|Year : 2013 | Volume
| Issue : 6 | Page : 612-615
Laparoscopic surgeries during second and third trimesters of pregnancy in a tertiary care centre in South India: Anaesthetic implications and long-term effects on children
Nisha Rajmohan, Hassy Prakasam, J Simy
Department of Anaesthesiology, PVS Memorial Hospital, Kaloor, Kochi, Kerala, India
|Date of Web Publication||20-Dec-2013|
Department of Anaesthesiology, PVS Memorial Hospital, Kaloor, Kochi - 682 017, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rajmohan N, Prakasam H, Simy J. Laparoscopic surgeries during second and third trimesters of pregnancy in a tertiary care centre in South India: Anaesthetic implications and long-term effects on children. Indian J Anaesth 2013;57:612-5
|How to cite this URL:|
Rajmohan N, Prakasam H, Simy J. Laparoscopic surgeries during second and third trimesters of pregnancy in a tertiary care centre in South India: Anaesthetic implications and long-term effects on children. Indian J Anaesth [serial online] 2013 [cited 2019 Dec 15];57:612-5. Available from: http://www.ijaweb.org/text.asp?2013/57/6/612/123339
| Introduction|| |
Recent literature reports successful attempts of laparoscopic surgery in pregnancy.  We report our experience with anaesthesia for laparoscopic surgeries during the second and third trimesters of pregnancy. Evidences from limited number of studies available on long-term effects on babies are encouraging.
| Methods|| |
All patients who underwent laparoscopic surgeries during the second and third trimesters of pregnancy between January 2000 and January 2011 were included in this retrospective analysis after institutional review board approval. Medical records were reviewed for pre-operative patient profile, intraoperative parameters and obstetric outcome [Table 1] and [Table 2]. Babies were assessed yearly by Denver developmental screening test II (DDST II).
| Results|| |
Eight pregnant patients underwent laparoscopic surgery during the study period. The mean gestational age and the mean age of the patients were 20.75 ± 6.5 weeks and 27.25 ± 4.77 years respectively. All, except three patients were categorised as American Society of Anaesthesiologist physical status 1. Foetal well-being was assessed by pre- and post-operative ultrasound. All patients received prophylactic intravenous isoxsuprine infusion as per institutional protocol. General anaesthesia was administered by rapid sequence induction using propofol/thiopentone and succinylcholine along with fentanyl/morphine/pethidine and intravenous midazolam. Halothane was used in one patient while the rest received isoflurane. Nitrous oxide was used in all patients. Two patients were positioned in the left lateral decubitus and the rest as per the surgical requirement, but with wedge under right gluteus [Table 1]. Open Hasson's technique was used to induce pneumoperitoneum while Verre's needle was used in two patients. Pneumoperitoneum was achieved with carbon dioxide with intra-abdominal pressures maintained below 15 mmHg and end-tidal carbon dioxide (ETCO 2 ) between 28 and 32 mmHg [Table 1]. All surgeries could be completed by laparoscopy except pyeloplasty, which was managed with double J stenting due to inadequate working space. Mean operative time was 116.62 ± 75.80 min [Table 1]. Electrocardiogram, non-invasive blood pressures, oxygen saturation and ETCO 2 were monitored in all and foetal Doppler performed in two patients. Haemodynamic parameters were maintained within 30% of the baseline values. Patients had compression stockings, early ambulation or pharmacological deep vein thrombosis (DVT) prophylaxis and tramadol/paracetamol analgesia. All patients had an uneventful post-operative recovery. The gestational age at delivery was greater than or equal to 37 weeks in all (mean 38.25 ± 0.71 weeks). Apgar Scores and birth weight of babies were optimal, none required neonatal intensive care. Patients were discharged from the hospital at mean of 5.25 ± 1.75 days post-delivery with an uneventful postpartum period [Table 2]. Follow up of the babies, as evaluated retrospectively from paediatric charts was done yearly by Denver Developmental Screening Test II (DDST II) until five years of age. Few younger babies continue to be assessed.
| Discussion|| |
Surgeons were initially reluctant to perform laparoscopic surgeries during pregnancy but technical refinements in laparoscopy have led to a change in approach. , The reported major benefits of laparoscopy include lesser uterine manipulation, wide and adequate exposure of surgical field with lesser adverse obstetric events and lesser analgesic requirement along with early ambulation. , The major concerns of laparoscopy during pregnancy include iatrogenic insult to the gravid uterus, preterm delivery, foetal loss, abortion and maternal haemodynamic changes leading to decreased uterine blood flow and foetal asphyxia due to increased intra-abdominal pressures, maternal and foetal acidosis due to systemic carbon dioxide absorption apart from the risk of maternal mortality. ,, These risks may be obviated by a low intra-abdominal pressure (<15 mmHg) and a shortened duration of pneumoperitoneum, this evidenced by the tolerance of the gravid uterus to spontaneous contractions occurring during coughing and straining. ,,, The operating time needs to be less than 60 min as in our series, though one case lasted 270 min, highlighting the significance of performing such procedures in centres where sound surgical expertise is available. , The Society of American Gastrointestinal and endoscopic surgeons (SAGES) recommends monitoring and maintenance of ETCO 2 at 28-32 mmHg which was followed in our unit too. All anaesthetic concerns for non-obstetric surgery during pregnancy are applicable.  Acid aspiration prophylaxis and adequate pre-oxygenation was given and ketamine was avoided as it may increase uterine tone with risks of foetal asphyxia in the first two trimesters. Thiopentone, propofol, single dose benzodiazepine, most muscle relaxants and inhalational agents are safe. Nitrous oxide was used safely in 50:50 ratio as teratogenic effects have not yet been proven in humans.  Morphine, pethidine and fentanyl can prevent stress due to inadequate analgesia. Non-steroidal anti-inflammatory drugs may be avoided in third trimester as they may cause premature closure of ductus arteriosus.
Discussion with surgeon helps in optimal patient positioning and avoids decubitus related complications. Supine decubitus results in aortocaval compression and should be avoided. Left lateral decubitus is ideal as was performed in two patients  [Figure 1]. Left lateral tilt (20-30°) and placement of wedge also helped.  Trendelenburg decubitus for limited duration is well tolerated. 
|Figure 1: Lateral decubitus position is preferred and the port insertion site|
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Both Verre's needle and the open Hasson's technique can be used for establishing pneumoperitoneum. , Pneumatic compression stockings, though recommended is not universally available hence early ambulation along with heparin/low molecular weight heparin prophylaxis may be tried.
SAGES recommendations argues against undue surgical delay for obstetric consultation while American Congress of Obstetricians and Gynaecologists recommends prior consultation for all types of non-obstetric surgeries during pregnancy. , Prophylactic tocolysis is not recommended as it cannot prevent pre-term labour and may have adverse events.  We left this decision to our obstetrician. Pre- and post-operative foetal monitoring is crucial, while intraoperative monitoring is no longer recommended. , These surgeries should be performed in well-equipped centres due to the potential for complications. We recommend pharmacological DVT prophylaxis and obstetric backup. The protocol practiced in our centre is shown in [Figure 2].
|Figure 2: Perioperative management of laparoscopic surgery in Pregnancy-protocol in our institution|
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Limited studies on long-term foetal effects have reported no adverse events.  DDST II assessed yearly in our children up to 5-years-revealed no abnormalities until now.
Limitations of our study are that it is a retrospective analysis with only eight patients, with no control arm for mothers and babies and further assessment of babies is ongoing and not complete yet.
| Conclusion|| |
Laparoscopic surgeries during pregnancy may be a viable alternative to open surgery provided it is performed in centres with multidisciplinary facilities and recommendations are followed.
| References|| |
|1.||Pearl J, Price R, Richardson W, Fanelli R, Society of American Gastrointestinal Endoscopic Surgeons. Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy. Surg Endosc 2011;25:3479-92. |
|2.||Moreno-Sanz C, Pascual-Pedreño A, Picazo-Yeste JS, Seoane-Gonzalez JB. Laparoscopic appendectomy during pregnancy: Between personal experiences and scientific evidence. J Am Coll Surg 2007;205:37-42. |
|3.||Cruz AM, Southerland LC, Duke T, Townsend HG, Ferguson JG, Crone LA. Intraabdominal carbon dioxide insufflation in the pregnant ewe. Uterine blood flow, intraamniotic pressure, and cardiopulmonary effects. Anesthesiology 1996;85:1395-402. |
|4.||Upadhyay A, Stanten S, Kazantsev G, Horoupian R, Stanten A. Laparoscopic management of a nonobstetric emergency in the third trimester of pregnancy. Surg Endosc 2007;21:1344-8. |
|5.||Soper NJ, Hunter JG, Petrie RH. Laparoscopic cholecystectomy during pregnancy. Surg Endosc 1992;6:115-7. |
|6.||Williams JK, Rosemurgy AS, Albrink MH, Parsons MT, Stock S. Laparoscopic cholecystectomy in pregnancy: A case report. J Reprod Med 1995;40:243-5. |
|7.||Reitman E, Flood P. Anaesthetic considerations for non-obstetric surgery during pregnancy. Br J Anaesth 2011;107 Suppl 1:i72-8. |
|8.||Bassil S, Steinhart U, Donnez J. Successful laparoscopic management of adnexal torsion during week 25 of a twin pregnancy. Hum Reprod 1999;14:855-7. |
|9.||ACOG Committee Opinion No. 474: Nonobstetric surgery during pregnancy. ACOG Committee on Obstetric Practice. Obstet Gynecol. 2011;117:420-1. |
|10.||Rizzo AG. Laparoscopic surgery in pregnancy: Long-term follow-up. J Laparoendosc Adv Surg Tech A 2003;13:11-5. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]