Laparoscopic cholecystectomy ok in pregnancy: 150 successful cases.
When performed improperly, laparoscopic cholecystectomy can cause life-threatening injuries. In addition, many aspects of its use during pregnancy are controversial, including whether and when to operate; how and where to place trocars; the type and duration of fetal monitoring; the safety of insufflation gases and best insufflation pressure; the role of cholangiography; and the potential long-term effects on the fetus.
Nearly 4% of pregnant women develop asymptomatic cholelithiasis. Acute chotecystitis is the second most common nonobstetric emergency (after appendicitis) during pregnancy, occurring in 1-6 per 10,000 pregnancies and requiring surgery in 40% of cases.
Multiparity has been associated with an increased risk for developing gallstones, he said at an international congress of the Society of Laparoendoscopic Surgeons.
Traditional medical dogma says to delay the surgery until after delivery, but some surgeons perform laparoscopic cholecystectomy in patients with repeated episodes of pain or biliary complications such as choledocholithiasis or pancreatitis. Most patients can be managed with bed rest, analgesics, intravenous fluids, and nasogastric suction if emesis is severe. Antibiotics are appropriate in complex cases. Many physicians use prophylactic antibiotics to prevent sequelae of acute cholecystitis, but this remains controversial, said Dr. Lanzafame of Rochester (N.Y.) General Hospital.
Clinical signs of biliary colic and acute cholecystitis are similar in pregnant and nonpregnant patients: mid-upper gastric or right-upper quadrant pain in 60%-90% of cases; colic in more than 95% of acute cholecystitis cases; and nausea, vomiting, and fatty food intolerance in 30%-50% of cases.
Murphy's sign is less common in pregnancy. Fever and tachycardia may be present. Five percent of jaundice cases that develop during pregnancy can be traced to biliary causes.
Of the reported laparoscopic cholecystectomies that were done during pregnancy, most were performed in the second trimester, although the surgery has been done in all three trimesters. Most cases were managed medically in the first trimester. The third trimester poses the most challenges for laparoscopic cholecystectomy, because increased uterine size increases the risk for maternal or fetal injury, he commented.
"One has to be wary of placing trocars too low on the abdomen, because one will not be able to see over the horizon of the uterus," Dr. Lanzafame said.
Use sequential compression or heparin or both to avoid deep vein thrombosis, and rotate or reposition the patient to displace the uterus from the vena cava and pelvic organs. Keep carbon dioxide insufflation pressures low, and monitor the fetus perioperatively, he added. Preemptive analgesia improves patient comfort and reduces complications and length of hospitalization. Infiltration of the incisions with 0.25% bupivacaine with epinephrine before closure enhances patient comfort.
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|Publication:||OB GYN News|
|Date:||Nov 1, 2003|
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