We read with interest the paper published by Buser KB in JSLS. 2009;13:32-35. The author is to be congratulated on his work; this being quite an uncommon condition and most publications in the literature are case reports. It essentially deals with the safety and efficacy of laparoscopic procedures in pregnant patients. An important message conveyed is the safety of laparoscopy in the third trimester as well, while the current recommendation states that the second trimester is ideal for any surgical intervention. This series of laparoscopy in pregnancy represents the largest reported so far.Interestingly, our series was the largest until this paper was published.[1] Also in our paper, we presented for the first time 2 unique cases: laparoscopic mesh repair for diaphragmatic hernia and laparoscopic seromyotomy for achalasia cardia.Because Dr Buser is discussing the role of advanced laparoscopy in pregnancy, we thought he might have mentioned these cases.In acute appendicitis without complications, we have quoted the rate of fetal loss as 0% to 1.5%,[2] whereas Dr Buser has stated 3% to 5% in his article.First, I would like to thank you for your kind consideration of my paper reporting on my results for laparoscopic surgery in the pregnant patient. I would agree that your series, and that detailed in my paper, indicate that the fetal loss rates in cases of acute appendicitis are probably lower than the range reported in the previous literature reviews. I agree that the types of highly advanced laparoscopic procedures upon which you have reported are certainly technically feasible during pregnancy and can be performed safely by those with sufficient skills and practice in the conduct of such procedures. A point that I hoped to make in my paper, and would like to reiterate here, was that my patients were selected for operation because they had severe symptoms or conditions that could have adversely affected the outcome of their pregnancies or placed the patients or their fetuses, or both, at risk for severe morbidity or even mortality without operation. I am still of the opinion that if symptoms are minimal, in nonappendicitis cases, it would be prudent to delay operation until the pregnancy has run its course, if such delay would not place the patient or fetus at risk. In gallbladder disease, the patient and her referring caregiver must be made aware of what signs and symptoms would alter the plan into a more rapid surgical intervention. One gallbladder attack or an episode of gallstone pancreatitis should prompt one into action, as these conditions can be highly unpredictable.Similarly, if more rare conditions, such as diaphragmatic hernia or achalasia, are adversely affecting the course of a pregnancy, operation could be recommended in such patients, but if the conditions are coincidental and not a threat to the pregnancy and symptoms are minimal, I would favor delay until the pregnancy has concluded.