Beyond the irst trimester, technical modifications of standard pelvic laparoscopic entry are required to avoid uterine puncture or laceration (Fig. 46-1). Many recommend open enuy techniques to avoid perforations of the uterus, pelvic vessels, and adnexa (Kizer, 2011; Koo, 2012). The abdomen is incised at or above the umbilicus, and the peritoneal cavity entered under direct visualization (Fig. 46-2). At this point, the cannula is then connected to the insulation system, and a 12-mm Hg pneumoperitoneum is created. The initial insulation should be conducted slowly to allow for prompt assessment and reversal of any untoward pressure-related efects. Gas leakage around the cannula is managed by tightening the surrounding skin with a towel clamp. Insertion of secondary trocars into the abdomen is most safely performed under direct laparoscopic viewing. Single-port surgery has also been described (Dursun, 20l3).
In more advanced pregnancies, direct entry through a left upper quadrant port in the midclavicular line, 2 cm beneath the costal margin, may better avoid the fundus (Donkervoort, 2011; Stepp, 2004). Known as Palmer point, this entry site is also used in gynecological laparoscopy because visceroparietal adhesions infrequently form here (Vilos, 2007).
FIGURE 46-1 Pregnant uterus at 10,o20, and 36 weeks' gestation depicting distortion of other intraperitoneal organs. (Reproduced with permission from Kho KA: Diagnostic and operative laparoscopy. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics 3rd ed, New York McGraw-Hili Education, 201o7.)
FIGURE 46-2 Open entry technique for laparoscopic instrument placement. A. Fascia grasped with two Allis clamps and elevated prior to sharp incision. B.Two fascial stitches incorporate the peritoneum and fascia. C. These fascial sutures are wrapped around holders of the Hasson cannula to anchor it in place. (Reproduced with permission from Kho KA: Diagnostic and operative laparoscopy. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics 3rd ed, New York McGraw-Hili Education, 201o7.)
Gasless laparoscopy is a less commonly selected alternative approach that uses a rod with intraabdominal fan-blade-shaped retractors. When opened, these allow the abdominal wall to be lifted upward. It avoids the typical laparoscopic cardiovascular changes because the pneumoperitoneum is created by retraction rather than insuiation (Phupong, 2007).
Risks inherent to any abdominal endoscopic procedure are probably increased slightly during pregnancy. The obvious unique complication is perforation of the pregnant uterus with either a trocar or Veress needle (Azevedo, 2009; Kizer, 2011; Mala, 2014). hat said, reported complications are infrequent (Fatum, 2001; Koo, 2012). One Cochrane database review noted a need for randomized trials to deduce comparative benefits and risks of laparoscopy versus laparotomy during pregnancy (Bunyavejchevin, 2013). Pragmatically, this seems unfeasible, and common sense should dictate the approach.