Minimally invasive surgery in pregnancy

By Rebecca B. Singson
Philippine Daily Inquirer
First Posted 00:48:00 08/22/2009

Filed Under: Health, Science (general), Women

FIVE years ago, on her first pregnancy, I diagnosed Mrs. J., with a 7x7 cm
ovarian cyst. On her 4th month, an exploratory laparotomy was
contemplated for the removal of the ovarian cyst. Her abdomen was cut
open, way bigger than the usual, to be able to expose the pregnant uterus
and at the same time, manipulation of the ovarian mass located behind the
uterus.

The scar stretched as the pregnancy grew to term. The pregnancy

progressed without any problem and she had a spontaneous vaginal delivery
to a healthy baby boy. The surgery, however, left the mother with a midline
scar running up to her umbilicus, and going around it as shown in Fig. 1.

Mrs. J. refers an acquaintance, also pregnant for the first time at 16 weeks,
with a 7x7 cm ovarian cyst. By this time, the technology of minimally
invasive therapy through laparoscopy had come of age. I convinced the
patient that laparoscopic removal was the best to do in this case. Three 1-cm
incisions were made on the abdomen above the level of the umbilicus, the
mass was visualized, excised and later evacuated by slightly enlarging the
right hole where the instruments were being inserted. It was almost like
removing a tennis ball through a keyhole.

This was the first time a laparoscopic surgery in a pregnant woman was ever
performed at the Asian Hospital. On the team to assist for any surgical
complications which may occur were Dr. Miguel Mendoza, section chief of
Laparoscopic Surgery and Dr. Orlando Diomampo, chair of surgery. The
patient was discharged the following day in good condition, extremely
grateful for her small incisions and remarkable post-op recovery.

Minimally invasive surgery

In non-pregnant women, laparoscopic removal of ovarian cysts involves

making a 1-cm incision in the umbilicus, inserting a tube telescopic rod
attached to a video camera and a fiber-optic light source. Carbon dioxide gas
is then used to blow up the abdomen much like a balloon to lift the
abdominal wall from the intestines and create a working space. This gas is
natural to the human body and is later absorbed and eventually removed by
the respiratory system.
Two other incisions are made on the left and right side of the lower abdomen
to insert ports under camera guidance. This is where the instruments like
graspers and scissors are inserted into the abdominal cavity. Then, through a
TV monitor to which the camera image of the abdominal cavity is seen, the
surgery is accomplished with the instruments as a remote extension of the
surgeon’s hands.

In pregnancy, the incision is made midway between the umbilicus and the
lower tip of the breastbone to provide clearance to the uterus to insure that
the pregnancy will not be injured upon entry of the ports and instruments.

Advantages

Laparoscopy has the following advantages:

• Dramatically smaller scar, therefore, less post-operative pain and less need
for pain medications

• Less hemorrhage, thus reducing the chances of blood transfusion

• Less chances for wound infection due to reduced exposure of internal

organs to possible external contaminants and due to a smaller skin area
traumatized and exposed to skin bacteria

• Less chances of incisional hernias

• Increased chances of early mobilization because of minimal pain. The

patient can usually go home the following day or even on the same day.

• Since there is less or no manipulation of the uterus, which contains inside

the developing baby. This leads to less uterine irritability which leads to less
chances of abortion or premature labor.

• Due to decreased need for narcotic pain medications post-operatively,

there is less chance of depressing the heart rate and placental perfusion and
metabolism of the fetus.

• The patient can go back to work sooner.

• No growth or developmental delay was found in 11 children followed up

until 8 years after lap surgery on the mother.

Advanced technology has made minimally invasive surgery a preferred mode

of intervention particularly for removal of benign ovarian cysts. In pregnancy,
it becomes even a superior procedure compared to open surgery because of
the reduced discomfort for the mother postoperatively the minimal to
absence of manipulation of the uterus plus the tinier scars that are left with
the patient as a reminder of her surgery during pregnancy.