Laparoscopic cholecystectomy in pregnancy

ORIGINAL REPORTS

Laparoscopic Cholecystectomy in Pregnancy Sujal G. Patel, MD, and Thomas J. Veverka, MD Deparment of Surgery, Saginaw Cooperative Hospitals, Inc., Saginaw, Michigan PURPOSE: Since the start of laparoscopic cholecystectomy, a

debate about its use in the gravid patient has remained controversial. Concerns about the morbidity and mortality in the mother and fetus through all trimesters have been expressed. The objective of this retrospective review was to further evaluate the safety of laparoscopic cholecystectomy in the pregnant patient. METHODS: At Covenant Health Care—Cooper Campus

and Harrison Campus in Saginaw, Michigan, 10 cholecystectomies in pregnant patients were performed from 1995 to April 1998. Eight of these patients were done with laparoscopy, and 2 were done through the open technique. RESULTS: No mortality or significant morbidity occurred in

the laparoscopic group. However, the open group did have a fetal mortality. CONCLUSIONS: Our study showed that laparoscopic chole-

cystectomy can be performed safely in the pregnant patient in the first 2 trimesters. This is consistent with the findings in the current world literature. (Curr Surg 59:74 –78. © 2002 by the Association of Program Directors in Surgery.) KEY WORDS: cholecystectomy, laparoscopic, laparoscopy,

pregnancy, cholelithiasis, cholecystitis

INTRODUCTION Laparoscopic cholecystectomy has been performed in the United States since 1989 and currently is the treatment of choice for the management of symptomatic cholelithiasis.1 It was first performed by Dr. Philip Mouret in 1987.1 Its use in pregnancy has remained controversial. Laparoscopic surgery in the pregnant patient has been safely performed for indications other than cholecystectomy.1-5 Initial conservative management of biliary tract disease has been recommended for the pregnant patient, with surgical intervention reserved for failure of medical therapy.2,5,6 The general consensus agrees to delay cholecystectomy until delivery of the fetus, but with failed medical therapy, it is preferable to perform surgery in the second

Correspondence: Inquiries to Michelle Debernardi, RN, Saginaw Cooperative Hospitals, Inc., 1000 Houghton Ave., Saginaw, MI 48602-5303; fax: (517) 753-8420; e-mail: [email protected].

74

trimester because organogenesis may be affected in the first trimester and premature labor may be induced in the third.5,6 This study is a retrospective look at management of biliary disease in the pregnant patient, in private community hospitals in Saginaw, Michigan, with emphasis on the surgical management of these patients. A review of the available literature concerning laparoscopic cholecystectomy in pregnancy has also been evaluated to compare our treatment with current standards of care.2-6,8

PATIENTS AND METHODS The medical records of pregnant women with biliary tract disease at Covenant —Harrison and Covenant—Cooper campuses, Saginaw, Michigan, between 1995 and April 1998 were reviewed. The definition of biliary tract disease for this study included those found to have cholecystitis, cholelithiasis, gallstone pancreatitis, and biliary colic. Patients studied were those who specifically underwent surgical treatment of their biliary disease. During this period, 50 patients with biliary disease were found at these 2 institutions. Forty patients were managed nonoperatively, and 10 patients were managed operatively. The matemal records were reviewed to obtain data on age, race, presenting symptoms, gestational age, diagnosis/treatment, length of stay, number of times readmitted for biliary disease, gallbladder ultrasound results, and delivery information. In the operative group, the charts were also reviewed for indication for surgery, type of surgery performed, pathologic findings, complications/outcome, and number of days hospitalized postoperatively.

SUMMARY OF CASES Case 1 This patient was an 18-year-old Hispanic woman who presented at 6 weeks gestation with a 1-week history of nausea, vomiting, abdominal pain, and acholic stools. Ultrasound showed cholelithiasis and choledocholithiasis. She was taken to the operating room for an open cholecystectomy with common bile duct exploration, because this was the lowest risk option at the time of her presentation. Pathology revealed chronic chole-

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cystitis with cholelithiasis and ulceration. She was sent home on the fifth postoperative day in stable condition. Her pregnancy was complicated with a spontaneous abortion and a dilatation, and curettage was done at approximately 14 weeks gestation. Case 2 This patient was an 18-year-old white woman who presented at 9 weeks gestation with a 2-month history of right upper quadrant (RUQ), abdominal pain, diarrhea for 1 week, nausea, and a 10-pound weight loss over 1 month. Ultrasound showed cholelithiasis 1 month before this admission. She was taken to the operating room for a laparoscopic cholecystectomy. Pathology revealed chronic cholecystitis with cholelithiasis. Her postoperative course was uneventful, and she was sent home on the second postoperative day in stable condition. Her pregnancy was uncomplicated. A Cesarean section was performed for failure to progress and macrosomia at 39 weeks gestation. Case 3 This patient was a 28-year-old white woman who presented at 10.5 weeks gestation with a 1-month history of increasing RUQ and mid-abdominal pain. Ultrasound 1-month prior showed cholelithiasis with some inflammatory changes consistent with cholecystitis. She was taken to the operating room for a laparoscopic cholecystectomy. Pathology showed chronic cholecystitis with cholelithiasis. Her postoperative course was uneventful, and she was sent home on the second postoperative day in stable condition. Her pregnancy was uncomplicated. At 40 weeks gestation, she had a repeat Cesarean section for failed induction. Case 4 This patient was a 22-year-old black woman who presented at 14 weeks gestation, with RUQ pain radiating to her back and a history of eating high-fat meals. Ultrasound showed cholelithiasis. She was taken to the operating room on the eighth hospital day for intractable pain and failed medical treatment. A laparoscopic cholecystectomy was performed at 15 weeks gestation with pathology revealing chronic cholecystitis and cholelithiasis. She was discharged home on the fourth postoperative day in stable condition. The remainder of her pregnancy remained uncomplicated. At 40 weeks, she went on to deliver by normal spontaneous vaginal delivery. Case 5 This patient was a 30-year-old white woman who presented at 7 weeks gestation with a 1-week history of indigestion, RUQ pain with radiation to her right shoulder, and nausea. Her ultrasound revealed cholelithiasis. She was electively brought back to the hospital for a laparoscopic cholecystectomy at 16 weeks gestation. Pathology revealed chronic cholecystitis with cholelithiasis. She was sent home the same day in stable condiCURRENT SURGERY • Volume 59/Number 1 • January/February 2002

tion. The remainder of her pregnancy was uncomplicated. At 39 weeks, she had a normal vaginal delivery. Case 6 This patient was a 30-year-old white woman who presented at 18 weeks gestation with a 2-month history of upper abdominal pain, nausea, and vomiting. Ultrasound showed cholelithiasis. She was admitted with a diagnosis of acute cholecystitis with cholelithiasis. She was taken to the operating room for a laparoscopic cholecystectomy. Pathology showed subacute cholecystitis. She was sent home on the first postoperative day. The remainder of her pregnancy was uncomplicated, and at 39 weeks gestation, she had a normal vaginal delivery. Case 7 The patient was a 22-year-old white woman who presented at 18 weeks gestation with RUQ abdominal pain. Ultrasound showed cholelithiasis. She was taken to the operating room at 19 weeks gestation for symptomatic cholelithiasis. A laparoscopic cholecystectomy was performed, and pathology revealed chronic cholecystitis with cholelithiasis. Her postoperative course was uneventful, and she was sent home after the first postoperative day. The remainder of her pregnancy was uncomplicated. At 39 weeks gestation, she had a normal vaginal delivery. Case 8 This patient was a 20-year-old white woman who presented at 19 weeks gestation with a 2-week history of RUQ pain radiating to her back. Ultrasound 2 weeks prior showed cholelithiasis. She was taken to the operating room for a laparoscopic cholecystectomy. Pathology revealed cholelithiasis. Her postoperative course was unremarkable, and she went home on the second postoperative day in stable condition. The remainder of her pregnancy was uncomplicated, and at 40 weeks gestation, she had a normal vaginal delivery. Case 9 This patient was a 32-year-old white woman who presented at 19 weeks gestation with a 3-week history of RUQ pain, nausea, vomiting, and weight loss. Ultrasound showed cholelithiasis 3 weeks before this admission. She went to the operating room for a laparoscopic cholecystectomy. Pathology revealed chronic cholecystitis with cholelithiasis. She was sent home on the fourth postoperative day in stable condition. The remainder of her pregnancy remained uncomplicated, and at 38 weeks, she underwent a Cesarean section for a breech presentation. Case 10 This patient was a 28-year-old white woman who presented at 27 weeks gestation with an epigastric pain radiating to her back, nausea, and vomiting. Ultrasound showed a thickened gallblad75

TABLE 1. Summary of Cases Age of Gestational Case Patient Age (weeks) 1

18

6

2

18

9

3

28

10 1⁄2

4

22

14

5

30

16

6 7

30 22

18 18

8 9

20 32

19 19

10

28

27

Ultrasound

Pathology

stones—GB & CBD chronic cholecystitis, cholelithiasis stones—GB chronic cholecystitis, cholelithiasis stones—GB, chronic cholecystitis, inflammation cholelithiasis stones—GB chronic cholecystitis, cholelithiasis stones—GB chronic cholecystitis, cholelithiasis stones—GB subacute cholecystitis stones—GB chronic cholecystitis, cholelithiasis stones—GB cholelithiasis stones—GB chronic cholecystitis, cholelithiasis stones—GB, CBD, chronic cholecystitis, thickened GB wall cholelithiasis

der wall, cholelithiasis, and choledocholithiasis. She had an open cholecystectomy and choledocholithotomy performed. Pathology revealed chronic cholecystitis with cholelithiasis. Her postoperative course was uneventful, and she was discharged home on the third postoperative day. No record is available for follow-up for the remainder of her pregnancy.

RESULTS As seen in Table 1, ultrasound showed cholelithiasis in all 10 cases. Two patients (20%) underwent open cholecystectomy, and it is this group with the only fetal complication. Table 2 shows operative characteristics by time of surgery. Trimesters are defined as follows: first trimester from 0 to 13 weeks, second trimester from 14 to 26 weeks, and third trimester from 27 to 40 weeks. In the laparoscopic group, 2 patients (25%) presented in the first trimester and could not be delayed for surgery until the second trimester. No complications occurred in this group, and both women delivered healthy infants at term. A third patient (12.5%) who presented in the first trimester was managed medically until she reached the second trimester where she did not have any complications with her pregnancy or the laparoscopic cholecystectomy. The remainder of the group (62.5%) presented in the second trimester. The attempt TABLE 2. Operative Characteristics Open Laparoscopic Procedure Procedure Gestational Age (weeks) 1st trimester (0–13) 2nd trimester (14–26) 3rd trimester (27–40) Length of Hospitalization (days) Mean total length of stay 76

Complications

Fetal Outcomes Surgery

low-grade fever, emesis ⫻ 1 none

spont abortion at open 14 wks C-section—39 wks lapar.

none

C-section—40 wks lapar.

low-grade fever, NSVD—40 wks incision bile drainage none NSVD—39 wks

lapar. lapar.

none none

NSVD—39 wks NSVD—39 wks

lapar. lapar.

none uterine contractions

NSVD—40 wks lapar. C-section—38 wks lapar.

none

Lost to follow-up

open

to manage 2 of these patients (40%) medically was made, but with continued symptoms, surgery was done 1 week later. Two patients (40%) had postoperative complications. The first patient had bile drainage from her incision and developed a lowgrade fever. Both of these symptoms resolved before discharge. The other patient had uterine contractions, which were controlled with tocolytics with resolution by discharge. None of the patients operated on in the second trimester had problems with their pregnancy after surgery. Table 2 also lists 2 patients (20%) of the 10 who had open surgery and had intraoperative cholangiograms for common bile duct obstruction. One lost her baby in the first trimester. One patient was lost to follow-up after her surgery. The 8 laparoscopic patients (80%) all tolerated their procedure without complication intraoperatively. Table 3 lists the patient characteristics comparing the operative and nonoperative groups. The average age of the operative group was 24.8 years (range, 18 to 32) versus 25.5 years (range, 16 to 36) in the nonoperative group. Interestingly, most patients managed medically presented in the third trimester, indicating current trends to manage conservatively until delivery. The major difference between the 2 groups appears to be in the hospitalization for readmission group. Patients managed conservatively were readmitted twice as often as were those managed with surgery. The average length of stay for readmission was 3 times more in the nonoperative group than in the operative group.

DISCUSSION 1 0 1

2 6 0

4

2

The 2 most common situations encountered by the general surgeon in a pregnant patient are acute appendicitis and acute cholecystitis. Acute appendicitis occurs with the same frequency in gravid and nongravid females of the same age leading CURRENT SURGERY • Volume 59/Number 1 • January/February 2002

TABLE 3. Patient Characteristics Operative Nonoperative management management Total number of patients Age (years) Range Mean Race White Hispanic Black Gestational Age (weeks) 1st trimester (0–13) 2nd trimester (14–26) 3rd trimester (27–40) Length of Hospitalization (days) Mean total length of stay Mean for readmission days Mean for number of times readmitted Mean postoperative length of stay

10 18–32 24.8

40 16–36 25.5

8 1 1

23 10 7

3 6 1

4 8 28

4.7 0.2 0.2

3.1 0.6 0.4

2.4

—

to appendectomy in 1 out of every 2000 pregnancies.2,5 Cholecystectomy is second to appendectomy as the most common nonobstetric surgery during pregnancy, approximately 0.05% of the time.1,2,6 Studies have shown that multiparity is associated with an increased risk of developing gallstones.3 This increase in incidence suggests that gallstone formation may be mediated by changes in estrogen or progesterone levels. Studies have also shown a similar increase in incidence in women using oral contraceptives.3 It seems that bile is significantly more saturated with cholesterol in women using oral contraceptives than in those not taking similar agents.3 Evidence also exists of abnormal gallbladder motility, impaired fluid absorption, and impaired gallbladder emptying during pregnancy.3 Incomplete emptying of the gallbladder in late pregnancy leaves a large residual volume and may cause retention of cholesterol crystals, a prerequisite for cholesterol gallstone formation. Increased fasting gallbladder volume might be caused by decreased absorption of water from the gallbladder mucosa. This could be related to high concentrations of estrogen, which have been shown to decrease the activity of the sodium pump in the gallbladder mucosa. Progesterone may impair gallbladder contraction by inhibiting cholecystokinin-mediated smooth muscle contraction.3 Progesterone may also reduce the responsiveness of the gallbladder to cholecystokinin.3 This causes a sluggish gallbladder, leading to sequestration and precipitation of cholesterol or calcium salts. Bile is found to be more saturated with cholesterol in the second and third trimester. All of these facts suggest that pregnancy increases the risk of forming gallstones.3 In the past, operating on the pregnant patient with cholecystitis was aggressively avoided; however, recent studies have shown a higher morbidity and mortality in patients managed CURRENT SURGERY • Volume 59/Number 1 • January/February 2002

nonoperatively.3,5,8,9 Medical therapy fails in up to 44% (but on average fails in ⬎10%) of patients with acute cholecystitis.5,6 Our data show that medical therapy was successful in 80% of patients with no mortality or significant morbidity. This held true for 96.6% of patients presenting during the third trimester. Our study also showed that of the 8 patients who underwent laparoscopic cholecystectomies, 7 (87.5%) failed medical therapy. Most authors agree that surgery is indicated in any trimester for obstructive jaundice, acute cholecystitis failing medical treatment, gallstone pancreatitis, suspected peritonitis, or when surgery may be life-saving.1,3,6 Unlike cholecystitis, acute pancreatitis has been associated with a significant maternal mortality rate (15% to 60%) and a fetal mortality rate approaching 60%.3,8,10 In this study, 3 patients (30%) in the operative group presented with gallstone pancreatitis. One (33%) out of the 3 spontaneously aborted in the first trimester. The other 2 patients had resolution of their pancreatitis with no further complications. Two of these patients had open cholecystectomies. The only 1 done laparoscopically continued her pregnancy without complication. Studies show that between 35% and 58% of symptomatic pregnant patients will have recurrent biliary colic refractory to medical therapy.4 Swisher et al reported a 72% relapse rate after conservative treatment of gallstone pancreatitis in pregnant patients, requiring hospitalization 90% of the time.6 Our study showed readmission rates to be twice as much in the nonoperative group than in the operative group. Of the 40 patients in the nonoperative group, 14 (35%) had recurrent symptoms requiring hospitalization. The operative group had a 2 out of 10 (20%) readmission rate. The remainder of the operative group who failed medical therapy (50%) had surgery during the same hospitalization. Also, the nonoperative group stayed in the hospital 3 times longer for readmission for biliary problems than did the operative group, with patients staying in the hospital with a range of 1 to 12 days. Most authors agree that the second trimester is the safest to perform surgery. Many reasons for this exist. McKellar et al1,8 found that the risk of spontaneous abortion decreased, with gestational age being 12% in the first trimester, 5% to 6% during the second, and 0% during the third. They further noted that the incidence of premature labor was zero during the second trimester and 40% during the third trimester.1,8 Other reasons surgeons prefer to operate in the second trimester include the completion of organogenesis at 12 weeks and that the uterine size is not large enough to interfere with the operative field.6,8 Our study indicates that laparoscopic surgery is safe to perform in the first 2 trimesters. Only 1 patient (10%) in this study was operated on in the third trimester, but this was through the open technique. Although first trimester laparoscopic procedures still remain controversial, most initial case reports reveal safe outcomes in these patients.4 Laparoscopic surgery has several advantages over open cholecystectomy. Reduced postoperative pain leads to lessened postoperative narcotic requirements, thus, avoiding decreased fetal depression.1,2,5-7 Because of the small incisions, a lower 77

risk of wound complications and a decreased chance of incisional hernias occurs.2,5-7 A quicker return to normal diet and activity and a shortened hospital stay also result.1,2 The shortened postoperative immobility may diminish the risk of thromboembolic complications known to occur during pregnancy.1 Diminished postoperative maternal hypoventilation occurs.7 Finally, the laparoscopic procedure is less traumatic to the uterus than is the normal retraction required for open cholecystectomy and may decrease the incidence of preterm labor.1,2,8 Potential risks of laparoscopic surgery include trocar injury to uterus and fetus, effect of pneumoperitoneum on both mother and fetus, induction of preterm labor, decreased uterine blood flow, and increased fetal acidosis.1,5,7 The effects of prolonged carbon dioxide pneumoperitoneum on fetal physiology remain largely understudied, and perioperative fetal monitoring is recommended.5,8 Decreased uterine blood flow remains hypothetical and is probably not a major concern.7 Fetal acidosis probably does not occur because changes in maternal blood gases have not been demonstrated after a pneumoperitoneum has been established.5,10 The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has adopted some guidelines to enhance operative safety in the pregnant patient.7 These include the following:

supports the safety in performing laparoscopic cholecystectomy in the second trimester with minimal maternal or fetal morbidity. The literature also states that if medical therapy fails, laparoscopic cholecystectomy should be performed early in any stage of pregnancy, which will reduce maternal and fetal morbidity, as well as relapses and the length of hospital stay. This study supports the concept that laparoscopic cholecystectomy can be performed safely in pregnant patients in the first or second trimester with no additional complications during the remainder of the pregnancy. The proven benefits of minimally invasive surgery apply to the pregnant patient and should be considered in those patients requiring nongynecologic surgery.2

1. When possible, operative intervention should be deferred until the second trimester, when fetal risk is low. 2. Because pneumoperitoneum enhances lower extremity venous stasis already present in the gravid patient, and because pregnancy induces a hypercoagulable state, pneumatic compression devices must be used. 3. Fetal and uterine status, as well as matemal end-tidal CO2 and arterial blood gases, should be monitored. 4. The uterus should be protected with a lead shield if intraoperative cholangiography is a possibility. Fluoroscopy should be used selectively. 5. Given the enlarged gravid uterus, abdominal access should be attained using an open technique. 6. Dependent positioning should be used to shift the uterus off of the inferior vena cava. 7. Pneumoperitoneum pressures should be minimized (to 8 to 12 mm Hg) and not allowed to exceed 15 mm Hg. 8. Obstetrical consultation should be obtained preoperatively.

4. Gouldman JW, Sticca RP, Rippon MB, McAlhany JC.

CONCLUSION Conservative therapy in the gravid woman with cholelithiasis still remains the current standard of care initially. Our study shows that this can be done successfully and safely, especially in women presenting during the third trimester. The literature

78

REFERENCES 1. Andreoli M, Sayegh SK, Hoefer R, Matthews G, Mann

WJ. Laparoscopic cholecystectomy for recurrent gallstone pancreatitis during pregnancy. South Med J. 1996;89: 1114-1115. 2. Curet MJ, Allen D, Josloff RK, et al. Laparoscopy during

pregnancy. Arch Surg. 1996;131:546-551. 3. Ghumman E, Barry M, Grace PA. Management of gall-

stones in pregnancy. Br J Surg. 1997;84:1646-1650. Laparoscopic cholecystectomy in pregnancy. Am Surg. 1998;64:93-98. 5. SAGES Committee on Standards of Practice. Guidelines

for laparoscopic surgery during pregnancy. Surg Endosc. 1998;12:189-190. 6. Jamal A, Gorski TF, Nguyen HQ, Davis R. Laparoscopic

cholecystectomy during pregnancy. Surg Rounds. 1997; 20:408-415. 7. Gurbuz AT, Peetz ME. The acute abdomen in the preg-

nant patient: is there a role for laparoscopic? Surg Endosc. 1997;11:98-102. 8. O’Connor LA, Kavena CF, Horton S. The Phoenix In-

dian medical center experience with laparoscopic cholecystectomy during pregnancy. Surg Laparosc Endosc. 1996;6:441-444. 9. Schwartzberg BS, Conyers JA, Moore JA. First trimester

of pregnancy laparoscopic procedures. Surg Endosc. 1997; 11:1216-1217. 10. Thomas SJ, Brisson P. Laparoscopic appendectomy and

cholecystectomy during pregnancy: six case reports. JSLS. 1998;2:41-46.

CURRENT SURGERY • Volume 59/Number 1 • January/February 2002