sages guidelines for laparoscopic surgery during pregnancy steven j. heneghan md facs director...

SAGES Guidelines for Laparoscopic Surgery During Pregnancy

Steven J. Heneghan MD FACSDirector Mithoefer Center for Rural Surgery

Surgeon in Chief Bassett Healthcare

The SAGES Guidelines for the Diagnosis, Treatment, and Use of Laparoscopy for Surgical

Problems During Pregnancy

Heidi Jackson MD Steven Granger MD

Raymond R. Price MD Vice-Chairman Dept of SurgeryIntermountain Medical Center

Intermountain Healthcare

Adjunct Assistant Clinical Professor of SurgeryUniversity of Utah

Michael Rollins MDRobert Fanelli MD William Richardson MD David Earle MD

Guidelines• There is a considerable amount of effort toward

standardizing guidelines– Rating the evidence

– Rating the recommendations

• Avoiding using guidelines to reduce professional competition and a move to having them a resource for both patients and clinicians

• There is an effort to have agreement between organizations with regard to guidelines.

Guidelines for Diagnosis, Treatment, Guidelines for Diagnosis, Treatment, and use of Laparoscopy for Surgical and use of Laparoscopy for Surgical

Problems During Pregnancy*Problems During Pregnancy*

Guidelines for Laparoscopic Surgery Guidelines for Laparoscopic Surgery During Pregnancy*During Pregnancy*

1996

2007

SAGESSAGES

* 8 guidelines

* 23 guidelines

22 References

175 References

Levels of EvidenceLevels of Evidence

Level 1 Evidence from properly conducted randomized, controlled trials

Level II Evidence from controlled trials without randomization

Cohort or case-control studies

Multiple time series, dramatic uncontrolled experiments

Level III Descriptive case series, opinions of expert panels

Scale for Evidence GradingScale for Evidence Grading

Grade AGrade AHigh-level (level I or II), well-performed studies with uniform interpretation and conclusions by the expert panel

Grade BGrade BHigh-level, well-performed studies with varying interpretation and conclusion by the expert panel

Grade CGrade CLower level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel

Guidelines Imaging• 1 Ultrasonographic imaging during pregnancy

is safe and useful in identifying the etiology of acute abdominal pain in the pregnant patient Level II Grade A

• 2 Expeditious and accurate diagnosis should take precedence over concerns for ionizing radiation. Radiation dosage should be limited to 5 to 10 rads Level III Grade B

• 3 CT delivers 2-4 rads which falls below the limit and may be considered an appropriate test Level III Grade B

Guidelines Imaging

• 4 MR Imaging can be performed without IV Gadolinium Level III Grade B

• 5 Nuclear medicine administration of radio nucleotides can generally be done at safe levels Level III Grade C

• 6 Intraoperative Cholangiography exposes the mother and fetus to minimal radiation and may be uses selectively during surgery. Level III Grade B

Changes in Recommendations

1996 2007

Second trimester deferment 2nd

Monitoring Fetus

Trimester

Pneumoperitoneum

Intra-operative Monitoring

Abdominal Access

1st, 2nd, 3rd

8-12 mm Hg 10-15 mm Hg

Open (Hasson) Open (Hasson) or Closed (Verres)

ETCO2 30-40Serial maternal ABG/ ETCO2

Intra-operative Pre- and post-operative

• 24 yo female 12 weeks pregnant– RUQ abdominal pain every 3-4 days– Occurs after fatty meals– US: multiple stones, no wall thickening– Normal LFT’s, amylase, lipase

Clinical Scenario

“I was told by another surgeon that because I was pregnant, I could not

have laparoscopic surgery.”

Questions?

• Should I offer her a cholecystectomy?– Timing of surgery?– Open or laparoscopic?– Monitoring of fetus intraoperatively?

• If laparoscopic:– What entry technique should be used?– Port placement?– Appropriate level of pneumoperitoneum?– Patient positioning?– Need for OB consultation?– ERCP or intraoperative cholangiogram?

TocolyticsGuideline 23: Tocolytics should not be used

prophylactically, but should be considered peri-operatively when signs of preterm labor are present in coordination with obstetric consultation (Level I,

Grade A).

$94.8 million awarded to mother of 8 year-old boy. Failure to use tocolytics.

Fetal Heart MonitoringGuideline 21: Fetal heart monitoring should occur

pre and postoperatively in the setting of urgent abdominal surgery during pregnancy (Level III,

Grade B).

No intra-operative fetal heart rate abnormalities reported.

Laparoscopy and Trimester of PregnancyLaparoscopy and Trimester of PregnancyGuideline 9: Laparoscopy can be safely performed Guideline 9: Laparoscopy can be safely performed

during any trimester of pregnancy (Level II, Grade B).during any trimester of pregnancy (Level II, Grade B).

Abortion Rate?Preterm Delivery

Rate?

Long term effects on the children?

Gallbladder DiseaseGuideline 15: Laparoscopic cholecystectomy is the

treatment of choice in the pregnant patient with gallbladder disease regardless of trimester (Level II,

Grade B).

Symptom recurrence

1st - 92% 2nd – 64% 3rd – 44%

Non-operative ManagementNon-operative Management

Hospitalizations

Spontaneous Abortions

Pre-term Labor

Initial Port PlacementGuideline 11: Initial access can be safely

accomplished with an open or Hassan, Verres needle or optical trocar if the location is adjusted according to fundal height, previous incisions and experience of

the surgeon (Level III, Grade B).

81216

20263236

40

Fundal Height by Gestational Age in Weeks

Rollins MD, Price RR. Laparoscopic surgery during pregnancy. In: Inderbir SG ed. Textbook of laparoscopic urology. New York: Informa Healthcare USA, Inc., 2006:983-986.

21

31

2

3

21

3

1st Trimester 3rd Trimester2nd Trimester

Rollins MD, Price RR. Laparoscopic surgery during pregnancy. In: Inderbir SG ed. Textbook of laparoscopic urology. New York: Informa Healthcare USA, Inc., 2006:983-986.

Trocar Placement for Laparoscopic Appendectomy

Changes by size of gravid uterus.

Insufflation PressureGuideline 12: CO2 insufflation of 10-15 mmHg can

be safely used for laparoscopy in the pregnant patient. Intra-abdominal pressure should be

sufficient to allow for adequate visualization (Level III, Grade C).

MaternalMaternal

FetalFetal

Pulmonary

Acidosis

Visualization

MaternalMaternal Pulmonary

Growing fetus

Pressure on diaphragm

Residual Volume

Functional Residual Capacity

Pressures of 15 mmHg – no increased adverse outcomes to the patient or fetus

PaO2

FetalFetal

Acidosis

No evidence to support long term detrimental effects No evidence to support long term detrimental effects resulting from COresulting from CO22 pneumoperitoneum in humans pneumoperitoneum in humans

Tachycardia Hypertension Hypercapnia

Animal StudiesAnimal Studies

CO2 Pneumoperitoneum

Devon’s Racing Rams (photo Rick Turner)

Intra-operative CO2 monitoringGuideline 13: Intra-operative CO2 monitoring by

capnography should be used during laparoscopy in the pregnant patient (Level III, Grade C).

Maternal arterial blood gas Maternal arterial blood gas (PaCO(PaCO22))

vs.

End-tidal COEnd-tidal CO22

(EtCO(EtCO22))

Capnography adequately reflects Capnography adequately reflects maternal acid/base status in humans.maternal acid/base status in humans.

• ER physician calls you to see a 27 year old 8 week pregnant patient with 8 hours of R lower quadrant pain. She has been nauseated for 8 wks.– Abdomen only mildly tender RLQ to deep

palpation– WBC 16

Clinical Scenario

Possible options:

US abdomenCT scanExploratory laparoscopy

UltrasoundGuideline 1: Ultrasonographic imaging during pregnancy is safe and useful in identifying the

etiology of acute abdominal pain in the pregnant patient (Level II, Grade A).

1. Radiographic test of choice for most gynecologic causes of abdominal pain

2. Useful 1st line diagnostic study for many non-gyn causes

Risk of Ionizing RadiationGuideline 2: Expeditious and accurate diagnosis

should take precedence over concerns for ionizing radiation. Radiation dosage should be limited to 5-10

rads in the first 25 weeks of pregnancy (Level III, Grade B).

* Fetal age at exposure

1st week of conception - mortality

10-17 weeks gestation – CNS teratogenesis

Later pregnancy – hematologic cancer

* Radiation dosage

< 5 rads minimal fetal risk

Fetal Radiation Exposure from Diagnostic Imaging Studies

Chest radiograph <0.001Abdominal series 0.245Pelvic radiograph 0.04Upper gastrointestinal series 0.05-0.1Barium enema 0.3-4HIDA scan 0.15Chest CT scan 0.01-0.2Abdominal CT scan 0.8-3Pelvic CT scan 2.2

Study Rads

Rollins MD, Price RR. Laparoscopic surgery during pregnancy. In: Inderbir SG ed. Textbook of laparoscopic urology. New York: Informa Healthcare USA, Inc., 2006:983-986.

Computed TomographyGuideline 3: Contemporary multi-detector CT protocols deliver a radiation dose to the fetus below detrimental levels and may

be considered as an appropriate test during pregnancy depending on the clinical situation (Level III, Grade B).

Practitioners should be aware of the radiation doses delivered by the CT

scanners in their facilities.

CT abdomen and pelvis

2-4 rads

Early identificationEarly identification

Rate of perforationRate of perforation

Laparoscopic AppendectomyGuideline 17: Laparoscopic appendectomy may be performed safely in any patients with suspicion of

appendicitis (Level II, Grade B).

Conclusions

• Guidelines are a moving process and when published they are a point in time rather than a completed process

• Guidelines are much more difficult than most people realize

• Guidelines should give the references for the conclusions the rating of the references and grading of the recommendations

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