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Laparoscopic cholecystectomy during pregnancy: three case reports.
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MedLine Citation:
PMID:  10323173     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECTIVE: The purpose of this presentation is to investigate the effects and feasibility of laparoscopic cholecystectomy during pregnancy.
METHODS AND PROCEDURES: We present three pregnant patients who underwent a laparoscopic cholecystectomy for biliary colic during the early second and early third trimester of pregnancy. We also reviewed the literature regarding this topic.
RESULTS: All three pregnant patients had uneventful hospital courses after their procedures and delivered full-term babies without complications. Laparoscopic cholecystectomy during the first trimester of pregnancy is contraindicated due to the ongoing fetal organogenesis and during the third trimester is not technically feasible due to the large uterine size.
CONCLUSIONS: We conclude that laparoscopic cholecystectomy during the second and very early third trimester of pregnancy is safe and feasible.
Authors:
T Chamogeorgakis; E Lo Menzo; R D Smink; B Feuerstein; M Fantazzio; J Kaufman; E J Brennan; R Russell
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Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons     Volume:  3     ISSN:  1086-8089     ISO Abbreviation:  JSLS     Publication Date:    1999 Jan-Mar
Date Detail:
Created Date:  1999-06-28     Completed Date:  1999-06-28     Revised Date:  2013-03-07    
Medline Journal Info:
Nlm Unique ID:  100884618     Medline TA:  JSLS     Country:  UNITED STATES    
Other Details:
Languages:  eng     Pagination:  67-9     Citation Subset:  IM    
Affiliation:
The Lankenau Hospital, Wynnewood, Pennsylvania 19096, USA.
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MeSH Terms
Descriptor/Qualifier:
Adult
Cholecystectomy, Laparoscopic*
Cholelithiasis / surgery*,  ultrasonography
Female
Humans
Pregnancy
Pregnancy Complications / surgery*
Pregnancy Outcome
Pregnancy Trimester, Second
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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Journal Information
Journal ID (nlm-ta): JSLS
Journal ID (hwp): jsls
Journal ID (pmc): jsls
Journal ID (publisher-id): JSLS
ISSN: 1086-8089
ISSN: 1938-3797
Publisher: Society of Laparoendoscopic Surgeons, Miami, FL
Article Information
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© 1999 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.
open-access:
Print publication date: Season: Jan–Mar Year: 1999
Volume: 3 Issue: 1
First Page: 67 Last Page: 69
ID: 3015349
PubMed Id: 10323173

Laparoscopic Cholecystectomy During Pregnancy: Three Case Reports
Themis Chamogeorgakis, MD
Emanuele Lo Menzo, MD
Robert D. Smink, Jr, MD
Brandt Feuerstein, MD
Michelle Fantazzio, MD
Jarrod Kaufman, MD
Edward J. Brennan, MD
Randal Russell, MD
The Lankenau Hospital, Wynnewood, Pennsylvania
Correspondence: Address reprint request to: Themis Chamogeorgakis, MD, The Lankenau Hospital, 100 Lancaster Ave, Suite 422 Wynnewood, PA 19096, USA. Fax: (610) 645-3354

INTRODUCTION

There is a strong association between pregnancy and gallstones. When biliary colic or acute cholecystitis occurs during pregnancy, medical treatment is indicated.1, , 3 Spontaneous abortion and congenital abnormalities are associated with cholecystectomy during the first trimester of pregnancy. Premature labor, on the other hand, can occur during the third trimester of pregnancy.4, , 6

We present three cases of laparoscopic cholecystectomy during pregnancy: two during the second trimester and one at the beginning of the third trimester. Laparoscopic cholecystectomy has the advantage of faster recovery due to less pain than open cholecystectomy.7


CASE REPORT 1

A 30-year-old white female, 22 weeks pregnant, was admitted with two episodes of right upper quadrant abdominal pain associated with nausea and vomiting. Ultrasonography of the gallbladder revealed gallstones with a normal size common bile duct. Because conservative treatment with diet failed, the patient was admitted for laparoscopic cholecystectomy. She received indocin to prevent premature contractions. A Hasson trocar was placed, and the abdominal cavity was insufflated with carbon dioxide, with the maximum insufflation pressure at 15 mm Hg.

The patient was placed on the left lateral decubitus position. Laparoscopic cholecystectomy was performed without incident. In the recovery, room she had fetal heart monitoring, which did not reveal any bradycardic episodes. She was then admitted to the ante-partum unit and discharged the following day, tolerating oral diet. The final pathology revealed chronic calculous cholecystitis. She subsequently delivered a full-term baby boy weighing 7 lb 13 oz.


CASE REPORT 2

A 25-year-old female, 26 weeks pregnant, was admitted to the hospital with two episodes of biliary colic, which resolved with conservative management. A third episode occurred, and she was again admitted, placed on antibiotics and taken to the operating room for laparoscopic cholecystectomy on the following day. A Hasson trocar was placed, and the abdominal cavity was insufflated with carbon dioxide with maximum insufflation pressure of 12 mm Hg. Intraoperative and postoperative fetal heart monitoring did not reveal any fetal heart compromise, although the patient had a few contractions. The patient was discharged on the second postoperative day, tolerating oral diet. The final pathology report was chronic calculous cholecystitis. She delivered a healthy, full-term 8 lb boy.


CASE REPORT 3

A 24-week pregnant female had two previous admissions for cholecystitis, which were treated with analgesics and antibiotics. The ultrasound revealed gallstones with a thickened gallbladder wall and a normal size common bile duct. Because the pain recurred, the patient was admitted for laparoscopic cholecystectomy. The patient had a Hasson trocar placed, and the abdominal wall was insufflated with a maximum pressure of 15 mm Hg. No perioperative fetal monitoring was applied. She was dis-charged on the first postoperative day, tolerating oral diet and delivered a full-term baby with vacuum-assisted vaginal delivery. The final pathology again revealed chronic calculous cholecystitis.


DISCUSSION

Biliary colic during pregnancy can most often be man-aged successfully with diet and analgesics. If acute cholecystitis is suspected, antibiotics can be added, and cholecystectomy can be postponed until after delivery. If these measures are not successful, cholecystectomy is indicated.8 The second trimester is the safest time to perform the procedure.9, , 12 During the first trimester, fetal malformation because of ongoing organogenesis is the major concern associated with anesthesia and abdominal surgery. During the third trimester, premature labor is the most important complication of cholecystectomy,4, , 6 although cases of successful laparoscopic cholecystectomy during that trimester have been reported.13

Recently, Graham et al. published six case reports of laparoscopic cholecystectomy during pregnancy and performed a literature research of 105 published similar cases. They concluded that, although the above procedure is technically feasible in all three pregnancy trimesters, the incidence of spontaneous abortion and premature delivery is lower during the second trimester.9 There are 14 cases of laparoscopic cholecystectomy reported during the third pregnancy trimester.9 Only one patient had pre-term delivery due to hypertension. The higher incidence of pre-term labor after open cholecystectomy (40%)14 during the third trimester of pregnancy justifies the laparoscopic approach when cholecystectomy is necessary. Our only third trimester pregnant patient who underwent laparoscopic cholecystectomy had a full-term, uneventful delivery.

The most common abdominal procedures performed during pregnancy are appendectomy, ovarian cystectomy, laparoscopy for ectopic pregnancy and laparoscopic cholecystectomy.15 Prophylactic tocolysis with intravenous magnesium have an uncertain effect on the incidence of pre-term labor.5,16 Our patients who underwent laparoscopic cholecystectomy received indocin with good results.

The effect of carbon dioxide pneumoperitoneum is unknown.4 Although the carbon dioxide can cause physiologic alterations in the fetus, the elimination of carbon dioxide from the placental circulation is rapid and should not cause serious problems. A case of gasless laparoscopic cholecystectomy has been reported by lafrati et al.15 Intraperitoneal pressure of carbon dioxide should be kept at a minimum. In our cases, carbon dioxide pneumoperitoneum with a maximum insufflation pressure of 15 mm Hg did not cause any fetal compromise, as shown by the good perioperative course of the three patients, as well as the healthy babies that resulted.

Concerns have been expressed about the effect of venous flow from the lower extremities with carbon dioxide pneumoperitoneum during pregnancy. Specifically, the application of intermittent pneumatic compressors cannot eliminate the phenomenon of venostasis during pregnancy.17 None of our patients developed deep vein thrombosis during laparoscopic cholecystectomy.

We found the use of a Hasson trocar to be extremely useful, because the open technique of port placement avoids injury to the uterus. Most other case reports of laparoscopic cholecystectomy during pregnancy report using the same technique.18,19

We felt that intraoperative cholangiogram is risky for the fetus due to the radiation exposure and prolonged anesthesia. However, this topic is controversial.13 We did not use intraoperative cholangiography during our cases because there was no evidence of choledocolithiasis on the ultrasonography or the laboratory evaluation. If cholangiography is necessary, a lead shield should be placed over the entire infraumbilical area to protect the fetus.20


CONCLUSION

We conclude that laparoscopic cholecystectomy during the second and early third trimester of pregnancy with perioperative fetal monitoring is safe for the mother and the fetus.


References:
1.. Higtt JK,Higtt JCG,Williams RA,Klein SR. Biliary disease in pregnancy: strategy for surgical management. Am J Surg. Year: 1986;56:245–250
2.. Sorensen VJ,Bivins BA,Obeid FN,Horst HM. Management of general surgical emergencies in pregnancy. Am Surg. Year: 1990;56:245–2502194416
3.. Soper NJ,Hunter JG,Petrie RH. Laparoscopic cholecystectomy during pregnancy. Surg Endose. Year: 1992;6:115–117
4.. Dixon NP,Faddis DM,Silberman H. Aggressive management of cholecystitis in pregnancy. Am J Surg. Year: 1987;154:292–3293631407
5.. Hill LM,Johnson CE,Lee F,Lee RA. Cholecystectomy in pregnancy. Obstet GynecolYear: 1975;46:291–2931161232
6.. Block P,Kelly TR. Management of gallstone pancreatitis during pregnancy and the postpartum period. Surg Gynecol Obstet. Year: 1989;168:426–4282711296
7.. Curet MJ,Allen D,Josloff RK,et al. Laparoscopy during pregnancy. Arch Surg. Year: 1996;13(5):546–5508624203
8.. Wishner JD,Zolfaghari D,Wohlgemuths D,et al. Laparoscopic cholecystectomy in pregnancy. A report of 6 cases and review of the literature. Surg Endose. Year: 1996;10:314–318
9.. Graham G,Baxil L,Tharakan T. Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature. Obstet Gyn Surg. Year: 1998;53(9):566–574
10.. Glasgow RE,Visser BC,Harris HW,Patti MG,Kilpatrick SJ,Mulvihill SJ. Changing management of gallstone disease during pregnancy. Surg Endose. Year: 1998;12(3):241–246
11.. Gouldman JW,Sticca RP,Rippon MB,McAlhany JC Jr. Laparoscopic cholecystectomy in pregnancy. Am Surg. Year: 1998;64(1):93–989457045
12.. Martin IG,Dexter SP,McMahon MJ. Laparoscopic cholecystectomy in pregnancy. A safe option during the second trimester?Surg Endose. Year: 1996;10(5):508–510
13.. Eichenberg BJ,Vanderlinden J,Miguel C,et al. Laparoscopic cholecystectomy in the third trimester of pregnancy. Am Surg. Year: 1996;62(10):874–8778813175
14.. Mc Kellar DP,Anderson CT,Boynton CJ,et al. Cholecystectomy during pregnancy without fetal loss. Surg Gynecol Obstet. Year: 1992;174:465–4681595022
15.. Iafrati MD,Yarmell R,Schwaitzberg SD. Gasless laparoscopic cholecystectomy in pregnancy. J Laparosc Surg. Year: 1995;5(2):127–130
16.. Hurt MG,Mastinjc,Martin R,Meeks R,Wiser W,Morison J. Perinatal aspects of abdominal surgery for non obstetric disease. Am J of Gastroent. Year: 1989;6:412–417
17.. Jorgensen JO,Lelak NJ,North L,Hanel K,Hunt DR,Morris DL. Venous stasis during laparoscopic cholecystectomy. J Laparosc Endose. Year: 1994;4:128–133
18.. Hast RO,Tamadon A,Fitzgibbons R,Flemming A. Open laparoscopic cholecystectomy during pregnancy. Surg Laparosc Endose. Year: 1993;3:13–16
19.. Schorr R. Laparoscopic cholecystectomy during pregnancy. J Laparoscopic Surg. Year: 1993;3:291–293
20.. Chandra M,Shapiro S,Gordon L. Laparoscopic cholecystectomy during the first trimester of pregnancy. Surg Laparosc Endose. Year: 1994;4:68–69

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