Operative laparoscopy in advanced pregnancy beyond 20 weeks

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

Operative Laparoscopy in Advanced Pregnancy Beyond 20 Weeks Morton S et al. Operative laparoscopy in advanced pregnancy beyond 20 weeks. TOG 2020;22:237–241. doi:10.1111/tog.12668

0.5–2% 10–12 mmHg ≤15 mmHg WOMEN NEEDING NON-OBSTETRIC SURGERY RECOMMENDED OPERATING PRESSURE MAX PRESSURE IF VISUAL ACCESS IMPAIRED IN PREGNANCY

DO N' T-M IS S FA C TS

  1. Non-obstetric surgery needed in 0.5–2% of pregnancies; appendicectomy is the commonest procedure (6.5% of cases in a 6.5-million-gestation study)

  2. From 20 weeks: apply left lateral tilt to prevent aortocaval compression; move positions slowly

  3. Operating pressure: 10–12 mmHg routine, up to 15 mmHg if visual access impaired

  4. Palmer's point entry (left subcostal, blunt trochar) or supra-umbilical incision (3–6 cm above umbilicus) minimise uterine injury risk in advanced pregnancy

  5. Fetal heart auscultated before and after surgery only (pneumoperitoneum precludes continuous monitoring)

  6. Bipolar diathermy preferred – amniotic fluid can conduct stray current to the fetus

  7. No routine tocolysis; consider tocolysis + corticosteroids + magnesium sulphate for neuroprotection if preterm labour risk

  8. Laparoscopic ovarian cystectomy: 51% lower preterm labour risk vs open (P=0.014); no reported laparoscopic cases beyond 2nd trimester

TOP TIPS (BOX 1)

Experienced surgeon and anaesthetist present Antacid prophylaxis; consider NG tube Left lateral tilt; move slowly Hasson (supra-umbilical) or Palmer's point entry Consider ultrasound-guided entry Operating pressure 10–12 mmHg Auscultate fetal heart before and after surgery

ENTRY PRESSURES

Initial insufflation 20 mmHg Maintenance 12 mmHg Max if impaired view: 15 mmHg

ABBREVIATION KEY

BSGE — British Society for Gynaecological Endoscopy LC — laparoscopic cholecystectomy

RCOG — Royal College of Obstetricians and Gynaecologists CO2 — carbon dioxide

SAGES — Society of American Gastrointestinal and Endoscopic NG — nasogastric Surgeons OG — orogastric LA — laparoscopic appendicectomy CTG — cardiotocograph/cardiotocography

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — doi:10.1111/tog.12668

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