Hg caused significant maternal cardiovascular and respiratory patients. Of these, higher conversion rates to laparotomy, changes after 20 minutes. hese included increased respiratory longer operating times, and longer hospitalizations have rate, respiratory acidosis, diminished cardiac output, and been reported. Also, adequate ventilation is more diicult, increased pulmonary artery and capillary wedge pressures. and greater pneumoperitoneal pressures are needed to create aEffects intensified when insufflation pressure >20 mm Hg in baboons (Reedy, 1995). bData primarily from animal studies.
CO2 =carbon dioxide; CSF = cerebrospinal fluid; PC02 = patial pressure of CO2, Data from O'Rourke, 2006; Reynolds, 2003.
suitable operating space. here is anatomical distortion of the abdominal wall with displaced landmarks. Finally, the risk of developing hernias at port sites is greater.
Because precise efects of laparoscopy in the human fetus are unknown, animal studies are informative. In early studies of pregnant ewes, various investigators reported that uteroplacental blood low declines when intraperitoneal insulation pressure exceeded 15 mm Hg (Barnard, 1995; Hunter, 1995). This was the result of decreased perfusion pressure and increased placental vessel resistance (see Table 46-3). The previously cited baboon studies by Reedy and coworkers (1995) produced similar findings.
Perinatal outcomes in women are limited to observational studies. Reedy and colleagues (1997) used the updated Swedish Birth Registry database to analyze a 20-year period with more than 2 million deliveries. Of 2181 laparoscopic procedures, most were performed during the irst trimester. Perinatal outcomes for these women were compared with those of all women in the database and those undergoing open surgical procedures. These investigators confirmed the earlier indings of an increased risk of low birthweight, preterm delivery, and fetal-growth restriction. Diferences were not found, however, in outcomes of women undergoing laparoscopy versus laparotomy. n observational study of 262 women undergoing surgery for an adnexal mass noted similar findings (Koo, 2012).
The following description is an overview of laparoscopic techniques in pregnancy. For a detailed description refer to Chapter 15 in Cunningham and Gistrap s Operative Obstetrics, 3rd edition (Kho, 2016).
Preparation for laparoscopy difers little from that used for laparotomy. Bowel cleansing is not needed but may aid visualization and manipulations by emptying the large intestine. N asogastric or orogastric decompression reduces the risk of stomach trocar puncture and aspiration. Aortocaval compression is avoided by a left-lateral tilt. Positioning of the lower extremities in boot-type stirrups maintains access to the vagina for fetal sonographic assessment or manual uterine displacement. Intrauterine manipulators are logically avoided.
Most reports describe the use of general anesthesia after tracheal intubation with monitoring of end-tidal carbon dioxideEtC02 (Hong, 2006; Ribic-Pucelj, 2007). With controlled ventilation, EtC02 is maintained at 30 to 35 mm Hg.