Operative laparoscopy in advanced pregnancybeyond 20 weeks

Laparoscopy in advanced pregnancy

TOG 2020

It is estimated that 0.5–2% of women will require non obstetric surgery during pregnancy, yet
operative laparoscopy after 20 weeks of gestation remains uncommon.

The most common indications for nonobstetric surgery during pregnancy are acute appendicitis, acute cholecystitis and torsion of adnexal masses.

Advancing pregnancy had been considered a contraindication to a laparoscopic approach, but there
is growing evidence of its safety profile in all trimesters.

Why operate laparoscopically?

They include a reduced length of hospital stay, faster return to work, less postoperative pain and lower
incidences of postoperative ileus, venous thromboembolism and wound site infection.

Pregnancy specific benefits include reduced maternal hypoventilation and neonatal respiratory depression secondary to reduced maternal opiate requirements.

Adnexal mass

The incidence of adnexal mass in pregnancy is 2% and, currently, conservative treatment is usually
advised for cystic lesions <6 cm in size.

Technical considerations for laparoscopy in pregnancy beyond 20 weeks of gestation

Anaesthetic concerns

there is no evidence of associated increased risk of teratogenicity,19 miscarriage,
preterm labour or intrauterine demise.

From 16 weeks of gestation onwards, a combination of delayed gastric emptying, reduced lower oesophageal sphincter tone and increased pressure from the gravid uterus means there is a greater risk of aspiration pneumonitis.

Antacid prophylaxis and elective orogastric or nasogastric tube insertion should be considered.

Patient positioning

A left lateral tilt should be applied to the maternal
position when manoeuvring into the Trendelenberg or reverse Trendelenberg position.

Entry and port placement

Both the open (Hasson) and closed (Veress) entry techniques have been used safely in pregnancy.

In advanced pregnancy, Palmer’s point (subcostal, left upper quadrant) entry, using a blunt-ended trochar, may minimise the risk of uterine injury and optimise visualisation.

Alternatively, a supra-umbilical incision can be utilised (3–6 cm above the umbilicus).

Intra-abdominal pressures

The lowest operating pressure (<12 mmHg) should be used, but if visual access is impaired, pressures of up to 15 mmHg can be used safely.

Laparoscopy in advanced pregnancy: techniques

The surgeon should use the method that they are most familiar with.

1. A 10-mm incision is made horizontally at the umbilicus (Figure 2), which is then everted
   using Littlewood forceps
2. A Langenbeck retractor is used to facilitate access to the deeper layers of the anterior
   abdominal wall
3. Sharp, blunt dissection is performed to expose the umbilical stalk, which is grasped by
   Littlewood tissue forceps and delivered into the wound (Figure 3)
4. A 1-cm vertical incision is made in the umbilical stalk, incising the linea alba
5. The linea alba is grasped by two Dunhill artery forceps on either side and the peritoneum is
   opened under direct vision using a knife or scissors (Figure 4)
6. The incision is checked with the tip of the finger to ensure no adherent bowel loops
7. The trochar is inserted under direct vision (Figure 5) and the pneumoperitoneum created by
   connecting the CO2 insufflator to the trocar to an initial pressure of 20 mmHg (this can be
   reduced later to maintenance of 12 mmHg)
8. A 360° check is performed.

Palmer’s entry

1. Clinical examination is performed before incision to ensure no splenomegaly
2. Consideration is given to emptying the stomach with an orogastric or nasogastric tube
3. A small incision is made with a scapel in the left mid-clavicular line, 2–3-cm below the costal
   margin, and the Veress needle is inserted so it enters the skin perpendicularly (Figure 6)
4. Palmer’s (Figure 7) and pressure profile tests are performed to check for correct
   intraperitoneal placement
5. Insufflation with CO2 is performed to 20 mmHg (which can be reduced later to a
   maintenance level of 12mmHg).
6. The incision is increased to 5 or 10 mm to allow trochar insertion.
7. The trochar is inserted into the pneumoperitoneum and a 360° check is performed.

Top tips for laparoscopy in advanced pregnancy

1. Ensure an experienced surgeon and anaesthetist are present
2. Give antacid prophylaxis
3. Consider nasogastric tube insertion
4. Apply a left lateral tile to avoid aortocaval compression
5. Perform any change of position slowly
6. Consider using Hasson entry (supra-umbilical incision)
7. Consider Palmer’s point entry
8. Consider the use of ultrasound to facilitate entry
9. Use operating pressures of 10–12 mmHg
10. Auscultate the fetal heart prior to and after surgery.

About the Author

admin

Administrator

Visit Website View All Posts