Video Description
The purpose of this educational video is to provide an overview of the guidelines and indications for laparoscopy in pregnancy.
We will review preoperative, intraoperative and postoperative considerations for laparoscopy in this patient population. Although historically contraindicated in pregnancy, laparoscopy is now the preferred treatment approach to surgical conditions in pregnancy and is considered safe in all trimesters.
In this video, we review topics such as patient positioning, recommendations for venous thromboembolism prophylaxis and appropriate monitoring for preterm labor. We also review and demonstrate options for safe laparoscopic port entry and surgical techniques to aid with visualization.
We aim to provide a thorough approach to laparoscopy in this unique patient population.
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Affiliations
University of Calgary
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Video Transcript: Laparoscopy in the Pregnant Patient
In this video, we will review the topic of laparoscopy in a pregnant patient. We will be providing an overview of the guidelines on laparoscopic surgery in pregnancy, discussing the indications for non-obstetric surgery in a gravid patient and reviewing preoperative, intraoperative and postoperative considerations.
Historically, laparoscopy was considered contraindicated in pregnancy due to concerns relating to uterine or fetal injury and uterine hypoperfusion. Over time, and with surgical experience, laparoscopy has become the preferred treatment in a gravid patient.
Some of the advantages of laparoscopy include decreased operative time, length of stay, postoperative pain and overall faster recovery. The advantages of laparoscopy in pregnancy include decreased complication rates, such as preterm birth, fetal respiratory depression, VTE, adhesion formation, better visualization and decreased wound infection.
Indications for laparoscopy in pregnancy can be divided into several categories. Obstetric indications include surgery for heterotopic pregnancies as well as cervical cerclage.
Here, we demonstrate a 14-week gravid uterus in a patient who has had prior second trimester losses. She underwent a prophylactic laparoscopic cerclage, as can be seen here, with the placement of the suture at the level of internal loss.
Gynecologic indications for surgery in pregnancy include ectopic pregnancy, adnexal mass and torsion and myomectomy. In this video, we demonstrate a laparoscopic myomectomy in a 26-year-old woman at 19 weeks gestation with a large, 19 cm pedunculated fibroid which failed medical management.
As can be seen here, a suture was placed to ligate the base of the pedunculated fibroid, and an electrosurgical device was used to detach the pedunculated fibroid from the uterus. Other surgical indications include appendicitis, cholecystitis, bowel obstruction and, more recently, fetal surgery.
Planning for laparoscopy in pregnancy. We will now review some important considerations when planning laparoscopic surgery in pregnancy. We will break it down into three sections, including preoperative, intraoperative and postoperative considerations. Preoperative planning includes knowing whom to notify, what medications to order and what kind of fetal surveillance is necessary.
When considering surgery in a pregnant patient, we recommend a multidisciplinary approach involving obstetrics, anesthesia, preferably obstetrical anesthesia, and pediatrics.
Being in a unit where these teams are available is important, especially when performing surgery after 23 weeks, in case of imminent or preterm delivery. Antibiotic administration depends on the clinical situation and type of surgical procedure.
In pregnancy, VTE prophylaxis is recommended in women undergoing surgery. One option is to use medical prophylaxis, such as low-molecular-weight heparin if the duration of surgery is over 45 minutes and mechanical prophylaxis, such as pneumatic compression devices if the expected duration is under 45 minutes. Depending on the clinical scenario, steroids, tocolytics, and magnesium sulphate can be considered. Laparoscopy is not listed as an Rh-sensitizing event and is, therefore, not routinely recommended.
If fetal surgery is being performed at a pre-viable gestational age, pre and postoperative fetal heartrate auscultation are sufficient. If the fetus is considered to be viable, fetal heart rate and contraction monitoring should be performed pre and postoperatively to ensure fetal wellbeing and the absence of contractions.
Intraoperative considerations include the anesthetic type and safety, patient positioning, access and visualization. A general anesthetic is recommended for laparoscopic surgery. There is no concern for teratogenicity when using usual concentrations, regardless of gestational age. And no evidence of harm on fetal brain development when the exposure time is under three hours.
As of 16 weeks, the gravid uterus can compress venous return. Therefore, a left lateral tilt is necessary. This can be achieved by tilting the entire OR table or by placing a wedge under the patient’s right side. When changing positions, it is important to do so in a gradual fashion.
When planning for abdominal entry, it is important to consider the anatomical differences caused by the gravid uterus, including the displacement of intra-abdominal organs and overall increased vascularity.
In this example of a 19-week uterus, one option for entry is in the left upper quadrant, 2 to 3 cm below the costal margin in the midclavicular line. Use of a nasogastric tube to empty the distended stomach is recommended prior to using the left upper quadrant. Other entry points include the subxiphoid and right upper quadrant. The Veress needle, Hasson or optical trocar are all considered safe approaches.
Gradual pneumoperitoneum to a pressure of 50 mm in mercury is safe. Once obtained, the initial port should be placed 5 cm above the uterine fundus when possible. Here, we see the insertion of a balloon trocar in the subxiphoid space under direct visualization.
The location of accessory ports depends on the surgical procedure being performed. However, as a general rule, ports will need to be more cephalad as gestation advances.
It has also been recommended to place ports on the ipsilateral side of the pathology so as not to pass instruments across the gravid uterus. In cases where the uterus is palpated below the entry point, gentle traction can be placed to displace it while an accessory port is inserted under direct visualization.
Some techniques to improve visualization include the Trendelenburg position. The use of a fan retractor, as shown here, where the retractor is used to support the uterus in order to get a better view posteriorly.
Here, we see a 5 mm, 30 degree scope being transferred from one port to another in order to obtain a better view. We now have a different vantage point and can see the pedunculated fibroid from above.
Postoperatively, fetal heart rate assessment and monitoring for signs and symptoms of preterm labour should be performed. Progesterone is recommended if surgery is done on the adnexa prior to 12 weeks. Pain management includes the use of acetaminophen and opioids when necessary. Steroids and magnesium sulphate are case-dependent.
Vaginal delivery and pushing in a second stage are not contraindicated following laparoscopic surgery in pregnancy.
In summary, one in 500 women requires surgery during pregnancy. Laparoscopy has become the preferred treatment and is safe during all trimesters.