Laparoscopic cholecystectomy in pregnancy: two case reports

Management of biliary tract disease during pregnancy: a decision analysis

BACKGROUND

The appropriate management of biliary tract disease during pregnancy is uncertain. Although laparoscopic cholecystectomy can be performed safely during pregnancy, the timing and indications for this surgical intervention have not been firmly established.

METHODS

We constructed a Markov decision analytic model that incorporates maternal well-being and fetal outcome into a choice between nonoperative management (NM) and laparoscopic cholecystectomy (LC) for pregnant women with biliary tract disease (BTD). Our model cycles through weeks of pregnancy for a cohort of 200 gravid women presenting with biliary tract disease in both the first and second trimesters. Weekly state probabilities and utilities for fetal outcome were derived from the literature, while weekly utilities for disease and operative states were estimated in consultation with obstetricians. We cycled the model from 6 to 42 weeks and from 19 to 42 weeks to simulate first and second trimester presentations. Outcomes are expressed in quality pregnancy weeks (QPWs). One QPW is the utility of a normal healthy week of pregnancy.

RESULTS

A comprehensive search of the literature yielded a fetal death rate following LC for biliary tract disease of 2.2% and following NM of 7%. Relapse rates were found to be trimester dependent and estimated to be 55%, 55%, and 40% in the first, second, and third trimester, respectively. For a hypothetical cohort of 100 women presenting with biliary tract disease in their first trimester, LC generated 12,800 QPWs compared with 12,400 QPWs for NM, an average gain of 4 QPWs per woman. For the cohort of women entering the model in the second trimester, 11,600 QPWs were accrued by the LC group and 11,400 QPWs by the NM group, an average gain of 2 QPWs per woman. These findings were sensitive only to changes in fetal death rates under the two treatment arms.

CONCLUSIONS

Laparoscopic cholecystectomy is superior to nonoperative management for pregnant women presenting in the first or second trimester with biliary tract disease.

Laparoscopic surgery during pregnancy

In the last decade, operative laparoscopic procedures are performed increasingly in both gynecology and general surgery. The major advantages of this newer minimally invasive approach are: decreased postoperative morbidity, less pain and decreased need for analgesics, early normal bowel function, shorter hospital stay, and early return to normal activity. With the advancement of laparoscopic surgery, its use during pregnancy is becoming more widely accepted. The most commonly reported laparoscopic operation during pregnancy is laparoscopic cholecystectomy (LC). Other laparoscopic procedures commonly performed during pregnancy include: management of adnexal mass, ovarian torsion, ovarian cystectomy, appendectomy, and ectopic pregnancy. The possible drawbacks of laparoscopic surgery during pregnancy may include injury of the pregnant uterus and the technical difficulty of laparoscopic surgery due to the growing mass of the gravid uterus. Also, the potential risk of decreased uterine blood flow secondary to the increase in intraabdominal pressure and the possible risk of carbon dioxide absorption to both the mother and fetus should be taken into account. To date, data on laparoscopic surgery during pregnancy are insufficient to draw conclusions on its safety and exact complication rate. This is due to the few cases reported and the lack of prospective studies. Furthermore, there is a common tendency to underreport unsuccessful cases. Finally, most reports in the literature come from centers and surgeons with special interest, experience, and skills in laparoscopy, and their results may not reflect the real complication rates. We have reviewed the pertinent English literature from the last decade. The cumulative experience suggests that laparoscopic surgery may be performed safely during pregnancy, although more studies are needed to establish its exact rate of adverse events.

Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy

Previous surgery, obesity, and pregnancy should no longer be considered contraindications to laparoscopic surgery. Surgeons should exercise good judgement in patient selection, use meticulous surgical techniques, and prepare thoroughly for the planned procedure. Patients and surgeons should be aware of increased conversion rates. With these caveats in mind, these patients can still experience the advantages of minimally invasive surgery without increased risks.

Laparoscopic surgery during pregnancy

STUDY OBJECTIVE

To describe the benefits, complications, and safety of laparoscopic surgery during pregnancy.

DESIGN

Retrospective case series (Canadian Task Force classification II-2).

SETTING

Community academic medical center.

PATIENTS

Nineteen pregnant women.

INTERVENTIONS

Five (26.3%) appendectomies, seven (36.8%) ovarian cystectomies, five (26.3%) cholecystectomies, one diagnostic laparoscopy (5.3%), and one (5.3%) salpingectomy. In one woman, laparoscopy was converted to exploratory laparotomy to complete a difficult ovarian cystectomy, and a second patient required a minilaparotomy incision to remove the specimen.

MEASUREMENTS AND MAIN RESULTS

No preterm labor or adverse perinatal outcome occurred, although one woman had irregular uterine contractions that promptly resolved with tocolytics. One patient delivered at 35 weeks' gestation and the rest carried their pregnancy to term, and all delivered normal infants. No malignancy was found on histopathologic examination of specimens. Hospital stay ranged from 1 to 4 days.

CONCLUSION

Laparoscopic surgery can be performed safely in pregnant women. This series adds 19 cases to the approximately 141 reported in the literature. (J Am Assoc Gynecol Laparosc 6(2):229-233, 1999)

Outcome study of cholecystectomy during pregnancy

BACKGROUND

Several anecdotal papers suggest that laparoscopic cholecystectomy can be done safely in pregnant patients, but few patients are reported and other patients such as those who underwent laparoscopic appendectomy are often included. A larger series would help clarify the situation.

METHODS

The Connecticut Laparoscopic Cholecystectomy Registry and data from the Connecticut Hospital Association (CHA) were combined to search for all cholecystectomies performed in pregnant patients from 1992 through 1996. Information on outcomes for both mother and infant was obtained through the cooperation of most of the CHA hospitals.

RESULTS

Complete data were available for 46 patients, 20 laparoscopic and 26 open cases. The groups were comparable in all demographic respects except for the timing of cholecystectomy, which was performed at a mean of 18.4 +/- 6.7 weeks (range 9 to 32) of gestation for the laparoscopic and 24.8 +/- 4.7 weeks (range 14 to 35) for the open patients (P = 0.01). A maternal-fetal mortality due to intra-abdominal hemorrhage occurred in the laparoscopic group 2 weeks postoperatively. In the open group, a fetal demise occurred at 21 weeks gestation, 5 weeks postcholecystectomy. The open patients experienced 8 episodes of premature contractions compared with one one such event in the laparoscopic group (P = 0.057).

CONCLUSIONS

This represents the largest reported series of laparoscopic cholecystectomy in pregnant patients. Laparoscopic cholecystectomy does not lead to increased numbers of fetal complications. Premature uterine contractions tend to occur more frequently after open cholecystectomy and when the procedure is performed later in gestation.

Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature

This study was conducted to evaluate the role of antepartum laparoscopic cholecystectomy (LC). Patients who underwent LC were identified from a hospital database with the use of CPT/ICD codes. Of 2093 cases performed at a major center (October 1991 to November 1997), only six were performed during pregnancy. On reviewing the English literature, gestational age at surgery and delivery and outcome of delivery were provided in only 69 of 105 patients (33 papers with 1-10 cases) and we tabulated different variables from the cases in this review. In this series, two patients who had LC in the first trimester underwent elective termination of pregnancy. Of the seven published cases of first trimester LC followed to delivery, one had preterm delivery. First trimester open cholecystectomy (OC) has a 12 percent spontaneous abortion rate. The four patients who had second trimester LC had normal deliveries at term. Of the 43 published cases of second trimester LC followed to delivery, 39 ended in uncomplicated, full-term deliveries. Three of four second trimester cases at one institution had spontaneous abortions. None of our patients underwent LC in the third trimester. Of the 12 published cases of third trimester LC followed to delivery, one had preterm delivery. Third trimester OC is reported to have a 40 percent rate of preterm delivery. There were no intraoperative cholangiograms (IOC), prophylactic or postoperative use of tocolytics, or intraoperative fetal monitoring in our series. We added six cases of LC during pregnancy to the previously reported 105 cases. The successful outcome in all trimesters suggests that LC is a safe procedure throughout pregnancy; however, surgery in the second trimester is preferable. Compared with OC, there is a decreased risk of spontaneous abortion in the first trimester and preterm labor in the third trimester.

Laparoscopic cholecystectomy during pregnancy

BACKGROUND

Cholecystectomy represents the second most common nonobstetric operation during pregnancy. Published guidelines for laparoscopic cholecystectomy (LC) have considered it to be contraindicated in the gravid patient. Several cases of successful LCs in the gravid patient have been reported recently. This study reviews LC during pregnancy in my series and compares this experience with the published literature.

METHODS

Five LCs were performed during pregnancy out of 380 cases between May 1990 and November 1994. Forty-one cases were retrieved via MEDLINE search.

RESULTS

Three patients were in their second trimester (14, 17, and 22 weeks), and two patients were in the third trimester (27.5 and 28 weeks) in my series. The open technique was used in one patient. Intraoperative cholangiography was not performed. No maternal or fetal morbidity occurred. Forty-one cases have been reported in the literature. Four patients were operated on during the first trimester, 35 during the second trimester, and two during the third trimester (range, 3 to 31 weeks) without fetal loss or maternal morbidity. Cholangiography was performed in 15 cases. Tocolytic agents were used in five of 46 patients.

CONCLUSIONS

Although additional clinical data are required, laparoscopic cholecystectomy is safe during pregnancy when undertaken by the skilled laparoscopic surgeon.