Laparoendoscopic single-site cholecystectomy in a pregnant patient.

Feasibility and safety of laparoscopic cholecystectomy during pregnancy for patients with symptomatic or complicated gallstone disease is well established. Laparoendoscopic single-site cholecystectomy (LESS-chole) is a new modality in which the entire surgery is undertaken via a transumbilical incision. We describe a 33-year-old patient who underwent a LESS-chole in the 20(th) week of pregnancy for gallstone disease complicated by episodes of obstructive jaundice and acute pancreatitis. This is the first reported case of LESS-chole performed using conventional laparoscopic instruments. The technical aspects as well as the various perioperative measures utilized to undertake this procedure safely are outlined.

INTRODUCTION

The incidence of gallstone disease including colic, acute cholecystitis, and biliary pancreatitis varies from 1-8/10,000 pregnant women per year.[1] Generally, presentation in the first trimester is treated with conservative therapy followed by a laparoscopic cholecystectomy (LC) in the second trimester. Those presenting in the second trimester can be offered LC in the same trimester. Open cholecystectomy was considered a better option for patients requiring surgery in the third trimester. However, recent SAGES guidelines for diagnosis, treatment, and use of laparoscopy in pregnancy suggest that LC can be safely carried out even in the third trimester.[2]

LESS-chole is a relatively new approach and its main proposed benefit appears to be improved cosmesis. A recent meta-analysis that pooled data from seven randomized trials suggested that LESS-chole is a safe procedure with postoperative outcomes similar to that of LC.[3] In particular, the incidence of postoperative complications appeared to be no higher than that after LC. The patient described here is the first reported case of LESS-chole in a pregnant patient using conventional instruments. The technique and the perioperative measures utilized to undertake this procedure safely are outlined.

CASE REPORT

A 33-year-old woman in the 16th week of her first pregnancy experienced two episodes of upper abdominal pain suggestive of biliary colic. Hematological and biochemical parameters were normal but ultrasonography showed previously undiagnosed multiple small gallbladder calculi. Two weeks later she experienced another episode of abdominal pain during which the liver function tests including bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase were marginally elevated. An endoscopic ultrasound (EUS) showed a patulous ampulla indicative of a recently passed bile duct stone and normal calibre bile ducts. At this point she was referred for a surgical consultation and was counselled regarding a LESS-chole. While awaiting her surgery scheduled 3 days later she developed another episode of abdominal and back pain. The serum amylase and lipase were elevated but the white cell count, liver function tests, serum calcium, and lactate dehydrogenase (LDH) were normal. This episode of mild acute pancreatitis settled within 48 h and a repeat EUS was normal. A LESS-chole was undertaken during the same admission. At the time of surgery she was in the 20th week of her pregnancy. An obstetric consultation was obtained and she was started on inj. terbutaline (Bricanyl, Astra-Zeneca, Mumbai, India) 5 mg subcutaneously on the evening before the surgery. Fetal heart monitoring was initiated on the morning of surgery and continued at an interval of 2 h in the postoperative period until discharge.

OPERATIVE TECHNIQUE

The surgery was performed under general endotracheal anesthesia with the patient in supine position with the legs split apart and secured to boards. Capnographic monitoring was done and intermittent pneumatic calf compression was used intraoperatively. A 1.5 cm transumbilical incision was made, skin flaps were dissected, and the underlying fascia was cleared for a distance of 2.5 cm all around. The peritoneum was lifted up with small Kocher's forceps and opened carefully. A 10 mm metal cannula with a blunt trocar was inserted and a carboperitoneum of 10 mmHg was established. The patient was positioned in an anti-Trendlenburg position with the right side elevated by around 40°. Preliminary survey with a 5 mm, 51 cm, 30° laparoscope connected to an HD camera system (Karl Storz, Tuttlingen, Germany) showed the uterus to be present just below the umbilicus and the gallbladder to be thin-walled without any adhesions. The small bowel had been pushed up and lay in the right upper quadrant [Figure 1]. A second low-profile 5 mm cannula was introduced under vision through the same skin incision but through a separate fascial puncture to the right side of the primary cannula [Figure 2]. A “puppeteer” technique described in detail previously was used for the LESS-chole.[4] A 2-0 nylon suture (Ethilon, Johnson and Johnson, Mumbai, India) on a partially straightened-up curved needle was introduced inside the abdomen. The back end of the suture had been pre-tied into a knot with multiple throws. The needle was passed through the fundus of the gallbladder and then through the undersurface of the rib cage. The needle was retrieved and then passed out of the abdominal wall just below the costal margin. Steady traction on the exteriorized suture brought the knot tied at the end of the suture to lie against the gallbladder like a stopper and further traction on it elevated the fundus towards the rib cage. The suture was secured to the drapes with a hemostat thus establishing a sustained cephalad retraction of the gallbladder. A second suture of 1-0 nylon on a straight needle was introduced to the right of the falciform ligament, two passes were made through the Hartmann's pouch and the suture was locked. This suture exited laterally just under the costal margin and acted as a “dynamic traction suture”[4] allowing the gallbladder to be rotated medially and laterally. The Calot's triangle was dissected to obtain the “critical view” and the 5 mm laparoscope was shifted to the 5 mm cannula. The cystic artery and cystic duct were clipped with a reusable clip applicator introduced through the 10 mm cannula and divided [Figure 3]. The gallbladder was excised from the liver bed, the fossa was irrigated, and hemostasis was confirmed. The specimen was placed in a plastic pouch and extracted through the 10 mm fascial incision. Both the fascial incisions were approximated with nonabsorbable sutures and the skin was closed with fine subcuticular absorbable suture. The skin incision and fascia were infiltrated with a local anesthetic. The procedure lasted 40 min and the blood loss was negligible.

Figure 1

Preliminary laparoscopic view of the uterus and small bowel. Gallbladder is seen in the distance

Figure 2

A 10-mm and a low-profile, 5-mm cannula at the umbilicus

Figure 3

Division of the clipped cystic duct

Perioperatively, she received three intravenous doses each of 1.5 gm cefuroxime (Supacef, Glaxo Smith-Kline, Mumbai, India) and 1 gm paracetamol (Perfalgan, Bristol Meyers-Squibb, Mumbai, India). The subcutaneous terbutaline was continued twice daily till discharge. She tolerated liquids and diet on the evening of surgery and was discharged 48 h postoperatively. No oral analgesics were required after discharge. She followed-up a week after surgery at which time the incision appeared to have healed well and was pleased with the cosmetic outcome. She went on to deliver a healthy baby boy in the 37th week of her pregnancy.

DISCUSSION

LESS is rapidly becoming accepted surgical approach to a variety of pathology but there are only two previous case reports describing its use in pregnancy. Topgul et al.,[5] performed a LESS-chole in a 24-week pregnant woman through a 2 cm incision using an access device (SILS port) along with a roticulating grasper, dissector, scissors, and a 5 mm endoclip applicator (Covidien, Dublin, Ireland). Svahn et al.,[6] reported a LESS appendectomy in a 27-week pregnant patient with acute appendicitis utilizing a glove-port made from a wound retractor device introduced through a 2 cm umbilical incision and a 5 mm 30° laparoscope. Our experience of over 225 LESS-chole using conventional instruments until the time of performance of this case (data under review for publication) had convinced us that the procedure could be safely undertaken without specialized and expensive disposable devices and instruments. This expertise prompted us to offer a LESS-chole to this pregnant patient.

The patient was counseled regarding the likelihood of her requiring placement of additional ports, as is our practice in all patients offered a LESS procedure. Although recent SAGES guidelines[2] indicate that routine use of tocolytics is not warranted in patients undergoing laparoscopy in pregnancy, we were guided by the judgment of the obstetrician and our patient received tocolytics in the perioperative period. As recommended in these guidelines, fetal heart rate monitoring was undertaken only in the pre- and postoperative periods but was not utilized intraoperatively. This recommendation has been prompted by the absence of intraoperative fetal heart rate abnormalities in pregnant women undergoing laparoscopic surgery.[7]

The various intraoperative measures instituted to add to the safety of the surgery merit highlighting. Pregnancy is a hypercoagulable state with a 0.1-0.2% incidence of deep venous thrombosis (DVT).[8] To mitigate this risk, intraoperative pneumatic calf compression device was used and she was placed in an exaggerated left lateral decubitus position to allow the gravid uterus to fall away from the inferior vena cava. Also, the carboperitoneum was maintained at 10 mmHg as against 12 mmHg, which is the pressure we use for all our laparoscopic cases. Near absence of pain at the LESS-chole incision allowed her to ambulate within a few hours of surgery, thus further reducing the risk of DVT. During LESS-chole, it has been our practice to induce carboperitonuem with a Verres needle followed by a sharp first cannula in an effort to minimize the gas leakage from the fascial incision. In this patient, however, we chose to place the first cannula using an open method so as to safeguard the underlying uterus. Having visually confirmed the position of the upper edge of the uterus, the second 5 mm cannula was placed as its entry was observed by the laparoscope placed in the primary cannula. During traditional LC, anti-Trendlenburg position of the patient ensures that the small bowel gravitates towards the pelvis. In our patient, the gravid uterus had pushed the small bowel upwards and it lay in the right upper quadrant throughout the procedure. Extra care was taken by the cameraperson to withdraw the laparoscope and observe the passage of each introduced instrument towards the Calot's triangle. The integrity of the insulation on all instruments used in conjunction with electrocautery was meticulously checked before surgery to guard against accidental electrical injury to a loop of small bowel lying in the path of the instrument.

The 51 cm, 30°, 5 mm laparoscope, we routinely use for LESS-chole allows the cameraperson's hand to move away from the abdominal wall, thus avoiding clashing of the surgical instruments with the camera. This allows us to use standard, reusable laparoscopic instruments, and makes the procedure cost-effective. We routinely use the “puppeteer” technique for LESS-chole that emulates a multi-port LC by providing adequate cephalad fundal traction. Further, the suture placed on the Hartmann's pouch allows its rotation medially and laterally so that the Calot's triangle can be dissected safely to obtain the “critical view”. While performing a LESS-chole we always maintain a low threshold for placement of additional cannulas when challenged by an intraoperative difficulty. In this patient, however, the LESS-chole could be completed uneventfully. The gallbladder was extracted after placing it in a plastic pouch to minimize the chance of wound infection. Aware of the fact that the increased abdominal pressure in pregnancy would produce stress on the umbilical incision, care was taken to meticulously close the fascial incisions with nonabsorbable sutures. To reduce the postoperative pain, all the carbon dioxide was carefully evacuated at the end of the surgery and the umbilical incision was generously infiltrated with local anesthetic. The minimal postoperative pain our patient experienced after LESS-chole was a distinct benefit as the dosage and duration of analgesics could be kept to a minimum.

In conclusion, LESS-chole can be safely undertaken using conventional instruments in pregnant patients. Minimal pain after this approach leading to reduction in postoperative analgesic medication and early ambulation are of great benefit in pregnant patients. However, in this setting the surgery should only be undertaken by surgeons with considerable expertise in LESS as well as LC. Careful attention to the technical details as well as specific pre-, intra- and postoperative measures as outlined in this report ensure a successful outcome. Larger studies confirming benefits of LESS-chole are required before this method becomes the standard of care for gallstone disease in pregnancy.