Introduction

Surgical intervention in the gravid patient presents a dilemma in which the surgeon must weigh the risks and benefits not only to the mother but also to the fetus. Approximately one in 500 to one in 635 women will require nonobstetrical abdominal surgery during pregnancy (1,2). Acute appendicitis, cholecystitis, and intestinal obstruction are the three most common nonobstetrical emergencies requiring surgery during pregnancy (1). Other conditions requiring surgical intervention during pregnancy include symptomatic cholelithiasis, adrenal tumors, hematological disorders that involve the spleen, ovarian cysts, adnexal mass or torsion, heterotopic pregnancy, and abdominal pain of unknown etiology.

Complications following intra-abdominal surgery during pregnancy have been attributed to disease severity and delay in diagnosis rather than to the operative procedure itself (3,4). Common reasons for this delay include the patient and physician attributing signs and symptoms of disease to pregnancy, anatomic alterations of the gravid abdomen masking classic findings of diseases, and nonoperative management of patients due to concern of endangering the fetus with diagnostic and therapeutic procedures.

Laparoscopy has improved dramatically since its advent, resulting in changes to the operative management of several disease processes. Although pregnancy was once considered an absolute contraindication to laparoscopic surgery, it is now being performed with increasing frequency. Significant experience has accrued with laparoscopy during pregnancy to rule out ectopic pregnancy and to evaluate adnexal masses in the gynecologic literature with most patients having normal intrauterine pregnancies.

Regardless of the trimester in which laparoscopy was performed, there have not been increases in fetal loss or adverse long-term outcomes (5-7).

These experiences prompted general surgeons to begin offering laparoscopic appendectomy and cholecystectomy to pregnant patients in 1991 (8-10). Multiple retrospective studies have found no significant differences in birth weight, gestational duration, intrauterine growth restriction, infant death, or fetal malformation when comparing open to laparoscopic procedures during pregnancy (11-13). Laparoscopy for nonobstetrical abdominal conditions during pregnancy is rapidly becoming the ess

It is important to place the gravid patient in the dependent position to shift the uterus off of the inferior vena cava and the aorta in order to avoid maternal hypotension and decreased placental perfusion during surgery.

Initial placement of the Verres needle or trocar into the left subcostal region may be necessary as the uterus enlarges in the second and third trimesters. Ancillary trocars are then inserted under direct visualization, modifying their typical location according to the size of the uterus.

preferred approach, as maternal and fetal outcomes are generally excellent following surgery.

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