The field of laparoscopic general surgery has exploded since the first laparoscopic cholecystectomy was found performed in the late 1980s.Initially, pregnancy was considered an absolute contraindication to laparoscopic surgery. Recent clinical reports have demonstrated the feasibility, advantages, and potential safety of laparoscopic cholecystectomy in the pregnant patient. However, concerns about the effects of a carbon dioxide (co2) pneumoperitoneum on mother and fetus persist, resulting in controversy and concern.
 

Nongynecologic surgery is required in 0.2% of all pregnancies.
 

1. The safest time to operate on the pregnant patient is during the second trimester when the risks of teratogenesis, miscarriage, and preterm delivery are lowest. The incidence of spontaneous abortion is highest in the first trimester (12%0), decreasing to 0%by the third. During the second trimester there is a 5%-8% incidence of preterm labour and premature delivery which increases to 30% in the third trimester. In addition, the risk of teratogen esis seen in the first trimester. In addition, the risk of teratogenesis seen in the first trimester is no longer present during the second trimester. Finally, the gravid uterus is not yet large enough to obscure the operative field, as in the case during the third trimester.
 

2. The most common indications for operation on the pregnant patient are acute appendicitis and biliary tract disease. Biliary tract disease: gallstone are present in 12% of all pregnancies, and a cholecystectomy is performed in 3 to 8 of 10,000 pregnancies.
 

I. An uncomplicated open cholecystectomy in a pregnant patient should be accompanied by a 0% maternal mortality, 5% fetal loss, and 7%preterm labor.
 

II. Complications such as gallstone pancreatitis or acute cholecystitis will increase maternal mortality to 15% and demise to 60%.
 

3. Patients with uncomplicated biliary colic should be treated medically with nonfat diets and pain medications until after delivery. Patients who present in the first trimester of pregnancy with 
 

a. Acute appendicitis occurs in 1 out of 1500 pregnancies. Accurate diagnosis becomes more difficult as the pregnancy progress: a correct preoperative diagnosis is given for 85% of patients evaluated in the first trimester of pregnancy, but accuracy is only 30%-50% in the third. the usual hallmarks of acute appendicitis such as abdominal pain, accompanying gastrointestinal symptoms and leukocytosis may already be present in abnormal third-trimester pregnancy, obscuring the correct diagnosis. In addition, the description and location of the pain may change significantly as the uterus enlarges. the morbidity and mortality seen in the pregnant patient with acute appendicitis results ion after from a delay in diagnosis and treatment. This delay leads to a 10 to 15%perforation rate .fetal mortality has been shown to increase with perforation from 5% to 28%, while premature delivery can be as high as 40% in this situation.. therefore, the pregnant patient suspected of having acute appendicitis should be treated as if she were not pregnant. Immediate exploration after appropriate resuscitation is mandated regardless of gestational age.
 

III. crescendo biliary colic or persistent vomiting should be medically managed if possible until they are in the second trimester. Pregnant patients in the second trimester. pregnant patients in the of second trimester of pregnancy who present with the foregoing complications of biliary tract disease will need operative treatment during the second trimester after appropriate resuscitation.
 

Patients with these complications who present in the third trimester   pregnancy should be treated conservatively until after delivery if possible or at least until a gestational age of 28 to 30 weeks, to maximize fetal viability.

 

B. Advantages and feasibility of laparoscopic surgery during pregnancy
 

Potentially, laparoscopic surgery in the pregnant patient should result in the proven advantages of laparoscopy seen in the nonpregnant patient; decreased pain ,earlier return of gastrointestinal function, earlier ambulation, decreased hospital stay, and faster return to routine activity .in addition  ,decreased rate of premature delivery due to decreased uterine manipulation, decreased fetal depression secondary to decreased narcotic usage, and a lower rate of incisional hernias may be seen in the pregnant patient.
 

To date, over 320 laparoscopic cholecystectomies in pregnant patients have been reported in the literature. average operative time was 68.5minutes (30-106 minutes) and average length of stay was 1.9 days (1-7) days. There is no report of a maternal and fetal death and 5 additional fetal deaths, one of which occurred after conversion. Of 268babies delivered at time of publication,10 were premature and one was born with hyaline membrane disease at 37 weeks gestation .the remaining 257 were full ,term and healthy .seven of these experienced preterm labor, which was controlled with tocolytics.

Two studies have retrospectively compared pregnant patients undergoing open laparotomy to pregnant patients undergoing laparoscopic surgery and found that the latter resumed regular diet earlier, required less pain medication, and were hospitalized for a short time. These differences were statistically significant. 
 

there have been 15 reports detailing77 undergoing laparoscopic appendectomies. The average time in the operating room was 56 minutes (30-85minutes),with mean length of stay of 3.7 days (1-11 Days) .there have been 4 fetal reported; 2 secondary to pneumoamnion after uterine puncture with veress needle .four patients delivered prematurely, while 58 patients delivered healthy infants at term. Four of these experienced preterm labor, which was controlled with to colytics.
 

C. Disadvantages and con concerns about Laparoscopic surgery during pregnancy
 

Concerns about laparoscopic surgery in the pregnant patient center on three areas:
 

1. Increased intra-abdominal pressure can lead to decreased inferior vena caval return resulting in decreased cardiac output. The fetus is dependent on maternal hemodynamic stability. The primary cause of fetal demise is maternal hypotension or hypoxia, so a fall in maternal cardiac output result in fetal distress.
 

2. The increased intra-abdominal pressure seen with a pneumoperitoneum could lead to decreased uterine blood flow and intrauterine pressure, both of which could result in fetal hypoxia. 
 

3. Carbon dioxide is absorbed across the peritoneum and can lead to respiratory  acidosis in both mother and fetus. Fetal acidosis could be potentiated by the decreased vena caval return.

 

Animal studies raise several concerns about the effects of a co2 pneumoperitoneum on the mother and fetus. Because of the complexity of the maternal-fetal unit, it is useful to summarize these individually;
 

1. In pregnant baboons, a co2 pneumoperitoneum held at 20mm hg pressure for 20 minutes resulted in increased pulmonary capillary wedge pressure, pulmonary artery pressure, and central venous presaure. The mother developed arespiratory acidosis despite controlled ventilation and an increase in respiratory rate. One fetus developed severe bradycardia, which responded to desufflation.
 

2. In pregnant eves, no change in maternal placental blood flow was seen after 2 hours of 13mm hg pressure. however, maternal and fetal respiratory acidosis developed. fetal tachycardia, fetal hypertension, an increase in intrauterine pressure, and a decrease in uterine blood flow were also seen in the pregnant ewes undergoing aco2 pneumoperitoneum at15 mm hg.
 

3. Maternal respiratory acidosis and severe fetal respiratory acidosis are common findings in all studies utilizing a co2 pneumoperitoneumin pregnant animals .changes inrespiratory rate did not completely corrects the problems. Despite these problems, one study demonstrated that the ewes delivered full term  healthy lambs following intraabdominal insufflations to 15mm hg pressure with co2 for one hour
 

4. The physiologic changes exhibited by the pregnant ewe fetus during insufflations with co2 are not present with nitrous oxide. Fetal tachycardia, hypertension , and acidosis, as well as maternal acidosis, are not present when a nitrous oxide pneumoperitoneum is used in animal studies .use of nitrous oxide as an insufflating gas in the oregnant women has yet to be evaluated, but may prove to be safer than co2.
 

D. Guidelines
 

The following practices should be followed when one is performing laparoscopic surgery in the pregnant patientto minimize adverse effects on the fetus or mother. More information is given in the SAGES guideline for laparoscopic surgery during pregnancy (see appendix).
 

1. Obtain an obstetric consultation for the perioperative management of the patient.
 

2. Be aware of the cardiovascular and pulmonary physiologic changes seen with pregnancy, including relative anemia, increased cardiac output and heart rate, increased oxygen consumption, increased tidal volume, and compensatory respiratory alkalosis.
 

3. Pregnant patients are at increased risk of aspiration because of decreased lower esophageal sphincter pressure and delayed gastric emptying.
 

4. Place the patient in the left lateral decubitus position as with open surgery to prevent uterine compression of the inferior vena cava. minimizing the degree of reverse Trendelenburg position may also further reduce possible uterine compression of the vena cava.
 

5. Use antiembolic devices to prevent deep venous thrombosis. Stasis of blood in the lower extremities is common in pregnancy. levels of fibrinogen and factors vii and xii are increased during pregnancy leading to an increased risk of thromboembolic events. These changes, coupled with the decreased venous return seen either increased intraabdominal pressure and the reverse trendendelenburg position used during laparoscopic surgery, significantly increase the risk of deepvenous thrombosis.
 

6. An open Hassan technique for gaining access to the abdominal cavity is safer than a closed percutaneous puncture. several authors have inserted veress needle in the right upper quadrant without complications, but the potential for puncture of the uterus or intestine stillexists, especially with increasing gestationalage and has been reported in 4 cases.
 

7. Maintain the intra-abdominal pressure as low as possible while still achieving adequate visualization. A pressure of less than 12 to 15mm hg should be used until concerns about the effect of high intraabdominal pressure on the fetus are answered.
 

8. Continuously monitor maternal end-tidal co2 and maintain it between25and 30mm by changing the minute ventilation. promptly correcting any evidence of maternal respiratory acidosis is critical, as the fetus is typically slightly more acidotic than the mother.
 

9. Use continuous intraoperative fetal monitoring if the fetus is viable. if fetal distress is noted, release the pneumoperitoneum immediately. The use of monitoring if the fetus is not viable is controversial, but is recommended by this author because disinflation may reverse fetal distress, preventing serious problems. If intraoperative monitoring is not used, then fetal heart tones should be documented pre-and postoperatively. transabdominal ultrasound fetal monitoring may not be effective because the establishment of the pneumoperitoneum may decrease fetal heart tones, so intravaginal ultrasound may be necessary for intraperative monitoring.
 

10. If introperative cholangiography is to be performed, protect the fetus.
 

11. Minimize operative time .several studies have demonstrated a correlation between the duration of a co2 pneumoperitoneum and an increase in portial pressure of arterial co2.
 

12. Tocolytic agents should not be administered prophylactically but are appropriate if there is any evidence of uterine irritability or contraction.
 

13. Trocar placement.
 

A. Biliary tract disease .place a hasson trocar above the umbilicus .place the reaming ports under direct visualization in the usual locations.
 

B. Appendicitis/diagnostic laparoscopy. Place a hasson trocar in the subxiphoid region .insert the camera and locate the appendix or other inflammatory process. insert the remaining trocars in locations appropriate to the pathology. For appendicitis, this will usually be the right upper quadrant at the costal margin and in the right lower quadrant. occasionally, an additional port might need to be placed just above the uterus. if the uterus is too large and appendectomy cannot be performed laparoscopically then laparoscopic visualization of the appendix may help determine the best location for the open incision. The best location for the open incision.

 

In conclusion, animal studies indicate that a co2pneumoperitoneum causes fetal acidosis, which may not be corrected by changes in maternal respiratory status. these intraoperative finding do not appear to have any long-term adverse effect on the fetus. the pregnant patient clearly benefits from laparoscopic surgery and should be offered this option as long as the foregoing guidelines are followed.