The pain of appendicitis must be differentiated from the pain of uterine origin. The latter often can be alleviated by providing adequate hydration and placing the patient in the decubitus position. Both Alder's sign (fixed tenderness) and Bryan's sign (tenderness in the right lateral position) can help with this differentiation.
Acute cholecystitis often presents initially with biliary colic associated with nausea and vomiting. When the common bile duct is obstructed by a stone, pain persists and often radiates to the subscapular area, right flank, or shoulder. Patients typically have right subcostal tenderness associated with fever.
Ultrasonography is usually effective for diagnosing the presence of stones or dilatation of the common bile duct. Technetium-99m-iminodiacetic acid scans of the gallbladder can be used in pregnancy with minimal risk of radiation exposure.
Whenever possible, first-trimester patients with cholecystitis should be treated conservatively until the second trimester. Any patient who does not improve with medical management, however, should undergo laparoscopic surgery regardless of the gestational age of the fetus.
With adnexal cysts, it is generally acceptable to provide expectant management if the enlargement is less than 6 cm. There is evidence that 80%-90% of these enlargements will resolve spontaneously.
Again, it is of paramount importance that the obstetrician/gynecologist is cognizant of the anatomic and physiological changes associated with pregnancy. The option of a minimally invasive approach is often appropriate and timely in the management of nonobstetric emergencies during pregnancy.
Source ELSEVIER GLOBAL MEDICAL NEWS
Laparoscopic Surgery During Pregnancy
In a large multisurgeon survey published by the Society of Laparoendoscopic Surgeons, 1.2% of the 16,329 surgeon members said they performed laparoscopic procedures in pregnancy. The most common of the 413 laparoscopic procedures performed in pregnancy by these 192 surgeons appeared to be cholecystectomies, adnexal procedures, and appendectomies (J. Reprod. Med. 1997;42:33–8).
In an excellent review article (Obstet. Gynecol. Surv. 2001;56:50–9), Dr. Mohammad Fatum and Dr. Nathan Rojansky from Hadassah Ein-Kerem Medical Center and the Hebrew University Medical School, Jerusalem, noted the following major advantages of laparoscopic surgery during pregnancy:
▸ Small abdominal incisions resulting in rapid postoperative recovery and early mobilization, thus minimizing the increased risk of thromboembolism associated with pregnancy.
▸ Early return of gastrointestinal activity because of less manipulation of the bowel during surgery, which may result in fewer postoperative adhesions and intestinal obstruction.
▸ Smaller scars.
▸ Fewer incisional hernias.
▸ A reduced rate of fetal depression because of decreased pain and less narcotic use.
▸ Shorter hospitalization time and a prompt return to regular life.
I am pleased that Dr. Joseph S. Sanfilippo agreed to author this edition of the Master Class in Gynecologic Surgery on laparoscopic surgery during pregnancy.
A 1973 Chicago Medical School graduate, Dr. Sanfilippo was honored with a Distinguished Alumnus Award in 1990. He completed his fellowship in reproductive endocrinology and infertility at the University of Louisville (Ky.) School of Medicine and later gained his MBA degree at Chatham College in Pittsburgh.
Currently, Dr. Sanfilippo is professor of obstetrics, gynecology, and reproductive sciences; vice chairman of reproductive sciences; and director of reproductive endocrinology and infertility at Magee-Womens Hospital, Pittsburgh.
He has been a prolific researcher and author, particularly in the areas of surgery, reproductive medicine, and adolescent gynecology.
He also is considered an expert in laparoscopic surgery in pregnancy and has contributed to literature in this area as well.
Laparoscopic Cholecystectomy
▸ The overall complication rate for this procedure has been reported to be 0.75% in the literature.
▸ The highest incidence of fetal loss associated with laparoscopic cholecystectomy is in the first trimester, and the highest incidence of premature labor is in the third trimester.
▸ Elective abortion is not recommended, even with an intraoperative cholangiogram.
▸ Extrahepatic biliary obstruction due to gallstones can be managed laparoscopically.
Source: Dr. Sanfilippo