Information regarding surgical approach selection in pregnancy comes from the American College of Surgeons database (Silvestri, 2011). During the 5-year period ending in 2009, almost 1300 pregnant women were studied who had undergone either appendectomy or cholecystectomy. Open appendectomy was performed in 36 percent of 857 gravidas compared with only 17 percent of those not pregnant. Of those undergoing cholecystectomy, an open procedure was used in 10 percent of 436 pregnant women compared with 5 percent of nonpregnant women. No randomized trials compare laparoscopic with open surgery, however, most reviews report equally satisfactory outcomes (Bunyavejchevin, 2013; Cox, 2015; Fatum, 2001). The most frequently performed procedures were cholecystectomy, adnexal surgery, and appendectomy. For adnexal mass surgery in pregnancy, laparoscopy is preferred, and several studies conirm its relative safety (Daykan, 2016; Hoover, 2011; Webb, 2015). At first, 26 to 28 weeks became the upper gestational-age limit recommended, but as experience has accrued, many now describe laparoscopic surgery performed in the third trimester (Kizer, 2011). In one report of 59 gravidas undergoing laparoscopic cholecystectomy or appendectomy, a third were > 26 weeks'
TABLE 46-2. Some Guidelines from the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) for Laparoscopic Surgery in Pregnant Women
Indications-same as for nonpregnant women
Investigation of acute abdominal processes
Appendectomy, cholecystectomy, nephrectomy, adrenalectomy, splenectomy
Position: lateral recumbent
Entry: open technique, careful Veress needle, or optical trocar; fundal height may alter insertion site selection Trocars: direct visualization for placement; fundal height may alter insertion site selection
CO2 insuflation pressures: 10-15 mm Hg
Monitoring: capnography intraoperatively, FHR assessment pre-and postoperatively Perioperative pneumatic compression devices and early postoperative ambulation
CO2 = carbon dioxide; FHR = fetal heart rate. Data from Pearl, 2017.
gestation (Rollins, 2004). No serious adverse sequelae are In women, cardiorespiratory changes are generally not linked to these procedures. In addition, laparoscopic splesevere if insulation pressures are kept below 15 mm Hg. With nectomy, adrenalectomy, and nephrectomy have also been noninvasive hemodynamic monitoring in women at midpregdescribed in pregnant women (Asizare, 2014; Dong, 2014; nancy, the cardiac index decreased 26 percent by 5 minutes of Gernsheimer, 2007; Miller, 2012; Stroup, 2007). insulation and 21 percent by 15 minutes (Steinbrook, 2001).
Despite this, mean arterial pressures, systemic vascular resistance, and heart rate did not change significantly.
changes that are summarized in Table 46-3. Reedy and associ ates (1995) studied baboons at the human equivalent of 22 to Laparoscopic surgery frequently is ideal for the obese woman 26 weeks' gestation. No substantive physiological changes were (Sisodia, 2015). However, some outcomes may be adversely found with insulation pressures of 10 mm Hg, but 20 mm afected in obese gravidas compared with normal-weight