Dr. Stavros Zarkadas MD, PhD
Obstetrician and Gynecologist
Larnaca General Hospital (Cyprus)
Member of World Association of Laparoscopic Surgeons (WALS)
The resolution through laparoscopy of the gynecological emergencies that are verified during pregnancy, represents a circle of notable interest, surely worthy of further close examination. Although the laparoscopic approach ,for the resolution of acute abdomen in pregnancy is still under large debate ,for the safety of both mother and fetus and the eventual long term effects on the child, appendicitis, cholecystitis, adnexal masses torsion or rupture have been successfully managed laparoscopically during pregnancy, as well as ectopic and even heterotopic pregnancies. Retrospective studies has shown that there were no significant differences in any measured outcome (birthweight, gestational duration, intrauterine growth restriction, congenital malformations, stillbirths, or neonatal deaths) ,and no adverse long-term effects on the offspring have been reported , among pregnand women that have been undergone laparoscopy or open surgery. Pregnant and nonpregnant women can draw the same advantage from laparoscopic surgery ; however, in the past years this procedure had been avoided during pregnancy because of concerns that it could harm the fetus. Laparoscopic surgery in pregnant women significantly reduce abdominal scars, days of hospitalisation, infectious complications ,post-operational pain and use of narcotics, and guarantees an early return to the normal intestinal function, minimizing adhesions and possible intestinal obstruction ,and a precocious mobilization conditioning this way a meaningful reduction of the risk of tromboembolic events and atelettasia. Nowadays pregnancy doesn't constitute absolute contraindication to the laparoscopic approach. The procedure has been performed as late as at 34 weeks of gestation, but the optimal time is the early second trimester. There are studies supporting that laparoscopy in pregnancy is a safe procedure, in all trimesters.
Special preacautions must be taken for trombophylaxis, position of the patient , creation of pneumoperitoneum , inserction of trocars and port placement, fetal monitoring and post-operative care. Laparoscopical procedure is not free of risks .Spontaneous abortion, penetration of the uterus by Veress needle or trocars, compromission of the uteroplacentar perfusion, maternal acidosis, caused by CO2, fetal ipossia, high fetal and maternal carbossihemoglobin due to the use of elletrocautery, pulmonary aspiration , gas embolism can all happen during this kind of operation. Despite the possible complications , laparoscopic management of acute abdomen in pregnancy , represents a safe and advantageous approach - even preferable - both for the mother and the fetus .
Abdominal pain, Acute abdomen , Laparoscopic surgery, Appendicitis, Appendectomy, Cholecystitis , Adnexal mass, Pelvic mass, Ovarian cyst, ovarian torsion, ectopic pregnancy, Heterotophic pregnancy, Diagnostic laparoscopy, Pneumoperitoneum, Anaesthesia in laparoscopy.
Materials and Methods
This review article on the laparoscopic approach of acute abdomen in pregnancy has been done through literature search using Google, Medscape, Medline , Pubmed , Uptodate library facility available at World Laparoscopy Hospital, Gurugram, NCR Delhi. The keywords mentioned above have been used on Google search engine in order to find out articles related to the title.
The resolution through laparoscopy of the gynecological emergencies that are verified during pregnancy, represents a circle of notable interest, surely worthy of further close examination. In the last decades the medical community has assisted to the progressive ascent of the operational laparoscopy, at first celebrating it as futuristic, then promising, and finally valid and concrete alternative to the classical laparotomic surgery. In the last decade techniques of avant-garde performed by experienced laparoscopes ascertain the success of laparoscopic approach and definitely consecrate it as a "golden standard " in a vast range of surgical procedures considered before , as exclusive appanage of the laparotomic surgery. Only few data relative to interventions realized in specialist centers by experienced surgeons are available, as well as perspective studies that draw certain conclusions regarding the safety and the rate of complications of similar procedures. This careful job of review and elaboration of the most recent available data in literature doesn't aim only to satisfy but ,rather, to revive the curiosity of every gynecologists ,and to reinforce the idea that laparoscopy is both ,a safe and a good outcome promising procedure in pregnancy.
The acute abdomen may be defined generally as an intraabdominal process causing severe pain and often requiring surgical intervention. 1 in 500-635 pregnancies are complicated by non-obstetrical surgical reasons 
The most common non-pregnancy-associated causes of acute abdominal pain in pregnancy
- Adnexal masses
- Intestinal Obstruction
- Inflammatory bowel Disease
- Urinal Tract infections
- Renal calculi
- Splenic artery aneurysms
Extra-abdominal causes of acute abdominal pain
- Sickle-cell crises
- Cardiac pain
- Lower lobe pneumonia
- Referred pleuritic pain from pulmonary embolism
- Psychological disturbance
Other causes of acute abdominal pain in pregnancy
1st trimester of Pregnancy
- Trophoblastic disease
- Ectopic pregnancy
- Ovarian cysts
- Fibroid degeneration
- CVS , amniocentesis complications
Late 2nd and 3rd trimester of Pregnancy
- Abruptio placentae
- Uterus rupture
- Fibroid degeneration
- Liver pain due to Glinsson’s membrane
- Distension ( HELLP syndrome)
- Lombar pain
APPENDICITIS IN PREGNANCY
The most common cause of acute abdomen in pregnancy is appendicitis. The incidence ranges from 1:2000 to 1:6000 [1,2 3] . The fisiological changes in pregnancy posses some chalenges for the correct diagnosis (anorexia , nausea , vomiting) . Nevertheless ,the majority (> 80%) presents with the classic right lower quadrant pain. Given the difficulties and the delays in diagnosis , there is a high incidence of perforation that goes from a basic 25% up to 66% in cases of very delayed diagnosis and delayed surgical intervention.  . The perforation is associate with high incidence of fetal loss and maternal morbidity. Even if the appendix appears normal, there are 2 reasons to remove it: (1) early disease may be present despite its grossly normal appearance and (2) diagnostic confusion can be avoided if the condition recurs..
In order to improve diagnosis and also minimize the negative appendectomy rates ,that is considered as risk factor for fetal loss , u/s scan is used, very widely, because is safe, rapid and inexpensive . MRI is an excellent diagnostic tool , but is not always available . Special role in the diagnosis is reserved for diagnostic laparoscopy. Appendicitis can occur in all the trimesters but it occurs more frequently in the second trimester. Although pregnancy doesn't influence the incidence of the disease it seems that the severity of appendicitis increases in pregnancy [5,6,7].
The data are very limited and conflicting, the is no Level 1 evidence to guide the surgical management of appendicitis in pregnancy, but there are numerous studies and series of case-reports suggest that laparoscopic appendectomy in pregnancy can be a safe procedure that can be effected in all trimesters with success and with only few complications. [8,9-12]. The only limitation would be the uterine volume in the last trimester that could interfere with the visualisation and laparoscopic instrumentation .As far as concerns the surgical approach , and especially in cases in which laparoscopic appendectomy is opted ,the experience of the surgeon , the presence of trained stuff and appropriate equipment is an important issue. The patient must be well informed about all the risks (informed consent) , and must be feet for general anaesthesia. The ideal positioning is 30 degrees Trendelemburg, with the patient slightly tilted to the left . The inizial port is usually placed with the open ( Hasson) technique . The pneumoperitoneum must be maintained at a pressure of 10-12 mmHg .
Figure 1: Port positioning in the 1st and 2nd-3th trimester Urinary catheter , pneumatic compression device for the lower limbs and antibiotic prophylaxis are mandatory. [ 68] For the mesoappendix the tendency is to use endoclips and ultracision , for the base of the appendix PDS endoloops. Macado and Grant , over a 11 year period , performed 32 appendectomies in pregnant women , 25 laparoscopic “ Lap group” and 7 “ open” appendectomies. At the “ Lap” group , 10 was at the 1st trimester , 11 at the 2nd , and 4 at the 3th trimester of pregnancy. Only one abortion (at the 1st trimester “ Lap group” ) ,no intraoperative complications , no preterm deliveries has been registrated , and the neonatal outcome was excellent . The conclusion was that laparoscopic appendectomy can be safely performed in all trimesters and the benefits are the same as in the non pregnand woman. 
Figure 2: Acute appendicitis in a pregnand woman
CHOLECYSTITIS IN PREGNANCY
Cholecystitis due to gall stones (up to 90% of the cases of cholecystitis in pregnancy) , jaundice (that strongly suggests choledocholitiasis) and even pancreatitis can complicate the run of pregnancy exposing both mother and fetus to an increase morbidity and mortality .  The incidence of acute cholecystitis in pregnancy goes from 1:1130 to 1:12,890. [14,15]. Asymptomatic gall bladder disease is more common, occurring in 3-4% of pregnant women, and only 30%-40% of pregnant patients with gallstones are symptomatic.  . Pancreatitis is an unusual and potentially devastating occurrence. The case-to-delivery ratio ranges from 1:1289 to 1:3333. [16-19] Pregnancy does not increase severity of complications . Symptoms, laboratory profile and imaging are basically identical in pregnant and non-pregnant patients.
Imaging options for the diagnosis are u/s scan , with no known adverse effects and with 95%-98% accuracy of detecting acute cholocystitis and choledocholithiasis, and MRI , also with no known adverse effects but only after informed consent in which is included the possibility that previously undiagnosed fetal abnormality may be found.  . Studies comparing conservative and surgical management of cholecystitis revealed the incidence of preterm delivery (3.5% vs 6.0%) and fetal mortality (2.2% vs 1.2%). However ,medical treatment offenly fails and even when is successful , the risk for symptoms recurrence is 92% at the 1st trimester , 64% at the 2nd trimester and 44% at the 3th trimester  ,and the surgical interference is presented as the last and only alternative. Fetal mortality in gallstone pancreatitis was 8.0% in a conservatively treated group of patients and 2.6% in a surgically treated group, suggesting that early surgical management is preferable.  The very first laparoscopic cholecystectomy performed in a pregnant patient took place in 1991, today the most largely effected procedure in pregnancy is laparoscopic cholecystectomy. Laparoscopic cholecystectomy , with or without bile duct exploration can be safely performed during any trimester of pregnancy. In some cases , patients during the first trimester can be treated with endoscopic or percutaneous techniques and definitively managed with laparoscopic cholecystectomy in the second trimester. . In all cases in which there is the indication to perform an intraoperative cholangiografy , the combination of ERCP and laparoscopic cholecystectomy is not contoindicated , but the gravid uterus must be protected by a lead shield , even if the shield can not protect the fetus from the reverse spread of radiation.
ADNEXAL MASSES COPLICATIONS IN PREGNANCY
Adnexal masses ,and ,especially ovarian cysts are common findings in pregnancy, and in most of the cases are asymptomatic [21-24]. To be more precise, ovarian cysts during pregnancy presents an incidence range from 1 in 81 to 1 in 1000. Most of the cystic masses that are detected during early pregnancy disappears within the first trimester.
Adnexal torsion in pregnancy
Although pregnancy predisposes to adnexal torsion, with the 20% of adnexal torsions occurring during pregnancy, [25,26] an adnexal torsion is an uncommon (actually ,has half the incidence of appendicitis , but unfortunately very serious contition when happens . The torsion is associated with an ovarian mass in 50-60% of the cases , and the most represented type of ovarian mass is the dermoid. Adnexal torsion occurs more frequently on the right than on the left, by a ratio of 3:2. It occurs most frequently in the first trimester, occasionally in the second, and rarely in the third  The torsion must be quickly faced in order not to end with the loss of the ovary . Laparoscopy in this cases represents an option of high value both for the differential diagnosis and for the therapy. The surgery must performed as soon as possible having in mind the necessity to save as much more ovarian tissue as possible  ,however, in cases ovarian necrosis the only option is salpingo-oophorectomy.
In cases of incomplete torsion of the ovary , the surgical therapy consists in the the detorsion of the adnexa mechanically and with the use of saline irrigation,  ,aspiration of the cyst and fixation of the ovary. If the histology performed on the speciment confirms that the cystic formation was the corpus luteum , a progesterone replace therapy is indicated until the 10th week of pregnancy. One review examined 47 patients (17 in the first trimester, 27 in the second trimester, 4 in the third trimester) who underwent laparoscopic management of ovarian cysts (n = 36), torsion (n = 8), pelvic mass (n = 3 ). One pregnancy loss occurred four days after the procedure, suggesting that the laparoscopic approach remains a safe option even in pregnancy . Other reviews have confirmed the safety and effectiveness of laparoscopic management of torsion in pregnant women [32-34].
Rupture of Ovarian Cyst
The rupture of ovarian cysts is a rare event during pregnancy . Its treatment is surgical , by laparoscopy in the most of the cases, and has as main purpose to conserve as much ovarian tissue as possible.
Benign cyst teratoma
As mentioned above ,in the majority of adnexal mass torsion during pregnancy the most represented type of ovarian mass is the dermoid (benign cystic teratoma ). There is a study in literature in which 8 cases of adnexal torsion, due to dermoid cyst , in gestational ages under 17 weeks of gestation , managed laparoscopically without any adverse outcome for the pregnancy.
The incidence of the rupture of an ectopic pregnancy is 1 % . Laparoscopic management is the golden standard procedure for this condition , as long as the hemoperitoneum is less than 1,5 lit and the hemodinamic condition of the patient is stable. Linear salpingotomy, linear salpingostomy, or salpingectomy can be performed. Laparoscopy remains strongly indicated even in cases of heterotopic pregnancy , with no exception even for those where the ectopic trophoblast is situated in the abdomen (and not in the salpinx as usually) as long as great vascular structures are not infiltrated by the trofoblast severe bleeding risk is not very high.
A retrospective study performed by Swedish health registries on the safety of laparoscopy during pregnancy  that compared the outcome of 2181 laparoscopies performed on pregnant patients prior to 20 weeks of gestation with the outcome of 1522 laparotomies performed in a similar population joined to the conclusion that there were no significant differences in any measured outcome among the two groups: birthweight, gestational duration, intrauterine growth restriction, congenital malformations, stillbirths, or neonatal deaths. No adverse long-term effects have been reported.
The indications for laparoscopic treatment of acute abdominal processes are the same in pregnant and non-pregnant patients ..
Manifold and well documented in literature 1-2 are the advantages guaranteed by laparoscopy. In first place the least resultant abdominal scars from such surgical approach that achieve, beyond an excellent - but more secondary - aesthetical effect, a meaningful reduction of the post-operational pain and therefore an decreased demand of analgesics. It must be underlined, besides, that such advantages still result more desirable in progress of pregnancy, whereas the tension progressively applied to the abdominal muscles and the anterior wall of the abdomen by the increasing uterus delays the recovery of the wounds, it exacerbates the pain and the infectious complications , favorite also by the immunitary depression that is characteristic in pregnancy. Still, the limited invasive laparoscopical approach guarantees an early return to the normal intestinal function, minimizing adhesions and possible intestinal obstruction ,and guaranties a brief hospitalization and a precocious mobilization conditioning this way a meaningful reduction of the risk of tromboembolic events or atelettasia .
There is no absolute maximum gestational age for performing laparoscopy, the operation can be performed in any trimester [40-41]; but optimal time to operate is the early second trimester. However, in some cases, a prompt surgical intervention is strongly recommended and surgery cannot be delayed from the first to the second trimester. In the event of direct threat to the mother and/or the fetus ,surgical intervention should be conducted regardless of the stage of pregnancy.
Laparoscopy during the last trimester can be difficult to perform due to the enlarged uterus that can interfere with adequate visualization. However, successful laparoscopic management of acute abdomen due to appendicitis and cholecystitis has been described even at 34 weeks of gestation [40-44]. Although procedures performed in the first trimester should be easier technically, introduction of a potential teratogenic risk during organogenesis is a concern. In addition, it is preferable to perform surgery after the period when spontaneous miscarriages are likely to occur.
Laparoscopy is a surgical procedure and ,as it is easy to intuit, the activation of the coagulation system takes place in similar entity for both laparoscopy and laparotomy. In addition , it is known that in a laparoscopic procedure the duration of the intervention probably is going to be bigger therefore immobilization on the operation table can be lengthy. Lastly, the use of pneumoperitoneum and reverse Trendelenberg , for some procedures ,contribute to venous stasis and, possibly, thrombosis. Taken in consideration all the above , the Society of American Gastrointestinal and Endoscopic Surgeons ,in 2008, recommended placing pneumatic compression devices on the lower limbs of pregnant women undergoing laparoscopic procedures for surgical problems .
There is no evidence to support the use of prophylactic tocolytics or glucocorticoids. However, these drugs may be indicated in management of threatened preterm delivery in patients that are presenting premature contractions. The use of monopolar electrocautery must be avoided in order to minimize the uterine contractility
Depending on the operation that is to be performed , the patient is placed in the supine or low lithotomy position with a leftward tilt (after 16 weeks of gestation) to avoid significant compression of the gross abdominal vessels . After the pneumoperitoneum has been created, left-sided rotation of 30 degrees improves visualization of the appendix and gall bladder [45,46]
Before introducing the pneumoperitoneum , a Folley catheter must be placed in the bladder and a nasogastric tube has to be placed in the stomach in order to prevent the risk of aspiration of gastric contents and perforation of the stomach
For the creation of pneumoperitoneum both the Hasson and the Veress needle technique can be used , even if the Hasson technich seems to offer greater assurance of safety to some surgeons [47-50]. Lately has been introduced the use of optical ports for the access in the abdomen .. A Veress needle approach in which the needle was inserted in the mid-clavicular line, 1 to 2 cm below the costal margin (Palmer’s point), or in the right upper quadrant  was successfully used in a series of 10 third trimester procedures. Given the feasibility of both methods, each surgeon should use the technique with which he or she has the most experience and comfort.
Establishing the pneumoperitoneum and insertion of trocars can be difficult and dangerous procedure in pregnancy due to the dimensions of the uterus. A safe approach is to place the primary trocar at least 6 cm above the uterine fundus (epigastically) after manual lift of the abdominal wall and displacement of the uterus laterally to the left .
Figures 3 and 4
Placement of trocars in a 22 weeks of gestation pregnant. The placement of transcervical probes and uterine manipulators is absolutely contoindicated . A high intraabdominal pressure during pneumoperitoneum could decrease utero-placental blood flow and result in fetal hypoxia. Intraabdominal pressure between 8 to 12 mm Hg and not exceeding 15 mmHg should be maintained [51,52]. Gasless laparoscopy may be a safer alternative to the traditional CO2 pneumoperitoneum, by using abdominal wall lifting devices [53,54]. Even the combination of pneumoperitoneum and abdominal wall retraction can be an option . Fetal acidosis could develop from absorption of carbon dioxide (CO2). It is recommend to keep the end-tidal CO2 at 32 to 34 mmHg, as respiratory acidosis has not been reported at this level [56,57].
Fetal heart rate should be confirmed and documented before and after the procedure, and is usually done with a hand-held Doppler device (eg, Doptone). If fetal monitoring is necessary during the procedure, transabdominal fetal monitoring may be possible through the left abdominal wall. If maternal acidosis is suspected and confirmed, it can be reversed by immediately hyperventilating the mother and decreasing intraabdominal pressure. These measures can help to resuscitate the fetus by improving placental blood flow and fetal oxygenation . The FHR should be documented before and right after the operation , by the use of a Doppler device. If maternal acidosis is suspected, during the procedure , it can be reversed by an immediate hyperventilation of the mother and a decrease of the intraabdominal pressure , in order to improve the placental perfusion and the fetal oxygenation .
A CTG (non stress test) should be effectuate in the recovery room, if the gestational age is appropriate . Opioids pain killers and antiemetics can be used to control pain and nausea. NSAID should be avoided, especially after 32 weeks of gestation.
COMPLICATIONS AND RISKS
Laparoscopy is not a risk – free procedure. As any surgical procedure effectuated during pregnancy , laparoscopy seems to be associate to low weight to the birth and IUGR. The risk of spontaneous abortion is high especially in the first trimester, and last , but not least , there is always to be kept in mind the risk correlated to anesthesia, that is directly proportional to the duration of the intervention.
Risks related exclusively to the laparoscopic intervention
Risk of penetration of the uterus by the Veress needle or the trocar with consequent bleeding , uterine rupture , loss of amniotic fluid, infection, direct fetal damage or - only one case brought in literature - creation of a pneumoamnion, consequent spontaneous rupture of the membranes, fetal distress and stillbirth .
Figure 5: Pneumoamnion con subcutaneous emphysema ( Friedman J et al., 2002)
Risks related to the pneumoperitoneum and the insufflation of CO2 .
The increased intraabdominal pressure determines important alterations of the materno-fetal emodinamics. The reduction of the blood flow in the vena cava and the limitation of the maternal diaphragm excursion can cause a compromission of the uteroplacentar perfusion, and ,especially, an interference to the already precarious acid-base equilibrium ,that is typical of the pregnancy. The greatest risk seems therefore correlated to the eventuality of a maternal acidosis, caused by CO2, and a consequent fetal ipossia. However , the results of the careful analysis performed by Barnard et to the. seems to show that laparoscopy produces a marked reduction of the blood flow towards the materno-placentar interface without altering neither the blood flow to the fetus neither the values of pH and the partial pressures of the blood gases .
Risks related to the electrosurgery
Notable attention has been turned to the harmful potential of the gas developed in abdomen because of the use of laser and bipolar elettrocautery during the laparoscopic procedures [60-62]. Ott et .  observed that, in patient in which the laser had been used, a meaningful increase of the levels of fetal carbossiemoglobin in the peripheral blood as well as an increase of the maternal intraddominal concentration of CO, has been registrated. On the other hand , no meaningful variation of these parameters has been registrated in operations in which electrocautery has been used, from Beebe et .. Unanimous recommendation of all the authors is that to minimize the harmful potential of the gases freed in the peritoneal cavity through a suitable elimination of the CO by ventilation at high concentrations of oxygen.
Pulmonary aspiration. This possibility is higher in pregnancy both for the reduction of the tone of the esophageal sphincter, induced by the endocrine profile of the pregnant , that ,for imputable mechanical effects by the enlarged uterus - it seems to be exacerbated due to the increase of the intrabdominal pressure which is verified during the creation of pneumoperitoneum. Besides, the Vena Cava Syndrome ,in supine position ,can be one of the greatest maternal complicancies . Nagao et . has recently shown that the insufflation should be started with low flow of gas , so that to limit the volume of gas that could be introduced in a blood vessel in case of an accidental insertion of the Veress needle.
LAPAROSCOPY VERSUS LAPAROTOMY IN PREGNANCY
Both approaches, [64-67] seem to be reasonably safe. Meaningful increases have not been brought in the incidence of abortions, malformations, stillbirths or premature deliveries verified after laparoscopy in comparison to laparotomy. In confront with open surgery , laparoscopic approach is safer for operations on HIV positive pregnant patient , as there is less risk of needle injury.From this revision of the available data in literature it seems therefore that the laparoscopic management of acute abdomen in pregnancy represents a sure and advantageous approach - even preferable - both for the mother and the fetus, under the condition , obviously, that it is performed by an experienced team of surgeons, in the respect of suitable technical principles and in association to a good anesthesiologic and obstetric assistance.
The role of laparoscopy in the treatment of acute abdomen in pregnancy is now better appreciated . Regardless of the limitations that can have due to the size of gravid uterus which can interfere with visualisation and instrumentation, mainly in the last trimester of pregnancy this approach is now being utilized for many different procedures that were once exclusively done by open surgery. Appendicitis, cholecystitis, adnexal masses torsion or rupture have been managed laparoscopically with successful outcome in all trimesters and this suggests that laparoscopy is a safe procedure during pregnancy. Recognized for the advantages it holds over open surgery such as minimized scarring, lower blood loss, decreased post-operative pain, and generally reduced recovery time, endoscopy is enjoying an ever growing following of surgeons. On the other hand , laparoscopy as a diagnostic tool in cases of uncertain diagnosis is unparalleled in its ability to permit the physician visual examination of internal organs without presenting major trauma to the patient. Exciting new advanced in laparoscopy and its associated benefits continue to expand the bounds of gynecologic surgical care. Laparoscopy is ready to answer the call for more efficient, effective, and economical methods of treatment.
The objective of this review article was reinforce the idea that laparoscopy is both ,a safe and a good outcome promising procedure in pregnancy, and breathe life into the curiosity of every gynecologists ,particularly the youthful ones ,in order to lead them to an effort of research and investigation of the world of laparoscopic surgery , hopping that ,at the end , surgery itself is going to be benefited. Laparoscopy is the surgical method of the future, and if somebody wants to be a part of the future, has no other option than to embrace laparoscopy.
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