Laparoscopy in pregnancy treats ovarian masses

OB/GYN News,  Feb 15, 2002  by Sherry Boschert

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SAN FRANCISCO -- Two separate studies favored laparoscopy over laparotomy for surgical treatment of ovarian masses during pregnancy, investigators reported at the annual meeting of the American Association of Gynecologic Laparoscopists.

In general, laparoscopy produces less postoperative pain and a lower risk of infection, compared with laparotomy. Laparoscopy, however, raises concerns about other problems, such as the effects of longer surgeries, potential trauma to the fetus, and compromise of uteroplacental blood flow.

In addition, data are just beginning to accumulate on the use of laparoscopy in pregnancy. "There are very few people in the world who have a lot of experience with this," commented Dr. William H. Parker of Santa Monica, Calif., a session moderator at the meeting.

In the first study, researchers analyzed data on 378 women who underwent a total of 389 surgeries using either laparotomy (192 cases) or laparoscopy (197 cases). Some women had more than one operation per pregnancy.

Most surgeries were done to treat adnexal masses (264 cases) or appendicitis (105 cases). The mean age of patients, parity, and operating times were similar between the laparoscopy and laparotomy groups.

Women in the laparoscopy group were discharged from the hospital sooner--in 3 days rather than 44--as might be expected. Significantly more complications occurred in the laparotomy group, compared with the laparoscopy group (26 vs. 6). The complications included more fevers and premature contractions and two cases of pulmonary emboli in the laparotomy group, compared with no pulmonary emboli in the laparoscopy group, reported Dr. Gabriel Oelsner of Kiryat Ono, Israel.

There were no differences between groups in spontaneous abortion rates in either the first or second trimester. No significant differences between groups were found in rates of preterm deliveries, low-birth-weight babies, or fetal anomalies.

Of seven total fetal anomalies--two in the laparotomy group in the second trimester and five in the laparoscopy group in the first trimester--three clearly had no connection to the operations. It's possible that the surgeries might have played a role in the remaining four anomalies: a cleft lip and palate, mild hypospadias, anterior placement of the anus, and pulmonary hypoplasia.

The overall rates of fetal anomalies, however, were comparable to 1999 data from the Israel Registry of Anomalies: 1% in the laparotomy group, 3% in the laparoscopy group, and 2% in the registry.

The findings echo results from a larger 1997 Swedish study, said Dr. Oelsner, who presented the current study on behalf of the lead investigator, Dr. David Stockheim of Sheba Medical Center, Tel-Hashomer, Israel.

A second study presented at the meeting compared outcomes in 41 women whose adnexal masses were treated by laparotomy with the outcomes of 13 women who underwent laparoscopy during the first or second trimester. The study found longer operating times but less use of general anesthesia in the laparoscopy group, Dr. Chih-Feng Yen of Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, reported.

Most surgeries were done for mature cystic teratomas. Tumor size was larger at diagnosis in the laparotomy group (10 cm) than in the laparoscopy group (8 cm), and the gestational age at the time of operation was higher in the laparotomy group (17 weeks and 13 weeks, respectively).

The longer operating times with laparoscopy did not seem to harm the fetus, No other differences were ere found between groups in baseline maternal characteristics, tumor size, blood loss, gesrational age at delivery, rates of miscarriage, fetal malformations, or complications, Dr. Yen said.

"In pregnant women with adnexal masses, laparoscopic surgery may be a safe alternative, but it is not an easy task. Patience and delicacy are very important. We also suggest that it be done only by very experienced laparoscopic surgeons," he said.

Physicians made several adjustments to usual laparoscopic techniques to adapt them to pregnant patients, he added. In most cases the first puncture for trocar insertion was moved up to the midpoint of the xiphoid-umbilicus line, sometimes preceded by ultrasonographic inspection, Most physicians preferred to do the surgery in the early second trimester when the risk of miscarriage is lower than it was in the first trimester.

Although there is no evidence that a pneumoperitoneum pressure of 15 mm Hg is harmful in pregnancy, the surgeons kept the pressure at 10-12 mm Hg. They used regional epidural anesthesia on a majority of patients in the laparoscopic group even though there is no evidence that general anesthesia is harmful ir pregnancy, Dr. Yen said.

Under epidural anesthesia some patients felt discomfort when the pneumoperitoneum pressure topped 10 mm Hg. , so the pressure was lowered to 8 mm Hg. This provided only adequate visualization, he notel.

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