Laparoscopic surgery for non-obstetric acute abdomen in pregnancy: A retrospective case series review.

BACKGROUND: Laparoscopic techniques have been used during pregnancy by obstetricians since the 1970's, primarily to diagnose and treat ectopic and heterotopic pregnancies. Pregnancy was considered as an absolute contraindication to laparoscopy by surgeons as recently as 1991, and a few still doubt the safety of minimal access in gravid patients. When an emergent operation is indicated, the surgery should not be withheld on the sole basis of patient's gravid state. On the contrary, the alleviation of maternal disease is thought to take priority because the health of the foetus is dependant on the mother.
MATERIALS AND METHODS: This is a retrospective study of a case series of 18 obstetric patients who presented with non-obstetric causes of acute abdomen requiring surgical intervention. Ultrasonography and magnetic resonance imaging (MRI) along with other laboratory investigations were carried out to reach the diagnosis. Laparoscopic surgery was considered as the modality of treatment. All the patients were given the necessary care post-surgery and were followed up till parturition to look for any complications.
RESULTS: The data were analysed considering the presentation, diagnostic variations and the surgical modifications statistically.
CONCLUSION: The decision of surgery should be prompt and should be weighed against complications of conserving the patient. Due to the diagnostic limitations of ultrasonography, MRI should be coupled to confirm the diagnosis. Laparoscopy offers less analgesic requirements and shorter hospital stay. The operative time is highly subjective to the experience and training of the surgeon and the laparoscopic set-up itself.

INTRODUCTION

Abdominal pain during pregnancy may result from a myriad of pathologies, including surgical problems such as appendicitis, acute cholecystitis and small bowel obstruction, obstetric problems such as ectopic pregnancy, miscarriage, placental abruptions and normal physiologic changes such as stretching of the round ligaments.[1] While early diagnosis and treatment usually translates into improved maternal and foetal outcomes, reaching correct diagnosis can be a challenge due to the confounding physiologic changes of pregnancy. Surgical intervention during pregnancy strives to alleviate maternal disease while concurrently minimising foetal harm. Acute surgical disease in and of itself increases maternal and foetal morbidity and mortality; the severity of the underlying surgical disease, as opposed to the surgery itself, may be the strongest factor influencing maternal and foetal outcome.[2] When a gravid patient presents with an acute abdomen, the risks and benefits to both the mother and foetus must be weighed for each step of the workup and treatment plan. When an emergent operation is indicated, the surgery should not be withheld on the sole basis of patient's gravid state. On the contrary, the alleviation of maternal disease is thought to take priority because the health of the foetus is dependent on the mother. The risks of surgery during pregnancy have been reduced by improvements in both maternal perioperative care and neonatal care, nevertheless, 'any surgery during pregnancy is not an innocent procedure and caution should always be exercised'.[34]

The common non-obstetrical emergencies complicating pregnancy are acute appendicitis, cholecystitis and intestinal obstruction. The most common cause of acute abdomen in pregnancy is appendicitis. The incidence ranges from 1:2000 to 1:6000.[56] The physiological changes in pregnancy pose some challenges for the correct diagnosis (anorexia, nausea and vomiting). Nevertheless, majority of the patients (>80) present with classic right lower quadrant pain. Given the difficulties and the delays in diagnosis, there is a high incidence of perforation that ranges from 25% to 66% in cases of delayed surgical intervention.[7] Acute cholecystitis is the second most common cause of acute abdomen during pregnancy occurring in 1 in 1600–10000 pregnancies.[2] Cholelithiasis is the cause of cholecystitis in 90% of cases. The incidence of cholelithiasis in pregnant women undergoing routine obstetric ultrasound examinations is 3.5%–10%.[8]

Aim and objectives

To study management strategy of surgical acute abdomen in obstetric patients and the complications of laparoscopic intervention with review of pre-existing guidelines for holistic approach.

MATERIALS AND METHODS

This is a retrospective study of 18 obstetric patients who presented with non-obstetric causes of acute abdomen in a tertiary centre and required surgical intervention for acute abdomen from January 2012 to May 2018. Institutional Ethics Committee approval was obtained. All patients were examined in detail and their history and findings were entered in a case recording pro forma. The patients were included in the study based on the following inclusion and exclusion criteria.

Inclusion criteria

All pregnant patients requiring surgical intervention for acute abdomen irrespective of gestational age were included in this study.

Exclusion criteria

The exclusion criteria were:

All patients treated by conservative management or open conventional surgery.

All patients with true labour pain.

All patients underwent ultrasonography as a primary radiological investigation. Magnetic resonance imaging (MRI) was used as a second-line investigation in most of the patient to confirm the diagnosis. Other relevant laboratory investigations were also carried out. All patients were consulted with obstetrics and gynaecology department regarding the status of maternal and foetal well-being both pre-operatively and post-operatively. All patients received one pre-operative antibiotic dose of ceftriaxone 1 g or piperacillin-tazobactam 4.5 g depending on radiological and biochemical parameters which was continued up to 3 post-operative days. Patients were operated with minimal access approach in general anaesthesia and were placed in supine position with a left lateral tilt of 15° to prevent aortocaval compression. Port position for laparoscopy surgery was determined based on gestational age and the disease in contention. Open Hasson's technique was used for primary port, which was supraumbilical in patients with gestational age <24 weeks and midway between the epigastrium and umbilicus for more than 24 weeks. Rest of the ports were placed under direct visualisation to achieve triangulation. Carbon dioxide insufflation pressure was kept at 12 mmHg with initial flow rate of 3 l/min. Dissection was carried with standard technique and intra-abdominal drains were placed depending on the severity of contamination of the peritoneal cavity. All patients were given compression stockings perioperatively which was continued till patients were ambulatory. Intravenous paracetamol 500 mg 12 hourly was used as analgesic for only a few patients. Patients were monitored in the post-operative period and were given the required supportive management. All patients were followed up till their parturition for any complication and morbidity. A note was made about the term and mode of delivery and development of foetus and the newborn.

RESULTS

A total of 18 patients were included for analysis based on the inclusion and exclusion criteria. All 18 patients presented with pain in abdomen with the mean duration being 3.37 days. Amongst 18 patients presenting with pain in abdomen, 9 patients had pain in right lumbar area, 7 patients in right hypochondriac area, 1 patient had peri-umbilical pain and 1 patient had right iliac fossa pain. Out of the 18 patients, 15 patients gave a history of fever, the mean duration of fever being 2 days. The mean gestational age was 26.44 weeks with the earliest being 20 weeks and the latest being 34 weeks. Amongst 18 patients, 12 patients were nulliparous, while 6 patients were multiparous with the highest parity being 2. Out of 6 multiparous patients, five multiparous patients had a history of previous Lower Segment Cesarian Section (LSCS). One patient also had a past history of open appendectomy. All 18 patients had leukocytosis with the average being 22,938.88/dl and the range was 11,000/dl–36,000/dl. Ultrasonography was done for all patients and MRI was done in 14 patients.

Amongst 18 patients, 55.55% (n = 10) had pathologies related to appendix and 44.45% (n = 8) had pathologies related to gall bladder. Amongst patients with acute appendicitis, 50% (n = 5) had perforation. In 8 patients with gall bladder pathology, 37.5% of patients (n = 3) had perforation. All the 18 patients were managed laparoscopically without conversion.

The mean operative time for laparoscopic cholecystectomy was 48.6 min and for laparoscopic appendectomy was 47.2 min. Intra-operative wash was given in 13 out of 18 patients. Foetal heart rate was normal in all cases post-operatively. The mean hospital stay of the patient was 3.37 days for laparoscopic cholecystectomy and 3.2 days for laparoscopic appendectomy. Post-operative analgesia was achieved with injection paracetamol 500 mg 12 hourly up to post-operative day 1 in 9 patients, however, 2 patients needed additional analgesia up to post-operative day 2. There were no complications seen in any of the 18 patients. All patients were followed up until parturition. There was 1 incidence of spontaneous abortion after 15 days of laparoscopic gangrenous cholecystectomy.

DISCUSSION

In acute appendicitis, diagnostic difficulties may arise particularly in the second and third trimesters due to atypical symptomatology associated with the changes in the appendiceal position as it is displaced upwards by the enlarged uterus. The most suggestive symptom is right lower quadrant pain which is found in 80% of cases.[9] However, tenderness can also be localised in the right flank, the right lumbar fossa, and sometimes even in the right upper quadrant. Rebound tenderness (55%–75% of cases) and muscular guarding (55%–65%) are classical signs; they can be partially masked, but should always be sought. Anorexia, nausea and vomiting are present in 87% of cases,[10] but these symptoms are also commonly seen in early pregnancy.

In acute cholecystitis, symptoms are almost identical to those in non-pregnant patients and include nausea and vomiting, dyspepsia, fatty food intolerance and colicky right upper quadrant pain or epigastric pain that may radiate to back. However, Murphy's sign is less relevant in advanced stage pregnancy. When interpreting laboratory findings, it is important to remember that an elevated alkaline phosphatase level is physiological in pregnancy. Ultrasound is the investigation of choice and has 95%–98% sensitivity for detecting gall stones.[11]

The mean gestational age was 26.44 weeks. Amongst the 18 patients, 66.66% (n = 12) were nulliparous while 33.33% (n = 6) were multiparous. In the study done by Turgal, Mert et al.[12] on a series of 24 cases of non-obstetric acute abdomen, similar data has been demonstrated.

Ultrasonography was done for all 18 patients and was diagnostic in 77.77% (n = 14) cases. MRI was done in 14 patients and was diagnostic in 92.85% (n = 13) cases. Ultrasonography accuracy is highly variable and depends on the experience of the operator; the sensitivity and specificity ranges from 50% to 100% and 33%–92%, respectively.[13] Chromosomal mutations, neurologic abnormalities, mental retardations and leukaemia due to cumulative radiation in excess of 10 rads rule out computed tomography (CT) scan as a routine diagnostic tool [Table 1].[1415] However, the diagnostic accuracy of CT during pregnancy is similar to that of normal population with a sensitivity and specificity of 92% and 99%, respectively. We did not use CT scan as a diagnostic modality. MRI is then the second diagnostic modality with a sensitivity of 100% and a specificity of 94%.[16] The cumulative radiation in pregnancy should be restricted up to 5–10 rads.[17]

Table 1

Radiation Exposure

Study	Radiation exposure (rads)
Abdominal radiograph	0.1-0.3
Intraoperative cholangiography	0.2
Lumbar spine radiograph	0.6
Intravenous pyelogram	0.6
Barium enema	0.7
CT of pelvis	1–5
ERCP (without pelvic shielding)	2–12.5

CT: Computed tomography, ERCP: Endoscopic retrograde cholangiopancreatography

Out of 18 patients, 55.55% (n = 10) were diagnosed with acute appendicitis and 44.45% (n = 8) were diagnosed with gall bladder pathology. Amongst the 10 patients with appendicitis, 50% (n = 5) had perforation and amongst 8 patients with gall bladder pathology, 37.5% (n = 3) had perforation. In the study done by Sunitha et al.[18] on 18 patients with non-obstetric acute abdomen, acute appendicitis was seen in 33.33% (n = 6) patients and cholecystitis was seen in 33.33% (n = 6) patients. In another study done by Rather and Salati,[19] the incidence of acute appendicitis was 53.06% (n = 26) and acute calculus cholecystitis was seen in 16.32% (n = 8) cases. We chose laparoscopic surgery as the modality of management for all the patients. Review of literature has shown that there are hardly any statistical differences between open and laparoscopic approach for management and outcome of acute abdomen in obstetric patients.[20]

Due to risk of aortocaval compression all patients were kept in supine position with a left lateral tilt of 15°. All patients were given compression stockings intra-operatively and were continued till they were ambulatory to minimise the risk of deep vein thrombosis. Pre-operative antibiotic prophylaxis was given and was continued till post-operative day 3. The choice of antibiotic was carefully selected to avoid teratogenicity. According to SAGES guidelines,[21]'initial access can be safely accomplished with an open or Hasson's technique, Verees needle or optical trocar'. We had used Hasson's technique for initial access in our study. Port positions were adjusted with the primary port being midway between the epigastrium and umbilicus for all cases above or with gestational age of 24 weeks, while it was adjusted to supraumbilical for all cases below 24-week gestational age. All working ports were adjusted according to gestational age and put under direct vision [Table 2].

Table 2

Demographic data with diagnosis and management

Age (years)	BMI	Gestational age (week)	Diagnosis	Confirmatory investigation	Surgery	Camera port	Working port	Drains
21	24.44	22	Gangrenous Gall bladder	MRI	Lap cholecystectomy	Supraumbilical	Standard	Yes
25	28.33	29	Acute appendicitis	Usg + MRI	Lap appendectomy	Epi-Umb	Rt hyp-epi	Yes
22	25.97	22	Gall Bladder calculus	Usg + MRI	Lap cholecystectomy	Supraumbilical	Standard	No
30	29.29	30	Gangrenous Gall bladder with perihepatic collection	MRI	Lap cholecystectomy	Epi-Umb	Higher	Yes
24	21.96	26	Gall bladder perforation	Usg + MRI	Lap cholecystectomy	Epi-Umb	Higher	Yes
20	21.13	25	Acute appendicitis with local perforation	MRI	Lap appendectomy	Epi-Umb	Rt hyp-infraumb	Yes
22	26.56	28	Perforated appendix	Usg	Lap appendectomy	Epi-Umb	Rt hyp-infraumb	Yes
26	28.67	34	Gall bladder calculus	Usg	Lap cholecystectomy	Epi-Umb	Higher	No
20	23.38	24	Acute appendicitis	Usg	Lap appendectomy	Epi-Umb	Rt hyp- Lt ilf	No
22	23.43	26	Perforated appendix	MRI	Lap appendectomy	Epi-Umb	Rt hyp- Lt ilf	Yes
24	27.50	28	Perforated appendix	Usg+MRI	Lap appendectomy	Epi-Umb	Rt hyp- Lt ilf	Yes
21	27.34	30	Gall bladder calculus	Usg+MRI	Lap cholecystectomy	Epi-Umb	Higher	No
22	23.11	26	Acute appendicitis	Usg+MRI	Lap appendectomy	Epi-Umb	Rt hyp- Lt ilf	No
23	22.06	20	Acute appendicitis with abscess	Usg+MRI	Lap appendectomy	Supraumbilical	Rt hyp-epi	Yes
22	26.66	30	Acute appendicitis with Peritonitis	Usg+MRI	Lap appendectomy	Epi-Umb	Rt hyp-epi	Yes
26	29.03	30	Gall bladder calculus	Usg+MRI	Lap cholecystectomy	Epi-Umb	Higher	No
27	24.21	22	Acute appendicitis	Usg	Lap appendectomy	Supraumbilical	Rt hyp-epi	No
23	24.44	24	Gall bladder calculus	Usg	Lap cholecystectomy	Epi-Umb	Rt hyp-epi	No

Epi-Umb: Epigastrium and umbilicus, Rt hyp-epi: Right hypochondriac and epigastric region, Rt hyp-infraumb: Right hypochondriac and infraumbilical region, Rt hyp-Lt ilf: Right hypochondriac and left iliac fossa, Usg: Ultrasonography, MRI: Magnetic resonance imaging

Most surgeons recommend using lower than normal maximum pressure to achieve pneumoperitoneum during pregnancy. However, the benefits of minimising pneumoperitoneal pressure must be weighed against impaired visualisation which may lengthen operative time and increase risk of iatrogenic injuries. We operated with pneumoperitoneal pressure at 12 mmHg and had mean operative time of 48.6 min for laparoscopic cholecystectomy and 47.2 min for laparoscopic appendectomy.

There were no complications seen in any of the patients post-operatively. Intravenous paracetamol 500 mg was chosen as the analgesic drug due to less toxicity and foetal respiratory suppression seen with opioids. The mean duration of hospital stay was 3.66 days with laparoscopic cholecystectomy patients and was 3 days for laparoscopic appendectomy cases. There were no conversions to open surgery in any of the patients. All patients were followed till their parturition. Out of the 18 patients, 9 patients had LSCS due to obstetric cause, 8 patients had normal vaginal deliveries and 1 patient had spontaneous abortion after 15 days of surgery. None of the patients had pre-term labour.

However, we would like to emphasise that the low rate of maternal and foetal complications can be attributed to shortened operative time, which in turn is based on laparoscopic training and experience with developed skills to perform complex and advanced laparoscopic procedures.

CONCLUSION

Acute abdomen in pregnant patients should be dealt with extreme caution due to the various diagnostic challenges. The decision of surgery should be prompt and should be weighed against complications of conserving the patient. Due to diagnostic limitations of ultrasonography, MRI should be coupled to confirm the correct diagnosis. Laparoscopic surgery can be safely performed in experienced hands in these patients with minor modifications. Care should be exercised in selection of drugs and thromboprophylaxis must be practiced. Laparoscopy offers less analgesic requirement and shorter hospital stay and theoretically decreased incidences of wound dehiscence with continued pregnancy. The operative time, which was previously considered as a bane of laparoscopic surgery is highly subjective to the experience and training of the surgeon and the laparoscopic set-up itself to perform such complex surgeries to decrease risk of maternal and foetal complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.