Surg Endosc (2008) 22:849861 DOI 10.

1007/s00464-008-9758-6

GUIDELINES

Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy
This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), September 2007. It was prepared by the SAGES Guidelines Committee.
Prepared by the Guidelines Committee of the Society of American Gastrointestinal and Endoscopic Surgeons

Received: 26 December 2007 / Accepted: 8 January 2008 / Published online: 21 February 2008 Springer Science+Business Media, LLC 2008

Preamble Early concerns about the performance of laparoscopic surgery performed on pregnant patients centered on the potential risk to the fetus due to trocar insertion, CO2 insufation, and the technical ability to obtain proper operative exposure with a gravid uterus. Additionally, risks to the mother that were thought to be important included altered physiology of pneumoperitoneum and decreased venous return to the heart. Evidence is accumulating to suggest that clinical outcomes are equivalent to open surgical techniques, while conferring all the advantages of the laparoscopic approach. This document provides specic recommendations and guidelines to assist physicians in the diagnostic workup and treatment of surgical problems in pregnant patients focusing on the use of laparoscopy. Surgical interventions during pregnancy should minimize fetal risk without compromising the safety of the mother.

applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only, acceptable approaches. Guidelines are intended to be exible. Given the wide range of specics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the Society of American Gastrointestinal Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed, and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.

Disclaimer Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the eld. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are
This is a revision of SAGES Publication #0023, originally printed 10/00. H. Yumi (&) Society of American Gastrointestinal and Endoscopic Surgeons 11300 W, Olympic Blvd. Suite 600, Los Angeles, CA 90064, USA e-mail: SAGESweb@sages.org; yumi@sages.org

Background Approximately 1 in 500 to 1 in 635 women will require nonobstetrical abdominal surgery during their pregnancy [1, 2]. The most common nonobstetrical surgical emergencies complicating pregnancy are acute appendicitis, cholecystitis, and intestinal obstruction [1]. Other conditions that may require surgery during pregnancy include ovarian cysts, masses or torsion, symptomatic cholelithiasis, adrenal tumors, splenic disorders, symptomatic hernias, complications of inammatory bowel diseases, and abdominal pain of unknown etiology. All of these diseases are routinely treated using laparoscopic techniques in the nonpregnant patient with good outcomes.

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During its infancy, some argued that laparoscopy was contraindicated during pregnancy. Many now utilize laparoscopy as an alternative to open surgery in order to provide the pregnant patient with the same benets of a minimally invasive approach that nonpregnant patients have realized. Many of the issues related to the minimally invasive approach for surgical treatment of diseases during pregnancy have been claried with the accumulation of data from its increased use and acceptance during pregnancy [3]. Denitions The denition document has been prepared and published by the SAGES Guidelines Committee.

causes of abdominal pain including adnexal mass, torsion, placental abruption, placenta previa, uterine rupture, and fetal demise. Ultrasound is also useful as a rst-line diagnostic study for many nongynecologic causes of abdominal pain, potentially allowing the practitioner to avoid the need for ionizing radiation exposure [511]. Risk of ionizing radiation Guideline 2: Expeditious and accurate diagnosis should take precedence over concerns for ionizing radiation. Radiation dosage should be limited to 510 rads in the rst 25 weeks of pregnancy (Level III, Grade B). Signicant radiation exposure may lead to chromosomal mutations, neurological abnormalities, mental retardation, and increase the risk of childhood leukemia. Radiation dosage is the most important risk factor but fetal age at exposure is also important [7, 8, 12]. Radiological exposure is measured using units of either rad or centiGrey (1 rad = 1 cGy). Fetal mortality is greatest when exposure occurs within the rst week of conception prior to oocyte implantation. It has been recommended that the cumulative radiation dose from the rst week of conception through week 25 be less than 510 rads [13]. The most sensitive time period for central nervous system (CNS) teratogenesis is between 10 and 17 weeks gestation and nonurgent X-rays should be avoided during this time. In later pregnancy the concern shifts from teratogenesis to increasing the risk of childhood hematologic cancer. The background incidence of childhood cancer and leukemia is approximately 0.2 0.3%. Radiation may increase that incidence by 0.06% per 1 rad delivered to the fetus [13]. Exposure of the fetus to 0.5 rad increases the risk of spontaneous abortion, major malformations, mental retardation, and childhood malignancy to one additional case in 6,000 above baseline risk. It has been suggested that fetal risk is negligible at 5 rads or less and that the risk of malformation is signicantly increased at doses above 15 rads. The accepted cumulative dose of ionizing radiation during pregnancy is 510 rads with no single diagnostic study exceeding 5 rads [8, 1217]. Computed tomography (CT) Guideline 3: Contemporary multidetector 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). Computed tomography (CT) has a well-established role as a diagnostic modality in the nonpregnant patient. Many of the same nonobstetric indications for its use can also be found in a woman during pregnancy [18]. Employment of

Diagnosis and Workup Abdominal pain in the gravid patient presents a dilemma in which the clinician must weigh the risks and benets of potential diagnostic modalities and therapy not only to the mother but also to the fetus. The clinical issues and pathological conditions differ between the trimesters of pregnancy. These guidelines assume intrauterine pregnancy has been conrmed. An underlying principle to the workup of abdominal pain was stated by Sir Zachary Cope in 1921, Earlier diagnosis means better prognosis. [4]. Although fetal safety during diagnostic imaging is an important goal for clinicians and patients, the benets to the mother outweigh the risk to the fetus, bearing in mind that the risk of fetal morbidity and mortality also increases when the mother is faced with an acute surgical disease. Imaging techniques A riskbenet discussion with the patient should be undertaken prior to initiating any diagnostic study.

Ultrasound Guideline 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). Abdominal pain in the pregnant patient can be separated into gynecologic and nongynecologic causes. When radiographic studies are needed, ultrasound is widely considered safe for the mother and fetus with relatively high sensitivity and specicity for many intra-abdominal processes. No maternal or fetal adverse effects have been reported. It is the radiographic test of choice for most gynecologic

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the CT scan should be weighed against the cumulative radiation exposure to the fetus. As a single test, radiation exposure to the fetus is highest when a full scan of the abdomen and pelvis is obtained, reaching exposure levels up to 24 rads for a single study [7, 19, 20], which falls below the maximum recommended dose of 5 rads for a single study. Advancements in CT technology and protocols have led to decreased radiation doses. These levels vary by institution and the practitioner should be aware of the potential radiation exposure. Magnetic resonance (MR) imaging Guideline 4: MR Imaging can be performed at any stage of pregnancy without the use of intravenous gadolinium (Level III, Grade B). MRI provides excellent soft-tissue multiplanar imaging without ionizing radiation. It is generally considered safe in pregnancy as no ionizing radiation is employed, although further research is needed. It should be used after a clinical riskbenet analysis is discussed between the clinician and the patient [2125]. Intravenous gadolinium agents do cross the placenta and any effects are not fully understood; therefore their use during pregnancy is controversial [22]. Nuclear medicine Guideline 5: Nuclear Medicine administration of radio nucleotides can generally be accomplished at fetal radiation levels of exposure that are well below any known detrimental levels (Level III, Grade C). Radiopharmaceuticals, including technetium99 m, can generally be administered at doses that provide whole fetal exposure of less than 0.5 rad [26], well within the known safe range of fetal exposure. Consultation with a nuclear medicine radiologist or technologist should be considered prior to performing the study. The study should be commensurate with the most expeditious and accurate method of securing the suspected diagnosis.

radiation dose of up to 20 rads/minute, but varies depending on the X-ray equipment utilized, patient positioning, and patient size. Radiation exposure is cumulative, suggesting that a selective approach to exposure of the pregnant patient to uoroscopy is prudent. During cholangiography, the fetus should be shielded as able. Placing a lead apron inside an impermeable sterile drape during surgery is helpful in accomplishing this goal. No adverse effects have been reported from cholangiography specically. Magnetic resonance cholangiopancreatography (MRCP) is an alternative approach, but is only diagnostic and accuracy will vary amongst institutions. These facts should be considered when selecting this approach. Endoscopic retrograde cholangiopancreatography (ERCP) also has risks beyond the radiation exposure such as bleeding and pancreatitis. In nonpregnant patients, the risk of bleeding is 1.3% and the risk of pancreatitis is 3.5% [27]. These additional risks warrant the same careful risk benet analysis and discussion with the patient as other operative and procedural interventions [7, 16, 28, 29]. Alternatives to uoroscopy include intraoperative ultrasound and choledochoscopy. These are both acceptable methods provided the surgeon has the appropriate equipment and skills to expeditiously and accurately perform the examinations.

Surgical techniques Guideline 7: Diagnostic laparoscopy is safe and effective when used selectively in the workup and treatment of acute abdominal processes in pregnancy (Level II, Grade B). Diagnostic laparoscopy provides direct visualization of intra-abdominal organs. While not enough data are available to recommend this as a primary diagnostic approach in the pregnant patient, it is certainly a reasonable alternative. The benets of operative exploration are avoidance of ionizing radiation, rapidity, and diagnostic accuracy, as well as the ability to treat a surgical problem at the time of diagnosis. Additionally, it has been shown that laparoscopy can be performed safely during any trimester of pregnancy with minimal morbidity to the fetus and mother [3042].

Cholangiography Guideline 6: Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal radiation and may be used selectively during pregnancy. The lower abdomen should be shielded when performing cholangiography during pregnancy to decrease the radiation exposure to the fetus (Level III, Grade B). Radiation exposure during cholangiography is estimated to be less than 0.5 rads. Fluoroscopy generally delivers a

Patient Selection Preoperative decision making Guideline 8: Laparoscopic treatment of acute abdominal processes has the same indications in pregnant and nonpregnant patients (Level II, Grade B).

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Once the decision to operate has been made, the surgical approach (laparotomy versus laparoscopy) should be determined based on the skills of the surgeon as well as the availability of the appropriate staff and equipment. Appropriate discussion with the patient regarding the risks and benets of surgical intervention should be undertaken. Benets of laparoscopy during pregnancy appear similar to those benets in nonpregnant patients including less postoperative pain, less postoperative ileus, decreased length of hospital stays, and faster return to work [31, 36, 4346].

postoperative narcotic requirements [36, 5759], lower risk of wound complications [57, 60, 61], diminished postoperative maternal hypoventilation [57, 58], shorter hospital stays, and decreased risks of thromboembolic events due to early mobilization. Laparoscopy reduces the risk of uterine irritability by decreasing the need for uterine manipulation because of improved visualization [62]. Decreased uterine irritability results in lower rates of spontaneous abortion and preterm delivery [63].

Patient positioning Laparoscopy and trimester of oregnancy Guideline 9: Laparoscopy can be safely performed during any trimester of pregnancy (Level II, Grade B). Operative intervention may be performed in any trimester if warranted by the patients condition. Historical recommendations, which were based on experiences with open surgical procedures during pregnancy, were to delay surgery until the second trimester. These recommendations were thought to minimize the spontaneous abortion rate of surgical intervention during the rst trimester, which has been reported to be as high as 12%, and to avoid preterm labor (up to 40%) when surgery occurs during the third trimester [47]. This experience has not been reproduced in more recent literature reporting on laparoscopic cases. Several recent studies have shown that pregnant patients may undergo laparoscopic surgery safely during any trimester without any appreciated increased risk to the mother or fetus [30, 31, 46, 4851]. It has been suggested that delaying surgical intervention in patients with symptomatic gallstone disease during pregnancy may lead to further complications of gallstone disease such as acute cholecystitis and gallstone pancreatitis [48, 5254] which can lead to higher spontaneous abortion rates and preterm labor. It has been suggested that the gestational age limit for successful completion of laparoscopic surgery during pregnancy is 2628 weeks [35]. This has been refuted by several studies in which laparoscopic cholecystectomy and appendectomy have been successfully performed late in the third trimester [49, 51, 55, 56]. Although laparoscopy can be performed safely in pregnancy with good fetal and maternal outcomes, the long-term effects to the children have not been well studied. One recent study evaluated 11 children from 18 years and found no growth or developmental delay [42]. Guideline 10: Gravid patients should be placed in the left lateral recumbent position to minimize compression of the vena cava and the aorta (Level II, Grade B). When the pregnant patient is placed in a supine position, the gravid uterus places pressure on the inferior vena cava, resulting in decreased venous return to the heart. This decrease in venous return results in maternal hypotension, reduction in cardiac output by 10% to 30%, and decreased placental perfusion during surgery [6466]. Placing the patient in a left lateral recumbent position will shift the uterus off the vena cava, improving venous return and cardiac output [64, 65].

Initial port placement Guideline 11: Initial access can be safely accomplished with open (Hassan), Verres needle or optical trocar technique if the location is adjusted according to fundal height, previous incisions, and experience of the surgeon (Level III, Grade B). There has been much debate regarding abdominal access in the pregnant patient with preferences toward either a Hassan technique or Verres needle. The concern for use of the Verres needle technique has largely been based on concerns for higher likelihood of injury to the uterus or other intra-abdominal organs as fundal height increases [67, 68]. Because the intra-abdominal domain is altered by the increasing fundal height, adaptation of the initial access site from the umbilicus to subcostal regions as the uterus enlarges in the second and third trimester has been recommended [49, 51, 55, 62]. If the site of initial abdominal access is adjusted according to fundal height and the abdominal wall is elevated during insertion, both the Hassan technique and Verres needle can be safely and effectively utilized [49, 51, 69]. It has also been recommended that placement of trocars is adjusted according to fundal height and that they are inserted under direct visualization [70, 71]. Ultrasoundguided trocar placement has been described in the literature as an additional method to visualize trocar placement [72].

Treatment There are many advantages of laparoscopy in the pregnant patient including decreased fetal depression due to lessened

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Insufation pressure Guideline 12: CO2 insufation of 1015 mmHg can be safely used for laparoscopy in the pregnant patient. Intra-abdominal pressure should be sufcient to allow for adequate visualization (Level III, Grade C). The potential effects of CO2 insufation on the pregnant patient and her fetus have led to apprehension over its use. The pulmonary effects of pneumoperitoneum in the pregnant patient and the potential risk for acidosis to the fetus have caused concern and have led some investigators to develop alternative approaches of gasless laparoscopy, but these have not been widely adopted [7380]. The pregnant patients diaphragm is upwardly displaced by the growing fetus, which results in decreased residual lung volume and functional residual capacity, making her more susceptible to arterial oxygen desaturation [81]. Upward displacement of the diaphragm by pneumoperitoneum is more worrisome in a pregnant patient with existing restrictive pulmonary physiology. Some have recommended that intra-abdominal insufation pressures be maintained at less than 12 mmHg to avoid worsening pulmonary physiology in this population [71, 82]. Others have argued that insufation less than 12 mmHg may not provide adequate visualization of the intra-abdominal cavity [49, 51]. Pressures of 15 mmHg have been implemented during laparoscopy in pregnant patients without increasing adverse outcomes to the patient or her fetus [49, 51]. Because CO2 exchange occurs with intraperitoneal insufation, there has been concern for effects to the fetus, specically the effects of acidosis. Some animal studies have conrmed fetal acidosis with associated tachycardia, hypertension, and hypercapnia during CO2 pneumoperitoneum [8385]. Other animal studies have demonstrated no fetal acidosis [86]. Regardless, no long-term adverse effects have been identied [8386]. Of more interest, there is no evidence to support long-term detrimental effects resulting from CO2 pneumoperitoneum in humans [35].

blood gas monitoring of arterial carbon dioxide (PaCO2) versus end-tidal carbon dioxide (ETCO2) monitoring, but the less invasive capnography has been demonstrated to reect maternal acid/base status adequately in humans [90]. Several large studies have documented the safety and efcacy of EtCO2 measurements in pregnant women [35, 49, 51], making routine blood gas monitoring unnecessary.

Venous thromboembolic (VTE) prophylaxis Guideline 14: Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient (Level III, Grade C). Pregnancy is a hypercoagulable state with a 0.10.2% incidence of deep venous thrombosis [91]. CO2 pneumoperitoneum may increase the risk of deep venous thrombosis by increasing venous stasis. Even insufation of 12 mmHg causes a statistically signicant decrease in blood ow that cannot be completely reversed with intermittent pneumatic compression devices or intermittent electric calf stimulators [92]. There is unfortunately a paucity of research on prophylaxis for deep venous thrombosis in the pregnant patient. Because of the increased risk of thrombosis, prophylaxis with pneumatic compression devices both intraoperatively and postoperatively and early postoperative ambulation are recommended as they are in the nonpregnant patient. There is no data regarding use of unfractionated or low-molecularweight heparin for prophylaxis in pregnant patients undergoing laparoscopy, though its use has been suggested in patients undergoing extended major surgery [93]. In patients that require anticoagulation during pregnancy, heparin has proven safe with monitoring and is the agent of choice [94].

Gallbladder disease Guideline 15: Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gallbladder disease regardless of trimester (Level II, Grade B). Management of symptomatic cholelithiasis in pregnancy has been controversial, with some recommending initial nonoperative management [52, 9597]. Those in favor of early surgical management are supported by the recurrence of symptomatic gallstones during pregnancy in 92% of patients managed nonoperatively who present in the rst trimester, 64% presenting in the second, and 44% in the third [98]. More important than recurrence, this delay in surgical management results in signicant morbidity including increased hospitalizations, spontaneous abortions,

Intraoperative CO2 monitoring Guideline 13: Intraoperative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient (Level III, Grade C). Fetal acidosis and associated fetal instability in CO2 pneumoperitoneum have been documented in animal studies, though no long-term effects from these changes have been identied [8385, 87]. Fetal acidosis with insufation has not been documented in the human fetus, but concerns over potential detrimental effects of acidosis have led to the recommendation of maternal CO2 monitoring [88, 89]. Initially, there was debate over maternal

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preterm labor, and preterm delivery compared to those undergoing cholecystectomy [39, 40, 52, 8891]. In addition, nonoperative management boasts a reported 57% symptom recurrence during pregnancy in patients with biliary colic and a 23% complication rate of acute cholecystitis and gallstone pancreatitis [48]. Gallstone pancreatitis results in fetal loss in 1060% of pregnant patients [99, 100]. The signicant morbidity and mortality associated with gallbladder disease in the gravid patient argue in favor of surgical management. When compared to open cholecystectomy, the laparoscopic approach has equivalent outcomes and the well established added benets of laparoscopy [50]. Improved outcomes with decreased risk of spontaneous abortion and preterm labor have been reported in laparoscopic cholecystectomy when compared to laparotomy [101].

Choledocholithiasis Guideline 16: Choledocholithiasis during pregnancy may be managed with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by laparoscopic cholecystectomy, intraoperative laparoscopic transcystic or choledochotomy common bile duct exploration, or postoperative ERCP depending on local resources and clinical scenario (Level III, Grade C). Complications associated with choledocholithiasis are relatively uncommon during pregnancy [102, 103]. However, these complications can result in signicant morbidity and mortality making appropriate management of these patients important. Unfortunately, there have been no trials comparing common bile duct exploration at the time of laparoscopic cholecystectomy to endoscopic retrograde cholangiopancreatography followed by cholecystectomy. Good outcomes have been described with intraoperative common bile duct exploration, but few cases have been reported [104]. Multiple studies have demonstrated safe and effective management of common bile duct stones with endoscopic retrograde cholangiopancreatography with sphincterotomy and subsequent laparoscopic cholecystectomy [105110].

complicated by the anatomic changes and leukocytosis associated with pregnancy [116119]. A recent article, however, has shown that the majority ([ 83%) of gravid patients with acute appendicitis present with classic right lower quadrant pain [120]. Negative appendectomy rates in the gravid patient have been reported to be as high as 22 55% [32, 69]. These high negative appendectomy rates may be due to the surgeons propensity to prevent perforation and avoid unnecessary morbidity and mortality. When the diagnosis of appendicitis by ultrasound is equivocal, promptly proceeding to diagnostic laparoscopy or CT scan may allow for early identication and intervention in appendicitis, decreasing the rate of perforation. Twenty ve percent of all pregnant women who have acute appendicits will develop perforated appendicitis [121, 122]. A 66% perforation incidence has been reported when surgery is delayed by more than 24 h compared to 0% incidence when surgical management is initiated prior to 24 h of presentation [123]. Of note, perforation of the appendix occurs twice as often in the third trimester (69%) compared to the rst and second trimesters [124].

Solid organ resection Guideline 18: Laparoscopic adrenalectomy, nephrectomy and splenectomy are safe procedures in pregnant patients when indicated and standard precautions are taken (Level III, Grade C). After successful laparoscopic management of appendicitis and gallbladder disease in pregnancy, surgeons began exploring laparoscopy in the management of other surgical diseases that arise in pregnancy. Laparoscopic adrenalectomy during pregnancy has proven effective in the management of primary hyperaldosteronism [125], Cushings syndrome [126128], and pheochromocytoma [129134]. Laparoscopic splenectomy has also become an increasingly accepted surgical approach in pregnancy [135]. Gravid patients with antiphospholipid syndrome [136], hereditary spherocytosis [137], and autoimmune thrombocytopenia purpura [135, 138, 139] have undergone laparoscopic splenectomy with excellent outcomes for mother and fetus. More recently, two cases of laparoscopic nephrectomy have been reported in the rst and second trimester without any associated complications and both infants were born healthy at term [140, 141].

Laparoscopic appendectomy Guideline 17: Laparoscopic appendectomy may be performed safely in pregnant patients with suspicion of appendicitis (Level II, Grade B). Laparoscopic appendectomy has become increasingly utilized in the gravid patient since its introduction and is considered by many to be the standard of care [49, 51, 111115]. Diagnosis of appendicitis is thought to be

Adnexal masses Guideline 19: Laparoscopy is safe and effective treatment in gravid patients with symptomatic adnexal cystic masses. Observation is acceptable for all other

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adnexal cystic lesions provided ultrasound is nonworrisome for malignancy and tumor markers are normal. Initial observation is warranted for most adnexal cystic lesions \6 cm in size (Level III, Grade C). The incidence of adnexal masses during pregnancy is 2% [142]. Most of these adnexal masses discovered during the rst trimester are functional cysts that resolve spontaneously by the second trimester [70]. Expectant management has been recommended for B6 cm adnexal masses in the pregnant patient based on an 82% [143] to 94% [144] rate of spontaneous resolution. Persistent masses are most commonly functional cysts or mature cystic teratomas with the incidence of malignancy reported at 26% [145]. Historically, the concern over malignant potential and risks associated with emergency surgery have led to elective removal of masses that persist at 16 weeks and are [6 cm in diameter [144146]. However, recent literature supports the safety of close observation in these patients when ultrasound ndings are not concerning for malignancy, tumor markers are normal (CA125, Lactate dehydrogenase (LDH)) and the patient is asymptomatic [147150]. In the event that surgery is indicated, various case reports support the use of laparoscopy in the management of adnexal masses [151159] in every trimester [160163]. Perhaps more informatively, a retrospective review of 88 pregnant women demonstrated equivalent maternal and fetal outcomes in adnexal masses managed laparoscopically and by laparotomy [62].

Perioperative Care Fetal heart monitoring Guideline 21: Fetal heart monitoring should occur preand postoperatively in the setting of urgent abdominal surgery during pregnancy (Level III, Grade B). While intraoperative fetal heart rate monitoring was once thought to be the most accurate method to detect fetal distress during laparoscopy, no intraoperative fetal heart rate abnormalities have been reported in the literature [48, 101]. This has led some to recommend preoperative and postoperative monitoring of the fetal heart rate with no increased fetal morbidity having been reported [49, 51].

Obstetrical consultation Guideline 22: Obstetric consultation can be obtained pre- and/or postoperatively based on the acuteness of the patients disease, gestational age, and availability of the consultant (Level III, Grade C). Maternal and fetal monitoring should be part of any pregnant patients care and continue throughout their hospitalization, but the timing of a formal obstetric consultation will vary based on availability and the acuteness of the patients condition. Delaying the treatment of an acute abdominal process to obtain such a consultation should be avoided as treatment delay may increase the risk of morbidity and mortality to the mother and fetus [174].

Adnexal torsion Guideline 20: Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion unless clinical severity warrants laparotomy (Level III, Grade C). Of adnexal masses 1015% undergo torsion [164]. Laparoscopy is the preferred method of both diagnosis and treatment in the gravid patient with adnexal torsion [165]. Multiple case reports have conrmed safety and efcacy of laparoscopy for adnexal torsion in pregnant patients [166 170]. If diagnosed before tissue necrosis, adnexal torsion may be managed by simple laparoscopic adnexal detorsion [171]. However, with late diagnosis of torsion adnexal infarction may ensue, which left untreated can result in peritonitis, spontaneous abortion, preterm delivery and death [146, 172]. The gangrenous adnexa should be completely resected [173] and progesterone therapy initiated after removal of the corpus luteum if at less than 12 weeks gestation [171]. Laparotomy may be necessary as dictated by the patients clinical severity and intraoperative ndings [122].

Tocolytics Guideline 23: Tocolytics should not be used prophylactically, but should be considered perioperatively when signs of preterm labor are present in coordination with obstetric consultation (Level I, Grade A). Threatened preterm labor can be successfully managed with tocolytic therapy. The specic agent and indications for the use of tocolytics should be individualized. An obstetric consultation may be necessary as controversy exists over which of several agents is the preferred [175178]. No literature supports the use of prophylactic tocolytics.

Summary of Recommendations More information has accumulated recently as laparoscopy has become more common during pregnancy. However, most of the data is found in case series and retrospective reviews, which limits the ability to provide absolute guidelines. Further controlled clinical studies are needed to

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clarify these guidelines, and revision may be necessary as new data appear. The current recommendations for laparoscopy during surgery are:

radiation and may be used selectively during pregnancy. The lower abdomen should be shielded when performing cholangiography during pregnancy to decrease the radiation exposure to the fetus (Level III, Grade B).

Diagnosis and Workup Surgical Techniques Imaging Techniques Ultrasound Guideline 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). Guideline 7: Diagnostic laparoscopy is safe and effective when used selectively in the workup and treatment of acute abdominal processes in pregnancy (Level II, Grade B).

Patient Selection Preoperative Decision Making

Risk of Ionizing Radiation Guideline 2: Expeditious and accurate diagnosis should take precedence over concerns for ionizing radiation. Radiation dosage should be limited to 510 rads in the rst 25 weeks of pregnancy (Level III, Grade B). Guideline 8: Laparoscopic treatment of acute abdominal processes has the same indications in pregnant and nonpregnant patients (Level II, Grade B).

Laparoscopy and Trimester of Pregnancy Computed Tomography Guideline 3: Contemporary multidetector 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). Guideline 9: Laparoscopy can be safely performed during any trimester of pregnancy (Level II, Grade B).

Treatment Patient Positioning Guideline 10: Gravid patients should be placed in the left lateral recumbent position to minimize compression of the vena cava and the aorta (Level II, Grade B).

Magnetic Resonance Imaging Guideline 4: MR Imaging can be performed at any stage of pregnancy without intravenous gadolinium (Level III, Grade B).

Initial Port Placement Guideline 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).

Nuclear Medicine Guideline 5: Nuclear medicine administration of radionucleotides can generally be accomplished at fetal radiation levels of exposure that are well below any known detrimental levels (Level III, Grade C).

Insufation Pressure Cholangiography Guideline 6: Intraoperative and endoscopic cholangiography exposes the mother and fetus to minimal Guideline 12: CO2 insufation of 1015 mmHg can be safely used for laparoscopy in the pregnant patient. Intra-abdominal pressure should be sufcient to allow for adequate visualization (Level III, Grade C).

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Intraoperative CO2 Monitoring Guideline 13: Intraoperative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient (Level III, Grade C). Venous Thromboembolic (VTE) Prophylaxis Guideline 14: Intraoperative and postoperative pneumatic compression devices and early postoperative ambulation are recommended prophylaxis for deep venous thrombosis in the gravid patient (Level III, Grade C). Gallbladder Disease Guideline 15: Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gallbladder disease regardless of trimester (Level II, Grade B). Choledocholithiasis

Observation is acceptable for all other cystic lesions provided ultrasound is non-worrisome for malignancy and tumor markers are normal. Initial observation is warranted for most cystic lesions \6 cm in size (Level III, Grade C).

Adnexal Torsion Guideline 20: Laparoscopy is recommended for both diagnosis and treatment of adnexal torsion unless clinical severity warrants laparotomy (Level III, Grade C).

Perioperative care Fetal Heart Monitoring Guideline 21: Fetal heart monitoring should occur preand postoperatively in the setting of urgent abdominal surgery during pregnancy (Level III, Grade B).

Obstetrical Consultation Guideline 16: Choledocholithiasis during pregnancy may be managed with preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy followed by laparoscopic cholecystectomy, intraoperative laparoscopic transcystic or choledochotomy common bile duct exploration, or postoperative ERCP depending on local resources and clinical scenario (Level III, Grade C). Guideline 22: Obstetric consultation can be obtained pre- and/or postoperatively based on the acuteness of the patients disease and availability (Level III, Grade B).

Tocolytics Guideline 23: Tocolytics should not be used prophylactically, but should be considered perioperatively when signs of preterm labor are present in coordination with obstetric consultation (Level I, Grade A).

Laparoscopic Appendectomy Guideline 17: Laparoscopic appendectomy may be performed safely in any patients with suspicion of appendicitis (Level II, Grade B).

Appendix A: Levels of Evidence Solid Organ Resection Guideline 18: Laparoscopic adrenalectomy, nephrectomy, splenectomy and mesenteric cyst excision are safe procedures in pregnant patients when indicated and standard precautions are taken (Level III, Grade C).

Level 1 Evidence from properly conducted randomized, controlled trials Level II Evidence from controlled trials without randomization Or Cohort or case-control studies Or Level III Multiple time series, dramatic uncontrolled experiments Descriptive case series, opinions of expert panels

Adnexal Mass Guideline 19: Laparoscopy is safe and effective treatment in gravid patients with symptomatic cystic masses.

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Appendix B: Scale for Evidence Grading

Grade A Grade B Grade C

High-level (level I or II), well-performed studies with uniform interpretation and conclusions by the expert panel High-level, well-performed studies with varying interpretation and conclusions by the expert panel Lower-level evidence (level II or less) with inconsistent ndings and/or varying interpretations or conclusions by the expert panel

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