Can laparoscopy be used instead of laparotomy to treat pelvic pain during pregnancy? Yes, it can,
according to Dr. James F. Carter, in his discussion of “Laparoscopy vs. Laparotomy in Pregnancy.” The incidence of surgery during pregnancy is 0.75%. Most surgeries are performed to treat masses and symptoms of acute pelvic pain. The majority of these surgeries are laparotomies, but evidence is growing regarding the safety of laparoscopy during pregnancy. Reedy found no difference between laparotomy and laparoscopy in pregnancy with regards to birth weight, gestational length, growth restriction, infant survival, and malformation. Some differences exist between laparotomy and laparoscopy when performed during pregnancy. For example, with laparotomy the patient is supine, but with laparoscopy, the patient is supine with a leftward tilt with sequential compression devices. With laparoscopy, the placement and size of trocars is different than with laparotomy, and if the uterus is more than 20 weeks the trocar is placed above the umbilicus. No more than 4 trocar sites are used, and the intraabdominal pressure is a maximum of 12mm Hg. Operative time is shorter with laparotomy, but hospital stay is longer. Overall, laparoscopy in pregnancy is feasible with low morbidity, operative times are longer, hospital stay is shorter, and patients have subsequent successful pregnancies.
Many complications can occur during laparoscopy. Among them are ureter injury, bladder injury, vascular injury, intraoperative vascular injury, and major retroperitoneal vessel injury, according to Ceana H. Nezhat, MD in his presentation “Complications of Laparoscopy.” Women are predisposed to ureteral injury because the ureter is embryologically associated with the development of the female genital tract. To prevent injuries, one should have a thorough understanding of the ureter’s path through the pelvis. Most injuries have occurred during attempts to stop bleeding by using electrocoagulation, lasers, stapling, or ultrasonic scalpel. If injury occurs to the ureter, consult a urologist. Bladder injury is uncommon and usually occurs in patients whose bladder is not empty and those who have had laparotomies. Trocars and uterine manipulators can damage the bladder, electricity and lasers can cause heat injury, and blunt devices can cause laceration of the bladder. To prevent bladder injuries, insert a Foley catheter into the bladder to drain it of excess urine. It is important to recognize a bladder injury intraoperatively to prevent long-term problems. Small cuts in the bladder usually heal themselves. Trocar injuries that are <1cm can be treated by draining the urine for 5 to 7 days. This encourages healing and spontaneous closure of the hole. For large lacerations, laparotomy may be required. Vascular injuries occur more frequently than other injuries in laparoscopy and can be life threatening if not treated immediately. They can occur during insertion of the Veress needle, trocars, or during surgery. To prevent vascular injuries, make an adequate incision, use a sharp trocar, insert the trocar under direct observation, aim the trocar to the mid-pelvis or abdomen, and insert the trocar under control--avoid sudden entry, especially in thin patients.
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