Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy

Common bile duct exploration with choledochotomy and primary repair during pregnancy: Case Report

We present a case of a woman in the second trimester of pregnancy who was admitted due to symptomatic common bile duct stones and gallstones. The patient underwent ultrasonography (US) and magnetic resonance cholangiopancreatography (MRCP) imaging, as well as a series of relevant blood tests, to establish a diagnosis. After a comprehensive assessment, simultaneous T-tube-free laparoscopic transcholedochal stone extraction and cholecystectomy were performed safely in the pregnant patient with common bile duct stones and gallstones. Postoperatively, the patient had an uneventful recovery. This case report aims to provide detailed information on the selection of treatment options for symptomatic choledocholithiasis combined with gallstones during pregnancy and to explore the feasibility and safety of performing concurrent T-tube-free laparoscopic choledochotomy for stone extraction in pregnant patients.

Non-Surgical Management of Gallstones During Pregnancy: A Clinical Case Report

Gallstone disease during pregnancy, or cholelithiasis, presents significant clinical challenges due to hormonal, anatomical, and metabolic changes. Progesterone therapy, commonly used in pregnancy for uterine bleeding, can exacerbate gallstone risk by reducing gallbladder motility and promoting cholesterol gallstone formation. This case report describes a 29-year-old pregnant woman with no prior gallbladder disease who developed multiple cholesterol gallstones during the third trimester while undergoing progesterone therapy for bleeding associated with a bicornuate uterus. Conservative management during pregnancy, including dietary modifications and close monitoring, was successful, and the patient delivered a healthy infant via cesarean section. Postpartum, the patient developed obstructive jaundice, severe right hypochondriac pain, and scleral icterus due to common bile duct obstruction from gallstones. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement resolved the obstruction, and pharmacological treatment with ursodeoxycholic acid (UDCA) and omega-3 fatty acids led to complete gallstone resolution within three months. Surgical intervention was avoided to prioritize postpartum recovery and breastfeeding, which resumed successfully after a brief interruption. This case highlights the value of individualized, multidisciplinary care in managing pregnancy-associated gallstone disease. Conservative approaches, including pharmacological and minimally invasive interventions, can achieve effective outcomes while minimizing maternal-fetal risks. Routine ultrasound screening in high-risk pregnancies and further investigation into UDCA and omega-3 therapies, progesterone-related gallbladder stasis, and postpartum biliary stenting protocols are recommended to optimize management strategies.

TU-LESS procedure for acute abdomen in late pregnancy: a retrospective study

BACKGROUND

Acute abdominal conditions during pregnancy are significant risks to maternal and fetal health, necessitating timely diagnosis and intervention. The choice of surgical approach is a major concern for obstetricians.

OBJECTIVE

To evaluate the safety and efficacy of the TU-LESS procedure for acute abdomen in late pregnancy.

METHODS

We retrospectively analyzed 12 patients who underwent TU-LESS for acute abdominal conditions in the third trimester from 2020 to 2023. We reviewed medical records for clinical characteristics, surgical interventions, postoperative complications, and pregnancy outcomes.

RESULTS

The study included patients with a median age of 27 (range 20-35) and a BMI of 24.33 kg/m2 (range 21.34-31.96). The median gestational age at surgery was 30 weeks (range, 28 + 3-32 + 4 weeks), with surgeries lasting an average of 60 min (range, 30-163 min). Blood loss was 2-20 mL, and the median hospital stay post-surgery was 6 days (range, 2-16 days). There were no significant complications. The median time to delivery after TU-LESS was 56 days (range, 26-66 days), resulting in 8 full-term deliveries, 2 preterm cesareans, and 2 preterm vaginal deliveries. All newborns were healthy, with no fetal losses or neonatal deaths.

CONCLUSION

TU-LESS, performed by experienced obstetricians and gynecologists with proper preoperative preparation, is safe and effective for managing acute abdomen in late pregnancy, without the need to delay surgery due to gestational age.

Safety of Laparoscopic Cholecystectomy for Cholecystitis during Pregnancy

Objectives

The aim of this study is to evaluate the safety of laparoscopic cholecystectomy to treat acute cholecystitis during pregnancy.

Materials and Methods

We conducted a retrospective multicenter study including pregnant women with acute cholecystitis managed in surgery departments in Tunisia from January 1, 2015, to December 31, 2019.

Results

Seventeen centers of surgery department participated in this study including 107 cases of acute cholecystitis. The average maternal age was 30.5 years. Nonoperative management was performed in eight patients, whereas 99 other patients had surgery. Postoperative follow-up was uneventful in 93.8% of cases and eventful in 6.2% of cases. There was no mortality as far. A medical complication occurred in two patients with a medical morbidity rate of 1.7%. It was about thromboembolic disease. A surgical complication occurred in two other patients with a surgical morbidity rate of 1.7%. It was about intraperitoneal infection in one case and biliary collection in the other case. In univariate analysis, variables related significantly to maternal complication were: age equal or over 35 years old (P = 0.001), jaundice (P = 0.024), C-reactive protein value equal or over 20 mg/L (P = 0.05), and biliary peritonitis (P = 0.05). In multivariate analysis, independent variable predictive of maternal complications was age equal or over 35 years old (P = 0.003), jaundice (P = 0.003), and biliary peritonitis (P = 0.011).

Conclusion

Laparoscopic cholecystectomy for cholecystitis can be safely achieved in pregnant women with low rates of morbidity and mortality. This study showed that independent variable predictive of maternal complications was age equal or over 35 years old, jaundice, and biliary peritonitis.

Adverse Fetal Outcomes and Maternal Mortality Following Nonobstetric Abdominopelvic Surgery in Pregnancy: A Systematic Review and Meta-analysis

OBJECTIVE

To quantify the absolute risks of adverse fetal outcomes and maternal mortality following nonobstetric abdominopelvic surgery in pregnancy.

SUMMARY BACKGROUND DATA

Surgery is often necessary in pregnancy, but absolute measures of risk required to guide perioperative management are lacking.

METHODS

We systematically searched MEDLINE, EMBASE, and EvidenceBased Medicine Reviews from January 1, 2000, to December 9, 2020, for observational studies and randomized trials of pregnant patients undergoing nonobstetric abdominopelvic surgery. We determined the pooled proportions of fetal loss, preterm birth, and maternal mortality using a generalized linear random/mixed effects model with a logit link.

RESULTS

We identified 114 observational studies (52 [46%] appendectomy, 34 [30%] adnexal, 8 [7%] cholecystectomy, 20 [17%] mixed types) reporting on 67,111 pregnant patients. Overall pooled proportions of fetal loss, preterm birth, and maternal mortality were 2.8% (95% CI 2.2-3.6), 9.7% (95% CI 8.3-11.4), and 0.04% (95% CI 0.02-0.09; 4/10,000), respectively. Rates of fetal loss and preterm birth were higher for pelvic inflammatory conditions (eg, appendectomy, adnexal torsion) than for abdominal or nonurgent conditions (eg, cholecystectomy, adnexal mass). Surgery in the second and third trimesters was associated with lower rates of fetal loss (0.1%) and higher rates of preterm birth (13.5%) than surgery in the first and second trimesters (fetal loss 2.9%, preterm birth 5.6%).

CONCLUSIONS

Absolute risks of adverse fetal outcomes after nonobstetric abdom- inopelvic surgery vary with gestational age, indication, and acuity. Pooled estimates derived here identify high-risk clinical scenarios, and can inform implementation of mitigation strategies and improve preoperative counselling.

Gasless laparoendoscopic single-site assisted extracorporeal ovarian cystectomy through the umbilicus for the management of ovarian torsion at 33 weeks of gestation: A case report with literature review

Ovarian torsion in the third trimester of pregnancy is a rare but potentially dangerous non-obstetric complication for both mother and fetus and presents a diagnostic and therapeutic challenge for the treating physicians. A 39-year-old woman (gravida 2, para 1) presented at 7 weeks of gestation. Asymptomatic bilateral small ovarian cysts were diagnosed at the initial presentation. Progesterone was intramuscularly administered every 2 weeks after 28 weeks of gestation because of uterine cervical length shortening. Sudden onset of right lateral abdominal pain was reported at 33 weeks and 2 days of gestation. Emergency laparoendoscopic single-site (LESS) surgery was performed through the umbilicus under strong suspicion of right adnexal torsion with ovarian cyst, as indicated by magnetic resonance imaging a day after admission. Isolated right ovarian torsion without fallopian tube involvement was identified under laparoscopic view. The contents of the right ovarian cyst were aspirated after confirming resumption of color tone of the right ovary after detorsion. Then, the right adnexal tissue was grasped through the umbilicus, followed by a successful ovarian cystectomy under direct vision. Tocolysis was postoperatively attempted by intravenous ritodorine hydrochloride and magnesium sulfate administration, which was continued through to 36 weeks and 4 days of gestation, because of increased uterine contraction frequency. The next day, spontaneous labor occurred, followed by the vaginal delivery of a healthy 2108-g female infant. The postnatal course was uneventful. Transumbilical LESS-assisted extracorporeal ovarian cystectomy is a feasible and minimally invasive option for ovarian torsion management in the third trimester of pregnancy.

Factors Associated With Operatively Confirmed Adnexal Torsion Among Pregnant Women - A Multicenter Cohort Study

PURPOSE

 The aim of this study was to investigate the association of clinical, laboratory, and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion during pregnancy.

MATERIALS AND METHODS

 A multicenter retrospective study of pregnant women who underwent urgent laparoscopy for suspected adnexal torsion during 2004-2019 in three tertiary medical centers.

RESULTS

 Adnexal torsion was found in 143/208 (68.8 %) cases. Women with adnexal torsion had lower parity and lower rates of previous cesarean section, but higher rates of fertility treatments and multiple gestations, and were more likely to report right lower abdominal pain, with shorter duration of symptoms (< 24 hrs) and vomiting but not nausea. Women with adnexal torsion were found to have higher rates of sonographic findings suggestive of ovarian edema, while normal-appearing ovaries on ultrasound were more common in women without torsion. A multivariate logistic regression analysis showed that complaints of right abdominal pain were positively associated with adnexal torsion (aOR [95 % CI] 5.03 (1.45-17.49), while previous cesarean delivery and ultrasound findings of normal-appearing ovaries were negatively associated with adnexal torsion (aOR of 0.17 (0.05-0.52) and 0.10 (0.02-0.43), respectively).

CONCLUSION

 Clinical characteristics and ultrasound findings may be incorporated into the emergency room workup of pregnant women with suspected adnexal torsion.

Adnexal masses during pregnancy: diagnosis, treatment, and prognosis

Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. Although most adnexal masses in pregnancy can be safely observed and approximately 70% spontaneously resolve, a minority of cases warrant surgical intervention because of symptoms, risk of torsion, or suspicion of malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy because of accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis Simple Rules, and International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adneXa scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant vs surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible because of consistently demonstrated shorter hospital length of stay and less postoperative pain and some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, preterm birth, and low birthweight. The best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester of pregnancy, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12 to 15 mm Hg, intraoperative maternal capnography, pre- and postoperative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxes. Although planning surgery for the second trimester of pregnancy generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed because of gestational age. When performed at a facility with appropriate obstetrical, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for pregnant patients and fetuses.

Laparoendoscopic single-site surgery for adnexal disease during pregnancy: A single-center preliminary experience

Purpose

This study aimed to evaluate the safety and efficacy of laparoendoscopic single-site surgery (LESS) in treating adnexal disease during pregnancy.

Methods

Medical records of included patients were retrospectively reviewed and follow-ups of all the patients were performed until the delivery of the fetus. The clinical characteristics, surgical interventions, postoperative complications, and pregnancy outcomes were analyzed.

Results

Six cases were included, with the gestational age ranging from 19 to 31 weeks 1 day. Procedures included salpingo-oophorectomy (n = 3), ovarian or paratubal cystectomy with detorsion (n = 2), and adnexal detorsion (n = 1). The median duration of surgery was 35 min (range, 20–60 min), and the estimated blood loss ranged from 5 to 50 ml. No major intraoperative or postoperative complications were noted. The final pathologic results included high-grade serous ovarian carcinoma, ovarian borderline serous cystadenoma, ovarian simple cyst, endometrioma, and mesosalpinx cyst. Five patients had a spontaneous vaginal delivery at full-term, and one patient had a cesarean section preterm followed by comprehensive staging surgery of ovarian cancer.

Conclusion

Based on the data we included, LESS performed by experienced surgeons appeared to be a safe and feasible alternative to multiport laparoscopic surgery for the management of selected patients with adnexal disease during pregnancy. More studies with large sample sizes at multiple centers are warranted.

Imaging Cancer in Pregnancy

Pregnancy-associated cancer (PAC) is defined as cancer that is detected during pregnancy and up to 1 year postpartum. Although rare (~1:1000 pregnancies), PAC is increasing owing to postponed childbearing and advanced maternal age at conception. Cancer-related symptoms masked by physiologic gestational changes may delay diagnosis. Imaging, clinical management, and treatment require a carefully choreographed multidisciplinary team approach. The risk-benefit of every imaging modality, the strategies to balance the safety of mother and fetus, and the support of the patient and family at every step are crucial. US and MRI are preferred imaging modalities that lack ionizing radiation. Radiation dose concerns should be addressed, noting that most imaging examinations (including mammography, radiography, CT, and technetium 99m-labeled sulfur colloid sentinel lymph node staging) are performed at radiation levels below thresholds at which deterministic side effects are seen. Dose estimates should be provided after each examination. The use of iodinated intravenous contrast material is safe during pregnancy, but gadolinium-based contrast material should be avoided. Accurate diagnosis and staging combined with gestational age affect decisions about surgery and chemotherapy. Whole-body MRI with diffusion-weighted sequences is ideal to screen for primary and metastatic sites, determine disease stage, identify biopsy targets, and guide further cancer site-specific imaging. The authors provide an update of the imaging triage, safety considerations, cancer-specific imaging, and treatment options for cancer in pregnancy. An invited commentary by Silverstein and Van Loon is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Choledocholithiasis in Pregnancy: A Case Report

Cholelithiasis during pregnancy and the postpartum period has an incidence of 12%, with pregnancy being an important risk factor for gallstones. Patients with choledocholithiasis can experience complications, such as obstructive jaundice, cholangitis, and pancreatitis, which may be detrimental to both mother and fetus.

A case of cholelithiasis in a second-trimester pregnancy was complicated by choledocholithiasis and obstructive jaundice. Ultrasonography (US), magnetic resonance cholangiopancreatography (MRCP), along with serial blood tests, confirmed the diagnosis. Treatment was safely achieved using endoscopic retrograde cholangiopancreatography (ERCP).

In pregnancy, complicated cholelithiasis is investigated using blood tests, ultrasonography, and cholangiography. Evidence supports the use of intraoperative or endoscopic cholangiography for the management of such complicated gallstone disease in pregnancy.

Laparoscopic treatment for appendicitis during pregnancy: Retrospective cohort study

Background

Acute appendicitis is the most frequent non-obstetric surgical emergency during pregnancy. The benefits of laparoscopy during pregnancy are well known, but complications can occur, and these can affect both the mother and/or the foetus.We present results of laparoscopic surgical treatment of acute appendicitis in pregnant women, analysing the occurrence of adverse postoperative, obstetric and foetal outcomes and reviewing literature.

Materials and methods

Retrospective observational study on pregnant women with a preoperative diagnosis of acute appendicitis.

Results

n = 63, mean age 28.4 years, average gestational age of 17.7 weeks (3-30 weeks). 6.4 % exploratory laparoscopies, 92 % laparoscopic appendectomies and one right colectomy were performed. Conversion rate was 3.2 %. When symptoms begun within 48 hours prior to surgery, a perforated appendicitis was found in 11 %; whereas when the time from symptom onset to surgery was greater than or equal to 48 hours, it was evident in 31 % of the cases (p 0.008). The only independent variable associated with the presence of postoperative complications was symptom duration prior to surgery greater than or equal to 48 hours (OR 4.8; 95 % CI 1.1-16.2; p 0.04). Seven minor and 2 mayor postoperative complications were observed. Patients with complications spent, on average, twice as many days hospitalized (p < 0.001); and had 8 times more risk of preterm delivery (p 0.03). Obstetric complications were more frequent in pregnant women operated during the first trimester. Foetal mortality was 1.6 %.

Conclusion

Surgical morbidity of acute appendicitis in pregnant women is linked to the delay in the diagnosis and treatment of the inflammatory condition. Laparoscopic appendectomy during pregnancy is not exempt from postoperative, obstetric and foetal complications. It is necessary to standardize the definitions of "complication" in order to collate reliably the outcomes presented in the literature.

Laparoscopic Versus Open Appendectomy for Appendicitis in Pregnancy: Systematic Review and Meta-Analysis

OBJECTIVES

The clinical safety, efficacy and feasibility of laparoscopic appendectomy (LA) compared with open appendectomy (OA) in pregnancy are still controversial. Herein, we are aiming to compare the clinical outcomes of LA and OA in patients with acute appendicitis during their pregnancy.

MATERIALS AND METHODS

This was a systematic review and meta-analysis of studies comparing laparoscopic and OA in pregnancy identifying using PubMed, Web of science, Embase, The Cochrane Library, Ovid and Scopus. Two independent reviewers extracted data on surgical complication, fetal loss, preterm delivery, hospital stay, Apgar score in both groups.

RESULTS

Twenty-seven studies with total of 6497 patients (4464 in open and 2031 in laparoscopic group) were included. LA was associated with lower rate of wound infection [odds risk (OR)=3.13, 95% confidence interval (CI): 1.77-5.56, P<0.0001] overall complications (OR=2.15, 95% CI: 1.47-3.14, P<0.0001) and shorter hospitalization (mean difference=0.72, 95% CI: 0.43-1.02, P<0.00001) compared with open group. LA was in a lower risk for 5-minute Apgar score (mean difference=0.09, 95% CI: 0.02-0.17, P=0.01) group than open group. No difference was found regarding preterm delivery between 2 groups. LA was associated with higher fetal loss (OR=0.57, 95% CI: 0.41-0.79, P=0.0007) compared with open surgery. However, laparoscopy was not associated with increased fetal loss after 2010 (OR=0.74, 95% CI: 0.44-1.24, P=0.26) compared with open group.

CONCLUSIONS

LA in pregnancy seems to be feasible with acceptable outcome, especially in patients with early and mid-trimester period, with sophisticated hands and experienced centers.

Ovarian cyst elevation using a metreurynter for laparoscopic cystectomy of a benign ovarian cyst during pregnancy

BACKGROUND

A uterine manipulator cannot be used to elevate the ovary in benign ovarian surgery during pregnancy. This report describes our method of elevation of the ovary using a metreurynter with the success rate of the procedure and a comparison of surgical results and pregnancy outcomes between the successful and unsuccessful cases.

METHODS

Between August 2003 and February 2020, 11 pregnant patients with a tumor found sunk in the Cul-de-sac underwent laparoscopic cystectomy for a benign ovarian cyst with a metreurynter. The surgical results, success and failure of the elevation by a metreurynter, pregnancy outcomes, and fetal status at delivery were evaluated.

RESULTS

Elevation of ovarian tumors with a metreurynter was successful in nine cases. However, it was unsuccessful in the remaining two cases wherein the ovary was lifted with forceps while the uterus was in a compressed state. The operative time was also longer in these cases. The pregnancy prognosis, however, was good for both, successful and unsuccessful cases.

CONCLUSIONS

The metreurynter is an inexpensive and practical obstetric device, and its optimal use allows the performance of a procedure with minimal burden on a pregnant uterus. Therefore, we recommend the appropriate use of this method to enable effective laparoscopic cystectomy of ovarian tumors during pregnancy.

A 27-Year-Old Primigravida with a Right Renal Cell Carcinoma Removed at 30 Weeks of Gestation by Robot-Assisted Retroperitoneoscopic Partial Nephrectomy

BACKGROUND Large renal tumors during pregnancy are rare findings (0.07-0.1%). Current guidelines recommend surgical removal. This surgery should be carefully planned in an interdisciplinary team and involves special risks for mother and fetus. This report describes a case of a 27-year-old primigravida woman with a right renal cell carcinoma involving the lower pole of the kidney, which was removed at 30 weeks of gestation by robot-assisted retroperitoneoscopic partial nephrectomy (RARPN). CASE REPORT The patient was referred by the treating obstetrician with a newly diagnosed right lower pole renal mass of 6×4 cm in greatest diameter extending deeply into the parenchyma. No metastasis or enlarged lymph nodes were described in subsequent magnetic resonance tomography. Clinical and laboratory examinations documented a healthy mother and fetus. A right-sided RARPN was advised and planned by an interdisciplinary team of treating physicians (gynecologists, oncologists, and urologists). The surgery was conducted under general anesthesia with an obstetrician on stand-by. Surgery was performed without any complications (operation time 95 min, renal-ischemia time 15 min, and negligible blood loss) and histopathology confirmed the diagnosis of a chromophobe renal cell carcinoma. Further follow-up consultations showed regular wound healing and normal progression of pregnancy, and the patient gave birth to a healthy child at term. Follow-up examinations of the patient were uneventful. CONCLUSIONS This case shows that RARPN can be a safe and effective surgical procedure for partial nephrectomy during pregnancy, where surgery is performed in a specialist center and by an interdisciplinary experienced surgical team. It seems to offer advantages and better risk profile over the laparoscopic approach.

Obstetrical outcomes following laparoscopy during pregnancy: a retrospective case-control study

PURPOSE

To evaluate pregnancy outcome of patients who undergo laparoscopy during pregnancy.

METHODS

A retrospective case-control study, conducted in a single university-affiliated tertiary care medical center, comparing pregnancy outcomes of women who underwent laparoscopy during pregnancy to women without operations during pregnancy. The study group (n = 232) included all pregnant women who underwent a single laparoscopic surgery during pregnancy (4-28 weeks of gestation) which culminated in delivery between 2006 and 2017; this study group was matched to a control group (n = 463) without surgical intervention during pregnancy, in a 2:1 ratio by maternal age, parity, and multiple gestation.

RESULTS

The main pregnancy outcomes included preterm birth, cesarean section, small for gestational age (≤ 10 percentile), and Apgar score of less than 7 in 5 min. Laparoscopy during pregnancy was associated with an increased risk for cesarean section (32.3% vs. 24.6%, adjusted OR = 1.9, CI 1.2-3.1, p = 0.011). We found no difference between the groups with regard to other outcomes, including rates of preterm birth (12.1% vs. 10.4%, adjusted OR = 1.3, CI 0.64-2.72, p = 0.451). In a subgroup analysis of the study group, various perioperative parameters such as operation duration, hospitalization length, and others, did not correlate with adverse pregnancy outcome.

CONCLUSIONS

Laparoscopy during pregnancy may be associated with an increased rate of cesarean section. We did not find an increase in any other pregnancy or neonatal complication. Different perioperative parameters did not appear to predict adverse pregnancy outcome.

Characteristics and surgical invervention of ovarian torsion in pregnant compared with nonpregnant women

The aim of our study was to compare the clinical and surgical characteristics of pregnant and nonpregnant women with surgically verified ovarian torsion, as well as the differences among 3 trimesters during pregnancy.We conducted a retrospective study of patients diagnosed with surgically proven ovarian torsion in our hospital from January 2012 to June 2018. The clinical characteristics, surgical procedure, pathologic outcomes, and trimesters of pregnancy were analyzed.Thirty-three pregnant and 72 nonpregnant patients diagnosed with surgically proven ovarian torsion were assessed during the study period. The most common presenting symptom in both groups was abdominal pain (90.2% and 99.0%, respectively). The median time from admission to surgery was shorter in pregnant patients than nonpregnant patients (5.3 compared with 47.7 hours, P < .001). Pregnant patients had a higher number of twists than nonpregnant patients (median of 2 compared with 1, P < .01). Benign cyst was the most common cyst causing ovarian torsion in both groups, and luteum cyst was more common in the pregnant group. The mean size of ovarian cyst in pregnant patients was much smaller in the third trimester than the first and the second trimesters (6.6 ± 2.0, 8.4 ± 2.1and 8.1 ± 1.5 cm, respectively; P = .097). Cystectomy performed in the third trimester was more frequent compared with the other 2 trimesters (77.8%, 26.7%, and 22.2%, respectively; P = .021).Abdominal pain is the most common feature of ovarian torsion. Clinical presentation of ovarian torsion is relatively similar between pregnant and nonpregnant women, and among different trimesters. The tumor size was smaller in the third trimester of pregnancy than the other 2 trimesters of pregnancy. Cystectomy performed in pregnant patients is more during the third trimester compared with the other 2 trimesters.

Managing choledocholithiasis in pregnancy: a novel approach

The management of choledocholithiasis in pregnancy can present a challenge due to radiation risk to the fetus and the possibility of severe maternal pancreatitis. We describe a case in which both these risks were avoided using a trans-cystic stent placed under endoscopic guidance during laparoscopic cholecystectomy.

Comparison of subsequent pregnancy outcomes after surgery for adnexal masses performed in the first and second trimester of pregnancy

OBJECTIVE

To determine whether surgery for adnexal masses in the first trimester of pregnancy affects subsequent pregnancy outcomes compared to surgery in the second trimester.

METHODS

Data were retrospectively reviewed from women who underwent adnexal mass surgery before 26 weeks of gestation at a university hospital between July 2008 and June 2018. Women who underwent surgery in the first trimester were classified as group 1 (n=78) and those in the second trimester were classified as group 2 (n=48). Information on clinical characteristics and pregnancy outcomes was obtained from medical records and follow-up interviews and compared between two groups.

RESULTS

There were no differences in age, parity, mass size, laparoscopy, and operation time between the two groups. A total of 98 cases were confirmed as ovarian torsion, including 72 cases in group 1 and 26 cases in group 2. Accordingly, adnexectomy was performed more often in group 1 (P=0.002). No significant differences concerning the rate of abortion, preterm birth, or cesarean delivery were found.

CONCLUSION

Surgery for adnexal masses performed in the first trimester is almost as safe as that in the second trimester. Surgery should be performed for women with a complex adnexal mass in the first trimester to avoid unfavorable complications.

Laparoscopic detorsion of the ovary in ovarian hyperstimulation syndrome during the sixth week of gestation: A case report and review

INTRODUCTION

Ovarian torsion in ovarian hyperstimulation syndrome (OHSS) is a relatively rare but serious complication in pregnant women. A delay in treatment increases the risk for functional loss of the ovary and early termination of pregnancy. In this report, we present the case of a 40-year-old female with OHSS who experienced ovarian torsion that was successfully treated with laparoscopic detorsion.

PRESENTATION OF CASE

A 40-year-old pregnant woman in the 6th week of gestation who had conceived following in vitro fertilization presented to us with severe and persistent lower abdominal pain. Ultrasound examination revealed a viable singleton intrauterine pregnancy and bilateral enlarged ovaries with scanty ascites. Approximately 14 h after symptom onset, exploratory laparoscopy was performed. The right ovary was found to be twisted once around over the pedicle, and laparoscopic detorsion was completed. Postoperative follow-up was uneventful, and she successfully delivered a healthy infant at 38 weeks of gestation.

DISCUSSION

Although the reports on successful laparoscopic surgery for pregnant women with ovarian torsion are becoming more frequent, there are few reports on laparoscopic surgery for ovarian torsion in OHSS during the early first trimester. Optimal management of ovarian torsion during pregnancy needs to be explored for these patients.

CONCLUSION

Immediate explorative laparoscopic surgery is a potentially safe and useful strategy for treating ovarian torsion during the early first trimester of pregnancy.

Is the laparoscopic approach a safe choice for the management of acute appendicitis in pregnant women? A meta-analysis of observational studies

INTRODUCTION

Acute appendicitis is a common and serious situation during pregnancy, because of the increased risk of fetal loss and perforation in the third trimester, as well as a diagnostic difficulty. During recent years laparoscopic approach has been introduced to clinical practice with encouraging results. The purpose of this meta-analysis is to compare the surgical and obstetrical outcomes between laparoscopic and open appendectomy during pregnancy.

MATERIALS AND METHODS

MEDLINE, SCOPUS, Clinicaltrials.gov, CENTRAL and Google Scholar were searched for studies reporting on postoperative outcomes between laparoscopic and open appendectomy during pregnancy. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when high heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented.

RESULTS

Twenty-one studies that enrolled 6276 pregnant women are included in the present meta-analysis. Of these women, 1963 underwent laparoscopic appendectomy and 4313 underwent an open appendectomy. Women who underwent laparoscopic appendectomy demonstrated an increase in fetal loss risk, while neonates of women that underwent open appendectomy presented decreased Apgar score at five minutes after birth. All the rest outcomes were similar between the two groups. The time that each study took place seemed to affect the comparison of birth weight and postoperative hospital stay between the two groups.

CONCLUSION

Laparoscopic appendectomy seems to be a relatively safe therapeutic option in pregnancy when it is indicated. Thus, it should be implemented in clinical practice, always considering the experience of the surgeon in such procedures. Nevertheless, the need of new studies to enhance this statement remains crucial.

Ovarian dysgerminoma in pregnancy: A case report and literature review

BACKGROUND

Dysgerminoma is an uncommon malignant tumor arising from the germ cells of the ovary. Its association with pregnancy is extremely rare; the incidence is about 0.2-1 per 100,000 pregnancies. Because of its infrequency, there are few recommendations regarding its management in pregnancy; therefore, it is important to discuss and summarize the treatment strategy.

CASE

We presented a case of a 23-year-old pregnant woman with a large dysgerminoma originated from the right ovary, which had the unusual coincidence of being associated with an abdominal desmoid tumor simultaneously. We did not find any similar cases published in the PubMed database after 1947. A cesarean section was performed at 34 + 6 weeks gestation secondary to her abdominal pain worsening. The patient delivered a healthy boy and had fertility-preserving surgery, followed by 6 cycles of chemotherapy. This case is compared with 21 other reported cases of pure ovarian dysgerminoma in the literature to evaluate the clinical characteristics, feto-maternal compromise, treatment, long-term survival, and fertility outcome.

CONCLUSION

The treatment strategy in women with ovarian dysgerminoma should be discussed and structured on an individual basis. If pregnancy is desired, surgical intervention undertaken in the second trimester seems to be the first choice. When chemotherapy is indicated, unless delivery can be accomplished within a few weeks of diagnosis, it should not necessarily be delayed until after delivery. Good reproductive function and high survival rate can be achieved in patients treated with conservative surgery and adjuvant chemotherapy.

Adnexal Torsion during Pregnancy: Outcomes after Surgical Intervention-A Retrospective Case-Control Study

STUDY OBJECTIVE

To investigate the pregnancy and neonatal outcomes of surgical treatment for adnexal torsion (AT) during pregnancy.

DESIGN

A retrospective case-control study (Canadian Task Force classification II-2).

SETTING

A tertiary care academic medical center.

MEASUREMENTS AND MAIN RESULTS

The study group included all parturients who underwent surgery for suspected AT during pregnancy from January 2005 to January 2017. The control group included parturients with an uneventful pregnancy matched by maternal age, parity, multiple gestation, and pregnancy complications. The primary outcome was gestational age at delivery. Secondary outcomes were perinatal outcomes and intraoperative and immediate postoperative complications. Among 85 study group patients with suspected AT, 78 (91.7%) underwent laparoscopy and 7 (8.3%) laparotomy. Torsion was diagnosed in 84 patients (98.8%). The gestational age at delivery was similar between the study and control groups (38.7 ± 1.5 vs 38.6 ± 1.6 weeks, respectively; p = .908) as was preterm labor (5.8% in both groups, p = 1.00). There was no significant difference between the study and control groups in pregnancy and neonatal outcomes, including Apgar scores, mean cord blood pH (7.25 ± 0.1 and 7.26 ± 0.08, respectively), and birth weight (3040 ± 473 g and 3115 ± 584 g, respectively). In the study group, the mean gestational age at surgery was 11.2 ± 6 weeks (range, 4-34 weeks). The average operative time was 40.2 ± 22 minutes. In the postoperative follow-up, 3 (3.5%) patients had a first trimester miscarriage. A previous cesarean delivery was a risk factor for ovarian torsion during pregnancy (p = .012).

CONCLUSION

Adnexal detorsion with or without additional surgical procedures during pregnancy did not affect the gestational age at delivery and did not appear to increase fetal or maternal complication rates.

The Evaluation of Laparoscopic Surgery on Pregnant Patients with Ovarian Cysts and Its Effects on Pregnancy over the Past 5 Years

STUDY OBJECTIVE

Study Objective: In this research paper, we demonstrate how to increase the success rate of laparoscopic surgery on pregnant patients with an ovarian cyst using rectal probe, SAND balloon, and lowering the insufficient level.

DESIGN

The study design wasa retrospective study.

SETTING

The study was conducted at Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan.

PATIENTS

Pregnant patients with an ovarian cyst who underwent laparoscopic surgeries at our institution during the period from January 2011 to December 2016.

MATERIALS AND METHODS

We reviewed 14 cases of pregnant women with ovarian cysts that underwent laparoscopic surgery during the study period by observing and analyzing the patient's characteristics, hospitalization practices, surgical complications, operational procedures, and obstetric outcomes.

MAIN RESULTS

Three cases were emergency surgeries and 11 cases were elective surgeries. In the 14 cases, the gestational age at the time of the surgeries ranged from 6 to 20 weeks. In our studies, we found no systemic complications after the surgery and none of the cases reported any fetal malformation or any fetal growth restriction.

CONCLUSION

In our review, laparoscopic surgery for ovarian cyst during pregnancy was very safe and successful, without any adverse effects on pregnancy outcome.

Laparoscopy during pregnancy: Case report and key points to improve laparoscopic management

CASE REPORT

A 34-year-old woman in her 19th week of gestation was admitted to the Emergency Department of our hospital for acute abdominal pain. The patient was diagnosed with haemoperitoneum. Laparoscopy was performed and revealed acute bleeding from a crumbly superficial uterine vascular network. Haemostasis was achieved and both mother and foetus recovered well after surgery. A caesarean section was performed at 38 weeks, delivering a healthy newborn and revealing that the pregnancy had developed in a rudimentary hemiuterus. Laparoscopy during pregnancy is safe and feasible and can be performed in any trimestre of pregnancy with no differences in perinatal outcomes but, as intervention complexity increases with gestational age, laparoscopy during pregnancy should be performed by experienced surgeons To minimise surgical risk several recommendations should be taken into account: gravid patients should be positioned in a left-tilted supine position, trocar placement should be adjusted to uterine size and gas insuflattion of 10-15mmHg can be used.

Laparoscopy in the second and third trimesters of pregnancy for abdominal surgical emergencies

OBJECTIVE

To assess complications and outcomes of pregnancies following laparoscopic abdominal surgery during the second and third trimesters of pregnancy.

MATERIAL AND METHODS

Retrospective single-center study of 23 cases of laparoscopic surgery in the second or third trimesters of pregnancy between January 2005 and May 2016.

RESULTS

The laparoscopies were performed between 15 and 33 weeks of gestation, a mean of 23 weeks+2 days, with 6 cases in the 3rd trimester. The operations were: 11 cholecystectomies, 6 appendectomies, 1 intestinal occlusion (volvulus on a gastric band), 3 adnexal torsions, 1 ovarian cyst and 1 paratubal cyst with torsion. No secondary laparotomy was required. The postoperative courses were favorable in most cases. However, 3 appendectomies were complicated, one by chorioamnionitis and miscarriage at 20½ weeks of gestation and 2 by right iliac fossa abscesses requiring percutaneous radiological drainage, one of these women delivered a healthy term baby and the other had chorioamnionitis and preterm delivery at 34 weeks, followed by neonatal death.

CONCLUSION

Laparoscopy can be safely performed for surgical indications in the second and third trimesters of pregnancy. In case of abdominal symptoms, a timely diagnosis is required to decide whether or not to operate and imaging should not be withheld particularly in case of suspected appendicitis which has a high risk of complications.

Gastric cancer in pregnancy: is laparoscopic gastrectomy with lymph node dissection feasible and safe?

Gastric cancer with pregnancy is rare and usually presents in late and advanced stage. Standard interventions in diagnosing, staging and treatment of cancer may be harmful for the fetus. The treatment of cancer in pregnancy should not differ significantly from the treatment in nonpregnant women. There have been case reports of open gastrectomy for gastric cancer in pregnancy. We present a case of early gastric cancer in a 37-year-old pregnant woman treated with laparoscopic distal gastrectomy with lymph node dissection with no postoperative complications. Laparoscopic distal gastrectomy with lymph node dissection seems to be feasible and safe in pregnancy for a mother and a fetus.

Episode of Familial Mediterranean Fever-Related Peritonitis in the Second Trimester of Pregnancy Followed by Acute Cholecystitis: Dilemmas and Pitfalls

BACKGROUND

Differential diagnosis of acute abdomen in pregnant patients is one of the greatest challenges for the clinician. Occurrence of Familial Mediterranean Fever (FMF) paroxysm of peritonitis and acute cholecystitis during pregnancy is a unique clinical entity that leads to serious diagnostic and therapeutic dilemmas.

CASE REPORT

We present the case of a 33-year-old Armenian patient at 16 weeks' gestational age with a history of FMF, who was admitted twice within 1 month with acute abdomen. The first episode was attributed to FMF and successfully treated conservatively with colchicine. The second episode was diagnosed as acute cholecystitis and led to emergent laparoscopic cholecystectomy and lysis of peritoneal adhesions from previous FMF attacks. The patient presented an uneventful postoperative clinical course and had a normal delivery of a healthy infant at the 39th week of gestation.

CONCLUSIONS

Pregnant patients with acute abdomen should be evaluated with open mind. To the best of our knowledge, this is the first published report of the coexistence of 2 different causes of acute abdomen during pregnancy. Meticulous history and thorough physical, laboratory, and radiologic examination are the keys to reach a correct diagnosis. Treatment of pregnant patients with acute abdomen should be individualized. Administration of colchicine should be continued during conception, pregnancy, and lactation in patients with FMF history. Laparoscopic intervention in pregnant patients with surgical abdomen such as acute cholecystitis is the optimal method of treatment.

Ovarian Torsion in the Third Trimester of Pregnancy Leading to Iatrogenic Preterm Delivery

Ovarian torsion in the third trimester of pregnancy leading to a midline laparotomy and caesarean section for the delivery of a preterm baby is an uncommon event. As the woman is likely to present with nonspecific symptoms of lower abdominal pain, nausea, and vomiting, ovarian torsion can often be misdiagnosed as appendicitis or preterm labour. Treatment and the opportunity to preserve the tube and ovary may consequently be delayed. We report the case of a multiparous woman who had undergone two previous caesarean sections at term, presenting at 35 weeks of gestation with a presumptive diagnosis of acute appendicitis. Ultrasonography described a cystic lesion 6 × 3 cm in the right adnexa, potentially a degenerating fibroid or a torted right ovary. MRI of the pelvis was unable to provide further clarity. The patient was managed by midline laparotomy and simultaneous detorsion of the ovarian pedicle and ovarian cystectomy together with caesarean section of a preterm infant. This report describes that prompt recognition and ensuring intraoperative access can achieve a successful maternal and fetal outcome in this rare and difficult scenario. Furthermore, we would like to emphasise that the risk for a pregnant woman and her newborn could be reduced by earlier diagnosis and management of ovarian masses (Krishnan et al., 2011).