Laparoscopic surgery in the pregnant patient--one surgeon's experience in a small rural hospital.

OBJECTIVES: The laparoscopic treatment of urgent surgical conditions that develop in pregnant patients has not been extensively addressed in the current literature. It is a potential issue to which surgeons, especially rural surgeons, should give careful consideration, prior to being faced with an urgent situation during the delivery process. This report details 1 surgeon's experience over a 5-year period with laparoscopic surgery in the pregnant patient, primarily laparoscopic cholecystectomy, at a small rural Nebraska hospital.
METHODS: Eleven laparoscopic operations were conducted in 10 patients.
RESULTS: One patient underwent 2 separate operations: cholecystectomy at 6 weeks gestation and reduction of ovarian torsion/appendectomy at 20 weeks. One patient, at term, underwent combination cesarian delivery and laparoscopic cholecystectomy. Three patients underwent laparoscopic cholecystectomy during their third trimester of pregnancy. All patients had severe signs and symptoms that threatened successful term gestation and/or failed attempts at conservative medical management aimed at delaying cholecystectomy until after delivery. One complication occurred involving uterine perforation with a blunt 10-mm port canula. No fetal injury occurred, and after initial recovery from the cholecystectomy, the baby was successfully delivered later in the pregnancy via cesarian delivery without adverse sequelae.
CONCLUSION: Urgent laparoscopic operations can be carried out successfully in pregnant patients throughout their pregnancy, even in remote locations lacking immediate on-site availability of subspecialty care. The surgeon must be skilled in surgical obstetrics and well trained and experienced in advanced laparoscopic techniques. It is recommended that the same lines of communication and referral for subspecialty involvement be in place as would be required in the management of premature delivery of pregnant patients without surgically urgent disease. Such lines of communication should be developed before the actual need arises. The rural surgeon must have a plan of action well in advance of that first encounter or any subsequent complication.

INTRODUCTION

The past 15 years have been a time of tremendous surgical innovation with respect to the minimalization of invasiveness. The laparoscopic technique has been the key that has unlocked the approach to the surgical treatment of several conditions, while becoming an application utilized within multiple surgical specialties. This has been the result of the demonstration that the approach is safe, while providing an advantage to the patient in terms of decreased pain and debility. As surgeons gain more operative experience with the various laparoscopic techniques, an increase follows in technical competence that can serve as the basis for the confident application of that skill in more demanding circumstances. One such demanding circumstance is the pregnant patient who develops an urgent surgical condition. If the setting is a small rural hospital well removed from on-site subspecialty access, that circumstance might be intimidating. Such encounters might present at any time, and the involved surgeon must be prepared to make treatment decisions based on the patient's condition, the surgeon's ability, and the available support mechanisms.

As many small town surgeons can attest, patients do not always follow the statistical norms with regards to prevalence or pathophysiologic behavior. A remote location does not offer the surgeon protection from the statistically unusual encounter. Therefore, it becomes important, especially for the rural surgeon, to plan for the unexpected.

PATIENTS AND METHODS

Tri-County Hospital is a 40-bed facility serving the 8,500 people of Lexington, Nebraska, and several surrounding, even smaller, rural communities. One general surgeon and 6 family practitioners serve this population. Subspecialty support in Omaha is a little over 200 miles away. Urgent patient transportation is subject to weather constraints.

Over the past 5 years, 1,276 births have taken place at Tri-County Hospital. Eleven laparoscopic operations were performed on 10 of the pregnant patients in this series. A single surgeon, the author, conducted all of the operations.

All patients had severe signs and symptoms that threatened successful term gestation and/or failed attempts at conservative medical management aimed at delaying operation until the postpartum period.

RESULTS

The operative incidence was 0.86%. The majority of the procedures were conducted for gallbladder disease (.

One unusual patient had the distinction of requiring 2 separate operations during the same pregnancy: cholecystectomy at 6 weeks gestation and reduction of ovarian torsion and appendectomy at 20 weeks gestation. One patient, at term, underwent combination cesarian delivery and laparoscopic cholecystectomy. Three patients underwent laparoscopic cholecystectomy during their third trimester of pregnancy.

One complication occurred involving the perforation of a uterus via manipulation of a blunt 10-mm port canula while attempting to insert the camera-telescope into the canula. No fetal injury resulted, and no uterine repair was required. An immediate telephone consultation was obtained with a perinatologist in Omaha. Recommendation was made for completion of the laparoscopic cholecystectomy and follow-up monitoring for uterine irritability. After initial recovery from the laparoscopic cholecystectomy and discharge from the hospital, the patient successfully delivered the baby later in the pregnancy via cesarian delivery without adverse sequelae. The cesarian delivery was prompted by an episode of premature labor; however, that could have been related to the previous uterine injury.

DISCUSSION

The pregnant patient has a set of physiologic circumstances that promote the dysfunction of the biliary and gastrointestinal systems, while making the precise diagnosis of such conditions more difficult than if the patient was not masked by the pregnant state. Pregnancy induces a variety of mechanical, hormonal, and chemical alterations that may confuse and mislead even the most experienced surgeon. A surgeon's natural inclination, when faced with a pregnant patient experiencing abdominal pain is to temporize. This tendency, which generally arises from the misconception that surgical intervention may injure the fetus, is responsible for delays in diagnosis and ultimately for the unfavorable outcomes often associated with acute abdominal pathology in pregnant patients.[1] Laparoscopy during pregnancy is no more dangerous to either the mother or the fetus than laparotomy.[1]

The conditions that present most commonly in the pregnant patient, which are of importance to the surgeon, are cholecystitis and appendicitis. Appendicitis does not occur more commonly in the pregnant patient than in the nonpregnant patient. Appendicitis may be more difficult to diagnose in the pregnant patient. This is due, in part, to the progressive shift in the position of the appendix and cecum (cephalad and lateral) as the pregnancy advances. Also usually some degree of white blood cell count elevation exists with pregnancy. Anorexia, nausea, and vomiting caused by pregnancy itself are also fairly common. Delay in diagnosis until after generalized peritonitis has developed can result in a fetal loss rate of 15% to 33%.[1,2,3] Initially, laparoscopic appendectomy was considered controversial,[4] but more recent literature advocates the laparoscopic approach in the pregnant patient.[3, 5]

Cholelithiasis occurs 2 to 3 times more often in women than in men. Gallbladder kinetics are altered during pregnancy. Both gallbladder volume during fasting and residual volume after contracting in response to a meal are twice as large after the first trimester as they are in the nonpregnant state. Incomplete emptying and stasis of bile may result in inflammation and in the formation and retention of cholesterol crystals and subsequently the formation of gallstones. Presumably, the very high progesterone levels of the second and third trimesters of pregnancy are responsible for diminished gallbladder activity. Progesterone has been shown to impair gallbladder response to exogenously administered cholecystokinin in experimental animals.[2, 6]

The reported incidence of a surgical condition arising in a pregnant patient is 0.1% to 2.0%.[1,2,6,7] However, an individual surgeon's experience may be quite variable and significantly lower or higher than that reported in the sparse literature. Every pregnant patient who presents with abdominal findings consistent with an acute surgical problem must be considered a potential patient in need of surgical intervention.

The surgical literature surrounding the treatment of pregnant patients with urgent surgical conditions has demonstrated a spectrum of treatment recommendations. Much of the early, prelaparoscopic approach literature simply suggests delaying definitive treatment until after the pregnancy has run its course or, conversely, initiating emergency surgical treatment when needed and applying the same criteria for operation as in the nonpregnant patient. Generally, when surgery is thought to be indicated in the pregnant woman, procrastination should be avoided. Delay might place the woman and her fetus in greater jeopardy.[1, 2, 5] The initial question was which approach, open or laparoscopic, was to be utilized. Recently, a shift in discussion has taken place advocating the laparoscopic approach to treat the involved conditions during pregnancy.[5, 8] The discussion has become more focused on the timing of the controlled, elective laparoscopic intervention, relative to the stage of gestation, with general agreement that the second trimester is the optimum point for that intervention.[1, 4] Obviously, if circumstances demand intervention in the first trimester, such action is acceptable. Of particular interest is the transition of opinion regarding operation during the third trimester, namely the shift from it being considered a relative contraindication to one of acceptable practice.[3, 9, 10] This is contingent on the surgeon's technical competence and the individual patient's abdominal and uterine configuration being appropriate to accommodate the approach. The opinion is growing that laparoscopic operation is safer than open operation with regards to risks of the pregnancy-specific operative complications of uterine injury and premature labor.[3, 8, 11]

The largest series of laparoscopic cholecystectomies in pregnancy yet reported consists of the Connecticut state experience of 20 patients over a 5-year period.[8] This statewide experience was compared to a concurrent group of pregnant patients undergoing open cholecystectomy. It was found that the laparoscopic group had fewer episodes of premature contractions and fetal distress. This advantage is in addition to the generally lower risk of postoperative wound infection associated with minimally invasive surgery and the decreased morbidities of discomfort, debility, and disfigurement.

Complications will occur. The complication rate is difficult to determine, due to the rarity of the situation and the few reports in the literature. There also may be a reluctance to report complications.

The important aspect of a complication is not so much that one may occur but how the surgeon responds in the management of the complication. The rural surgeon must have a lifeline of communication available for support and advice during the episode of intervention with the pregnant patient and utilize it freely should any complication ensue. It is best to have that network of support established prior to the laparoscopic encounter, which requires some forethought. That planning should include a realistic assessment of the surgeon's laparoscopic training and expertise, what immediate support is available at the local hospital, and what support is available at a distance. This pre-event contact with other surgeons, perinatologists, pediatricians, and the primary care providers will facilitate the correct treatment approach to potential complications while decreasing the adverse emotional reaction that might otherwise result from being unprepared at a time of crisis.

CONCLUSIONS

Urgent laparoscopic operations can be safely conducted in pregnant patients and in any trimester, but the surgeon should use individual patient assessment in making the choice for the method of approach within the technical limits of ability and physical circumstance. Elective operations for persistent symptoms are safest and perhaps technically easiest if performed in the second trimester. The surgeon must be skilled in advanced laparoscopic techniques and in surgical obstetrics. In a rural setting, the surgeon should have a well thought out plan of action to deal with potential operative complications and have subspecialty communication support readily available.

Table 1.

Laparoscopic Operations Among 1276 Pregnant Patients October 1995 - September 2000

Patient	Age	Trimester			Operation
		1st	2nd	3rd	Cholecystectomy	Appendectomy	Other
1	26	X			X
2	17			X	X
3	19			X	X
4	28		X		X
5	34		X		X
6	27			X*	X
7	23			X†	X
8	19		X		X
9	22	X			X
9	22		X			X	X
10	21		X		X
Totals	2	5	4	10	1	1

Combination cesarian delivery and laparoscopic cholecystectomy

Complication of uterine perforation