gestation. No miscarriages occurred. The authors concluded that in the
hands of the skilled surgeon, laparoscopy is well
suited for the diagnosis and treatment of adnexal
torsion occurring during the first trimester of pregnancy. They felt, however, that beyond 16 weeks of
gestation, or when there is suspicion of adnexal malignancy, laparotomy is preferable. In the latter case,
the authors recommend to carry out an open cystectomy because removal of the lesion permits a complete pathologic diagnosis and avoids recurrence of
torsion.
Adnexal Mass
The reported incidence of adnexal mass complicating pregnancy ranges from 1 in 81 to 1 in 2500 live
births with an average of 1 in 600 (1). Corpus luteum
cysts account for one third of the adnexal masses;
benign cystic teratomas contribute to another third.
Malignancy may occur in 2% to 5% of these patients
(1, 14) (Table 4).
Currently, conservative management of these simple cystic masses is recommended until the second
trimester. This often results in spontaneous resolu-

Adnexal torsion during pregnancy

Author

Trimester

Bider et al. (61)

1st and 2nd

Mashiach et al. (9)

1st and 2nd

Morice et al. (13)

6 13 weeks

Righi et al. (62)

Shalev and Peleg (11)
Shalev (12)
Wittich et al. (7)

1st
?
518 weeks
1st

Type of operation

Number of cases

Follow-up

Torsion of hyperstimulated
adnexa
Torsion of hyperstimulated
adnexa

Uneventful

12

4 untwisting followed by
puncture, 1 cystectomy,
1 untwisting
Oophoropexy
Aspiration and detorsion
Ovarian cyst unwinding
Right adnexal detorsion

2 OHSS, 3 functional cysts, 1

dermoid cyst
1
10 patients
4
1 patient

2 missed abortions, one PROM (with

IUFD) at 25 weeks, 2 ongoing
cases
Uneventful

Uneventful
Pregnancy unaffected
Positive outcomes
Uneventful

* OHSS ovarian hyperstimulation syndrome; PROM premature rupture of membranes; IUFD intrauterine fetal death.

1
12
2
39 patients

Puncture

Ovarian cystectomy
Cystectomy
Puncture
Management of adnexal
masses
Cystectomy

1 patient
Dermoid cystectomy

Reported uneventful until 35 weeks gestation

1 normal
1 preterm labor
1 laparotomy for uncontrolled bleeding
Uneventful
Uneventful
Uneventful
5 1st trimester miscarriages, 2 congenital
malformations
Uneventful

3
2

Uneventful. Except 1 irregular uterine contractions resolved with tocolytics.

One patient delivered at 35 weeks
Uneventful
Uneventful
7 (another 12 laparoscopies done
due to other indications)

Puncture and cystectomy

Puncture

No abortions or preterm deliveries

17 patients

Gasless laparoscopic ovarian

cystectomy
Ovarian cystectomy

Type of operation

Number of cases

Follow-up

Laparoscopic Surgery During Pregnancy Y CME Review Article

55

tion of non-neoplastic functional cysts (14, 15).

Masses that persist into the second trimester are
removed to prevent torsion or rupture during pregnancy, prevent possible obstruction at delivery, and
to rule out malignancy.
One study (16) suggests that elective removal of an
adnexal mass during pregnancy was less morbid than
removal of a symptomatic mass in an emergency
setting. To avoid the potential risks of a surgical
emergency, the authors recommended elective removal of any adnexal mass 6 cm that persists to the
16th week of gestation, regardless of its ultrasonic
appearance. Another study by Yuen and Chang (1)
reported on six pregnant women who underwent
laparoscopic surgery for persistent adnexal masses in
the second trimester. Laparoscopic removal of an
adnexal mass was performed in all patients without
any intraoperative or postoperative complications,
and all patients delivered healthy infants vaginally, at
term. They believe that with attention to the surgical
technique, laparoscopic removal of persistent adnexal mass during the second trimester of pregnancy
is safe and carries the same benefits over laparotomy
as in patients not pregnant. Parker et al. (15) presented a study in which 12 women who had laparoscopic removal of a benign cystic teratoma during
pregnancy (gestational age at surgery ranged from 9
to 17 weeks). No intraoperative or postoperative maternal or fetal complications occurred. From the
above mentioned reports, one can infer that laparoscopic surgery for treatment of gynecologic conditions during the first and second trimester is probably
safe and carries no substantial increase in complication rate.

6 27 weeks

1st trimester
1st trimester, 1 (?
early pregnancy)
16 weeks

2nd trimester

16 weeks
9 17 weeks
1st trimester
1st trimester

2nd trimester

Andreoli et al. (30)

Busine and Murillo (63)

Garzarelli and Marruca (8)

Levy et al. (2)

Nezhat et al. (65)

Parker et al. (15)
Shalev et al. (10)
Soriano et al. (66)

Yuen et al. (1)

Lang et al. (64)

1216 weeks

Week/Trimester
Author

Akira et al. (27)

TABLE 4

Ovarian cystectomy during pregnancy

DISCUSSION
It is difficult to differentiate between the effects of
surgery during pregnancy and the specific adverse
outcomes of laparoscopy during that period. The
relative effect of many factors on pregnancy is difficult to isolate. These include the indication for
surgery, type of surgery, maternal condition, type of
anesthesia, and the anesthetic agents used as well as
many other factors. Mazze and Kallen (17) published
the largest study on adverse outcomes after nonobstetric operations in patients who were pregnant.
Several important findings emerged from this study.
First, the incidence of stillbirths or congenital anomalies was not increased in each trimester when compared with the predicted incidence. Duncan et al. (18)
also reported similar results. Second, there was an
overall increase in low birth weight infants and ne-

56

Obstetrical and Gynecological Survey

onates who died within 7 days of delivery, probably

because of prematurity. The authors did not attribute
this last finding solely to the operation effect itself,
but considered the precipitating illness also as a
significant contributing factor to premature labor.
Finally, and most important, a total of 868 cases of
laparoscopy performed during pregnancy were reviewed; 768 in the first trimester, 29 in the second
trimester, and 71 in the third. There was no increased
incidence of adverse outcomes as compared with
matched controls.
The main specific complications of laparoscopy
during pregnancy are related to possible injury to the
enlarged uterus and ovaries situated outside the pelvis and to the cardiovascular and respiratory alterations introduced by the pneumoperitoneum pressure
and CO2 absorption.
1. Penetrating injuries are more likely to occur at
the beginning of the procedure when the insufflating needle is placed blindly (2). To avoid
this, the Veress needle, and subsequently the
trocar, should be inserted while simultaneously
pushing away the uterus and ovary or by elevating the abdominal wall to provide countertraction and to increase the distance between
the uterus and the abdominal wall. Furthermore, the needle can be inserted with the aid of
ultrasound guidance, pointing it away from the
enlarged uterus or in an alternate site (Palmer
Point). It is also possible to place the trocar by
an open technique or through an alternate site
as well (1, 2). It should be emphasized that no
instruments are inserted into the uterine cervix
or onto it for uterine manipulation during the
procedure.
2. Adequate pneumoperitoneum is essential for
visualization and performance of laparoscopic
procedures. However, this may be hazardous to
the pregnant woman who already has an altered
cardiovascular and respiratory function. The
Trendelenburg position and increased intraabdominal pressure might decrease the total lung
compliance and the functional residual capacity. The use of positive-pressure ventilation and
lower intraabdominal pressure overcome these
effects. In addition, high intraabdominal pressure might decrease venous return and cardiac
output resulting in reduction of uteroplacental
blood flow. The Trendelenburg position here
favors venous return, and an intraabdominal
pressure level below 15 mm Hg can minimize
this complication.

3. Another possible adverse effect is the rapid

CO2 absorption with an increase in arterial CO2
pressure and a concomitant possible decrease in
arterial pH that might affect the fetus. To date,
there is no evidence to support any detrimental
effect of the CO2 pneumoperitoneum on the
human fetus. Furthermore, it has been demonstrated that operative laparoscopy has little effect on maternal blood gases (1, 19). Given the
hyperdynamic nature of the pregnant circulation, any CO2 that diffuses across the placenta
should rapidly be removed. Nevertheless, controlled mechanical ventilation can effectively
maintain normal CO2 pressure in the majority
of patients (2). A study on the fetal response to
CO2 pneumoperitoneum in the pregnant ewe
confirms the lack of adverse effects of CO2
insufflation on the fetal placental perfusion and
blood gases (20). In the animal model, some
studies have shown a possible effect of CO2 on
fetal blood gases. Maternal and fetal hypoxemia, acidosis, and hypercarbia have been
noted in both sheep and baboons during insufflation with CO2. Southerland et al. (21)
showed decreased arterial oxygen tension and
pH and increased arterial to end-tidal CO2 gradient in the ewe and its fetus. Galan et al. (22)
in a study of four pregnant baboons found maternal respiratory acidosis in three of the four
animals. Fetal umbilical artery Doppler studies,
however, were unaltered immediately after insufflation
compared
with
baseline
measurements.
A significant fetal bradycardia occurred in one
baboon at 20 mm Hg of intraabdominal pressure.
Normal interval growth was shown by ultrasound 2
weeks after the procedure. Although showing possible alteration in fetal blood gases or pulse, these
reports were not related to poor perinatal outcome.
Furthermore, slight acidosis was reported to be normal and even beneficial (23). However, the effects of
moderate acidosis on the fetus are still unknown.
The absolute safety of laparoscopic surgery during
pregnancy in humans has yet to be established. In
1996, Amos et al. (24) reported seven cases of pregnant patients undergoing laparoscopic surgery
three appendectomies and four cholecystectomies.
There were four fetal deaths among them, three during the first operative week and another, 4 weeks
postoperative. Of five pregnant patients who underwent laparotomy for similar reasons, four subsequently progressed to term and one was lost to fol-

Laparoscopic Surgery During Pregnancy Y CME Review Article

low-up. The authors recommend caution when

considering nonobstetrical laparoscopic surgery in
pregnant women, and they speculate that the bad
outcomes in their series may be related to the pneumoperitoneum effect, demonstrated in animal studies, showing physiologic alterations in fetal blood
pressure and pulse with both tachycardia and bradycardia. Contrary to the very small series by Amos et
al. (24), the majority of studies and case reports
found in the literature report a favorable outcome. It
should be remembered, however, that any surgery
during pregnancy is not an innocent procedure, and
caution should always be exercised. Experienced
laparoscopic surgeons with strict adherence to good
technical and anesthetic principles have been successful in diminishing pregnancy-related laparoscopic complications, and together with good obstetrical management, successful outcomes can be
achieved in most patients (2, 3).
Suggested precautions that should be exercised
when laparoscopic surgery is performed in pregnant
patients include:
1. Intraoperative fetal monitoring may be performed routinely in these patients so that if fetal
distress develops, the pneumoperitoneum pressure can be diminished or the patient can be
hyperventilated in an attempt to correct the
problem. Intraoperative transvaginal ultrasound
fetal monitoring may be used, because transabdominal ultrasound monitoring may be impractical and problematic if the signal is lost during
abdominal insufflation.
2. The patient should be positioned in the left
lateral decubitus position to prevent uterine
compression of the inferior vena cava. This
may prevent further compromise in uteroplacental blood supply. Morrell et al. (25) have
suggested lateral rotation of the operating table
to displace the uterus.
3. A Hasson trocar open technique is safer to
prevent inadvertent puncture of the uterus, especially with increasing gestational age, although this point has not been investigated.
Ultrasonic guidance during insertion of a Veress needle can decrease the danger of injury to
the uterus.
4. Intraabdominal pressure should be kept as low
as possible and should be no higher than 15 mm
Hg.
5. Maternal end-tidal volume CO2 should be monitored and kept within the normal range. End-

57

tidal CO2 may not be sensitive enough to reflect

acute changes in arterial PCO2. Hence, it may
not be adequate as a guide to adjust pulmonary
ventilation during laparoscopic surgery. Consequently, arterial PaCO2 monitoring has been
recommended. Others (26) have suggested continuous transcutaneous CO2 pressure measurements as well as squeeze end-tidal CO2 pressure (at large tidal volume) to be of clinical
value in trending and preventing hypercarbia
during laparoscopic surgery. In experimental
animals, hyperventilation has not been sufficient to prevent hypercarbia and acidosis (21
23). Also, maintenance of maternal end-tidal
CO2 in the low to mid-30s did not prevent
adverse events in the report by Amos et al. (24).
However, laparoscopy in Amos series was performed for conditions generally felt to increase
the risk of fetal loss. Gasless laparoscopy was
proposed by Akira et al. (27) and Tanaka et al.
(28) as a safe alternative to standard laparoscopy during pregnancy. Whether this newer
approach is better for this purpose is unclear
and awaits additional data.
6. Tocolytic agents need not be used prophylactically, but can be administered if the patient demonstrates uterine irritability or contractions.
7. A gestational age of 26 to 28 weeks seems to be
the limit for successful completion of laparoscopic surgery. Late in the second trimester, the
size of the uterus interferes with adequate visualization of intraabdominal organs. The increasing uterine size may necessitate changes
in port-site placement to other places rather
than periumbilical site as the pregnancy
progresses.
In conclusion, surgical procedures during pregnancy are uncommon and laparoscopic procedures
are even less common. Many doctors still hesitate to
use the minimally invasive approach due to lack of
solid data on its safety and possible adverse effects
on gestation. From this literature review, it seems
that laparoscopic surgery is safe and advantageous
for both the mother and her fetus when performed
by an experienced team. A final conclusion, however, can be reached only when far more experience has been gained to evaluate the safety, appropriate indications, patient selection, efficacy, and
complication rate of this new surgical approach
during pregnancy.
References (2966) can be found in the tables.

58

Obstetrical and Gynecological Survey

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