Evidence-Based Guideline on Laparoscopy in Pregnancy: Commissioned by the British Society for Gynaecological Endoscopy (BSGE) Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG)

Abstract

Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical conditions. It has only been in recent years that laparoscopy has become an acceptable surgical alternative to open surgery in pregnancy. To date there is little clinical guidance pertaining to laparoscopic surgery in pregnancy. This is why the BSGE commissioned this guideline. MEDLINE, EMBASE, CINAHL and the Cochrane library were searched up to February 2017 and evidence was collated and graded following the NICE-approved process. The conditions included in this guideline are laparoscopic management of acute appendicitis, acute gall bladder disease and symptomatic benign adnexal tumours in pregnancy. The intended audience for this guideline is obstetricians and gynaecologists in secondary and tertiary care, general surgeons and anaesthetists. However, only laparoscopists who have adequate laparoscopic skills and who perform complex laparoscopic surgery regularly should undertake laparoscopy in pregnant women, since much of the evidence stems from specialised centres.

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1. Purpose and scope
The scope of this guideline is the laparoscopic
management of non-obstetric, abdominal conditions
in pregnancy. Laparoscopy is widely utilised to
diagnose and treat, acute and chronic, gynaecological
and general surgical conditions. It is only in recent
years that laparoscopy has become an acceptable
surgical alternative to open surgery in pregnancy.
To date there is little clinical guidance pertaining
to laparoscopic surgery in pregnancy. This is why
the British Society of Gynaecological Endoscopy
(BSGE) commissioned this guideline using evidence
grading as used by the Royal College of Obstetricians
and Gynaecologists (RCOG) (appendix 1) with the
help of contributors.
Evidence-Based Guideline on Laparoscopy in Pregnancy
Commissioned by the British Society for Gynaecological Endoscopy (BSGE)
Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG)
E. Ball1, N. WatErs2, N. CoopEr1,C. talati3, r. MalliCk4, s. raBas5, a. MukhErjEE6, Y. sri raNjaN7,
M. thaha1, r. DooDia8, r. kEEDWEll9, M. MaDhra10, N. kuruBa11, r. Malhas12, E. GauGhaN13, k.
toMpsEtt1, h.GiBsoN14, h. WriGht15, C. GNaNaChaNDraN16, t. hookaWaY18, C. BakEr19, k. Murali20,
D. jurkoviC21, N. aMso22, j. Clark23, s. thaNGaratiNaM5, t. ChalhouB24, p. kaloo25, E. sariDoGaN21
1Royal London Hospital; 2Royal Surrey County Hospital NHS Trust; 3Homerton Hospital; 4Brighton and Sussex University
Hospitals NHS Trust; 5Queen’s Hospital London and King George Hospital; 6Northwick Park Hospital; 7Chelsea and
Westminster Hospital; 8John Radcliffe Hospital; 9Royal Cornwall Hospitals NHS Trust; 10Royal Inrmary of Edinburgh;
11Norfolk and Norwich University Hospital; 12Walsall Manor Hospital; 13Rotunda Hospital, Dublin; 14Barking, Havering
and Redbridge University Hospitals NHS Trust; 15North Manchester General Hospital; 16Northampton General Hospital;
17Royal Gwent Hospital Aneurin Bevan Health Board; 18Plymouth Hospitals NHS Trust; 19Poole Hospital; 20Salisbury
District and General Hospital; 21University College Hospital; 22Cardiff University School of Medicine; 23Birmingham
Women’s Hospital; 24Royal Victoria Inrmary; 25Gloucestershire Hospitals NHS Foundation Trust.
Correspondence at: Elizabeth Ball, Royal London Hospital, E-mail: elizabeth.ball9@nhs.net
Abstract
Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical
conditions. It has only been in recent years that laparoscopy has become an acceptable surgical alternative to open
surgery in pregnancy. To date there is little clinical guidance pertaining to laparoscopic surgery in pregnancy.
This is why the BSGE commissioned this guideline. MEDLINE, EMBASE, CINAHL and the Cochrane library
were searched up to February 2017 and evidence was collated and graded following the NICE-approved process.
The conditions included in this guideline are laparoscopic management of acute appendicitis, acute gall bladder
disease and symptomatic benign adnexal tumours in pregnancy.
The intended audience for this guideline is obstetricians and gynaecologists in secondary and tertiary care, general
surgeons and anaesthetists. However, only laparoscopists who have adequate laparoscopic skills and who perform
complex laparoscopic surgery regularly should undertake laparoscopy in pregnant women, since much of the
evidence stems from specialised centres.
Key words: Laparoscopy in pregnancy, Appendicitis in pregnancy, Gallbladder disease / Cholecystitis in
pregnancy, Benign adnexal tumours / Ovarian cysts in pregnancy.
Facts Views Vis Obgyn, 2019, 11 (1): 5-25 Guideline

6 Facts Views Vis Obgyn
The conditions included in this guideline are
acute appendicitis, acute gall bladder disease and
symptomatic benign adnexal tumours in pregnancy.
The intended audience for this guideline is
obstetricians and gynaecologists in secondary and
tertiary care, general surgeons and anaesthetists.
However, only laparoscopists who have specialist
laparoscopic skills and who perform complex
laparoscopic surgery regularly should undertake
laparoscopy in pregnant women.
2. Identication and assessment of evidence
MEDLINE, EMBASE, CINAHL and the Cochrane
library were searched for relevant articles.
Literature searches were performed in MEDLINE
(from 1950 to September 2015), EMBASE (from
1980 to September 2015), CINAHL (from 1981
to September 2015) and the Cochrane library.
No restrictions were placed on the searches in an
attempt to reduce selection bias. The databases
were searched using the relevant MeSH terms and
keywords.
A subsequent update search ensured relevant papers
were included up to February 2017.
The main search terms were ‘laparoscopy’ and
‘pregnancy’, these were used with combinations
of the following words and appropriate synonyms,
depending upon the area of laparoscopy in pregnancy
being examined; anaesthesia, appendicectomy,
cholecystectomy, ovarian cysts, performance and
safety of imaging.
The results of the searches were systematically
reviewed to identify relevant articles. The reference
lists of selected papers were then searched to identify
any additional articles not captured by the literature
search. When a study, which was relevant to one of
the other topic areas, was identied in a search, we
cross-referenced to ensure that it was identied in
the relevant search. Studies were included if they
addressed the diagnosis and / or management of
acute surgical conditions, such as acute appendicitis,
acute cholecystitis and symptomatic benign
adnexal tumours in pregnancy. Suspected ovarian
malignancy, ectopic and heterotopic pregnancy
were excluded (guidance regarding these conditions
can be found in the National Institute of Clinical
Excellence (NICE) Guideline CG122, 2011(NICE,
2011) and the NICE Guideline CG154, 2012 (NICE,
2012), respectively).
Where possible, recommendations were based on
available evidence and the areas where evidence
was lacking were annotated as ‘good practice
points’. Further information about the assessment of
evidence and the grading of recommendations may
be found in appendix 1.
3. Introduction and background
epidemiology
What is the incidence of non-obstetrical
emergencies in pregnancy?
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The incidence of acute, non-obstetric
abdominal surgical emergencies in
pregnancy is low.
Clinicians should be aware of the possibility
of appendicitis in pregnancy, but its incidence
is lower than in the non-pregnant state.
Hormonal changes may increase the
ultrasound scan ndings of gallstones
and sludge in pregnancy. However, the
risk of gallbladder disease appears to be
reduced.
The absolute numbers of torted and
haemorrhagic ovarian cysts are low
in pregnancy. Fertility treatment with
GnRH analogues involving controlled
ovarian stimulation appears to increase
these risks.
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Non-obstetric abdominal surgery during
pregnancy is rare and occurs in 1–2/1000
pregnancies (Silvestri et al., 2011;
Balinskaite et al., 2017).
Two large cohort studies from the USA
reported the incidence of appendicitis to be
1 in 1000 pregnancies (Abbasi et al. (2014)
examined n=7037386 pregnancies, Mourad
et al. (2000) n=66993 pregnancies (0.1%)).
A Korean health registry study found that
the prevalence of acute appendicitis in
pregnant women (96 ± 97 per 100000) was
signicantly lower than that in non- pregnant
women (206 ± 3 per 100000), (OR, 0.376;
95% CI, 0.31- 0.46, p <0.001) (Yuk et al.,
2013).
The search identied one large series of
46075 pregnant women, that reported the
incidence of biliary disease in pregnancy
to be 0.16% (Swisher et al., 1994). In the
general population the incidence is 10-15%
with a female-to-male ratio of 4:1, despite the
predilection for sludge and stone formation in
pregnancy (Schirmer et al., 2005).
The reported incidence of ovarian cysts in
pregnancy varies between studies, depending
upon the study population, the inclusion
criteria and the size of ovarian cysts. If a
cut off of >3cm is used, the incidence in

EVIDENCE-BASED GUIDELINE ON LAPAROSCOPY IN PREGNANCY – BALL Et al. 7
5.2% (p=0.001) for PSI and 11.2% versus
4.8% (p=0.0010) for SIRS. The authors
suggested that compounding factors might
include suppressed maternal immunity in
pregnancy, difculty making the diagnosis
and reluctance to operate. There was a
higher rate of fetal loss and early delivery
when appendicitis was complicated by
generalised peritonitis or peritoneal abscess
(p<0.05); 6% fetal loss and 11% early
delivery in complex appendicitis versus 2%
fetal loss and 4% early delivery in simple
appendicitis (McGory et al., 2007).
No studies were identied that compared
the incidence of ovarian cyst complications
in pregnant and in non-pregnant women in
our search. For instance, there are no data on
whether cyst accidents lead to more severe
peritonitis or haemorrhage when a woman
is pregnant. The risk of torsion appears
to decrease with increasing gestation in a
retrospective series of 107 fertility patients
(Zanetta et al., 2003). After one episode of
torsion the recurrence risk of repeat torsion
was 19.5% in pregnant women and 9.1% in
non-pregnant women in a retrospective case
control study (n=118) (Hasson et al., 2010).
Pregnancy complications secondary
to ovarian cysts include fetal loss and
premature delivery.
pregnancy is 1.2%, if a cut off of >5 cm is
used the incidence in pregnancy is 0.05%
(Duic et al., 2002; Zanetta et al., 2003; Katz
et al., 2010). In non-pregnant women of
reproductive age the incidence is 1.8%, if
a cut off of > 4 cm is used (Borgfeldt and
Andolf, 1999).
Ovarian torsion in pregnancy is rare in
absolute terms. In Duic’s series, torsion, sub-
acute torsion or haemorrhage necessitating
a surgical intervention occurred in 1:4000
pregnancies. Katz et al. (2010) reported
a torsion rate of 1:70000, with hospital
admissions for pain required in 16% of
women with cysts. The incidence of ovarian
torsion in non- pregnant women is not
known.
An association with ovarian stimulation
for fertility treatment was observed in a
retrospective review of 180 consecutive
women of childbearing age over an 11-year
period with surgically conrmed adnexal
torsion; 48 women were pregnant (median
gestational age 7 weeks), of those 39 women
had received fertility treatment and nine
had not. The relationship between ovarian
enlargement and fertility treatment was not
investigated (Tsafrir et al., 2012).
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4. Ovarian cyst accidents, appendicitis and
cholecystitis causing complications specic to
pregnancy
What are the specic concerns of ovarian cyst
accidents, appendicitis and cholecystitis in
pregnancy?
Without appropriate surgical treatment,
appendicitis and cholecystitis carry
specific risks in pregnancy including
generalised peritonitis and maternal
sepsis resulting in miscarriage, preterm
delivery and stillbirth. No data was
identied regarding the effect of cyst
accidents on pregnancy.
When comparing pregnant to non-pregnant
women, a large retrospective cohort study
showed a higher rate of pre-operative
systemic infection (PSI) and systemic
inammatory response syndrome (SIRS)
in pregnant women (Silvestri et al., 2011).
For appendicitis the incidence of PSI was
39.7% versus 33.6% (p<0.001) and for SIRS
it was 35.7% versus 32.2% (p=0.001). For
cholecystitis the incidence was 11.9% versus
5. Safety of Laparoscopy
Is laparoscopy in pregnancy safe for mother and
fetus?
In comparison with open surgery,
laparoscopy for adnexal and gallbladder
disease has no increased risk for mother
and fetus. Where appropriate surgical
equipment and expertise is available,
laparoscopy should be considered an
appropriate surgical approach.
(Recommendations for appendicitis in
pregnancy see 9.1)
There is no additional risk of fetal
malformation or stillbirth in women who
undergo non-obstetric surgery compared
with pregnant women who do not
undergo surgery. The maternal condition
necessitating surgery may be associated with
risk of miscarriage and preterm labour.
Only experienced laparoscopists should
carry out these procedures and outcomes

8 Facts Views Vis Obgyn
Previously pregnancy was thought to be a
contraindication for laparoscopy, but now
there are numerous publications, showing
acceptable maternal and fetal outcomes.
Most evidence is based on case series and
systematic reviews of those.
Compared with laparotomy, laparoscopic
surgery for ovarian cysts in pregnancy was
associated with better maternal outcomes,
and no increase in adverse obstetric
outcomes (miscarriage, preterm delivery
or fetal growth restriction) in a systematic
review of 240 women (Liu et al., 2017).
Two systematic reviews of non-randomised
controlled trial (RCT) studies of laparoscopy
for gallbladder disease reported good maternal
and fetal safety. Adverse fetal outcomes
(OR=0.42, Condence interval (CI)=0.28-
0.63, p<0.001), maternal complications
(OR=0.42, CI=0.33-0.53, p<0.001), or intra-
operative immediate post-operative surgery
related complications (OR=0.45, CI= 0.25-
0.82, p=0.01) were all less frequent in
laparoscopy than in laparotomy (Sedaghat et
al., 2017). In a non-comparative systematic
review, Nasioudis et al. (2016) reported the
rate of fetal loss as 0.4%. Intraoperative
maternal complications were 3.86% and
postoperative maternal complications were
4%, of which fewer than 1/3 in each section
could be classed as severe (see section
9.2). A systematic review of suspected
appendicitis in pregnancy identified 11
non-randomised comparative studies of
open (n=2816) and laparoscopic (n=599)
treatment (Wilasrusmee et al., 2012).
Fetal loss was signicantly increased in the
laparoscopy group (RR=1.91, CI=1.31-2.77).
However, the increased report of fetal
loss was attributed to a single large study
(McGory et al., 2007). No adverse fetal
outcomes associated with laparoscopy
were reported by the remaining smaller
studies. McGory et al. (2007) studied
retrospective administrative hospital records
of pregnant (n=3133) and non-pregnant
women (n=91656) who underwent open
(n=73269) or laparoscopic appendicectomy
(n= 24214). Gestational ages at surgery and
at the time of fetal loss were not reported.
Fetal loss was identied by diagnosis codes
for miscarriage, dilatation and curettage
or intrauterine death. Laparoscopy was
associated with a higher rate of fetal loss
(7%) compared with open appendicectomy
(3%) (Odds ratio (OR)=2.31, CI=1.51-3.55,
p<0.5) but early delivery was less common
in laparoscopic appendicectomy (<1%)
compared to open (8%) (p<0.5). In this
study, it was not possible to make a causal
link between laparoscopic appendicectomy
and fetal loss. It has to be taken into
account that the laparoscopic approach is
the preferred approach in the rst trimester,
when spontaneous fetal loss occurs most
frequently, and the association could be
spurious.
When comparing laparoscopic to open
appendectomy, Balinskaite et al. (2017)
in a retrospective review of routinely
collected hospital data in the UK reported
higher incidence of spontaneous miscarriage
(OR=2.36, CI=1.71 – 3.26). There was no
increase in the other primary outcomes such
as delivery by caesarean section, preterm
delivery < 37 weeks’ gestation, low birth
weight of <2500g, stillbirth, long inpatient
stay and maternal death. They analysed data
of the 6486280 pregnant women of whom
47628 (0.7%) underwent non-obstetric
surgery, 26% underwent abdominal
surgery, including 3061 appendicectomies.
They reported that in the rst trimester
laparoscopic procedures were nearly 5
times more common than open surgery.
Conversely, in the third trimester open
procedures were 2.5 times more common
than laparoscopic surgery. The authors stated
that cause and effect could not be established
and that the higher risk of miscarriage could
be related to the preference of laparoscopic
approach in the rst trimester, when there is
a higher chance of miscarriage.
Mazze et al. (1989) reviewed Swedish
birth registries over a period of nine years,
and investigated the risk of adverse fetal
outcomes, after non-obstetric surgery in
pregnancy. A total of 5405 operations (25%
open abdominal - mainly appendicectomy,
19% gynaecological/urological and 16%
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should be carefully monitored. Joint
surgery between gynaecologists and
surgeons is encouraged.
The decision between laparoscopic
and open routes of surgery should be
based upon the available expertise,
infrastructure, background history,
gestation and the woman’s preference.

EVIDENCE-BASED GUIDELINE ON LAPAROSCOPY IN PREGNANCY – BALL Et al. 9
Laparoscopic surgery is associated with
faster recovery, shorter hospital stay and
a trend to lower rate of wound infection
for pregnant women.
Cox et al. (2016) using the US National
Surgical Quality Improvement Program
(NSQIP) which included 1999 pregnant
women undergoing laparoscopic or open
cholecystectomies or appendicectomies
in non-perforated appendicitis, reported
shorter operation time (p<0.0001), shorter
hospital stay (2.3 ± 5.8 versus 3.3 ± 2.5,
p<0.01), and fewer postoperative wound
complications (0.67% versus 3.9%, p<0.01)
for laparoscopic surgery.
In a retrospective review of 2000 cases of
open and laparoscopic appendicectomies
in pregnancy from the NSQIP database,
laparoscopy was associated with fewer
wound infections (p=0.04), return to theatre,
other infections, respiratory morbidity,
venous thromboembolism (VTE), and blood
transfusion (p=0.048), whilst open cases
had more pre-operative systemic infections
(Erekson et al., 2012).
Wilasrusmee et al. (2012) conducted a
meta- analysis of 11 non-RCT studies of
pregnant women undergoing surgery for
appendicectomy (n=599 laparoscopic,
n=2816 open). Only three studies reported
wound infection, which was not signicantly
reduced in laparoscopy (RR=0.91, CI=0.12
-7.18). Hospital stay was shorter by
half a day (CI=1.76-0.78 days) with the
laparoscopic approach.
Since the publication of Wilasrusmee et al.
(2012) two comparative case series have
been published. Laustsen et al. (2016)
reported a small-scale comparison between
19 laparoscopic and 25 open appendectomies
and reported fewer complications including
wound infection; abscess, haematoma (5.3%
versus 36%, p=0.03) and shorter hospital
stay (2.6 versus 5.5 days, p = 0.004) with
the laparoscopic approach.
Segev et al. (2016) compared 50 laparoscopic
with 42 open appendicectomy cases in
pregnancy. Two per cent of the open cases
were conversions from laparoscopy. The
laparoscopy group had a lower median
gestational age at surgery (16 weeks versus
24 weeks, p<0.001), a shorter median
hospital stay (5 days versus 3 days, p<0.
001), and a lower rate of postoperative
laparoscopic) were reviewed. Out of 868
women who had laparoscopic surgery, 768
had surgery in the rst, 29 in the second and
71 in the third trimester respectively. No
direct comparison was made between an
open and a laparoscopic approach. Mazze et
al. (1989) concluded there was no additional
risk of fetal malformation or stillbirth when
compared with expected rates in non-
surgical pregnant women. However, there
was an increase in the risk of low birth
weight (<1500 grams risk ratio 2.2, 95% CI
1.8-2.8; <2500 grams risk ratio 2.0, 95% CI
1.8-2.2); preterm birth <37/40 weeks (rate
7.5% versus 5.1% p=0.001) and neonatal
death at 168 hours (risk ratio 2.1 CI 1.6-
2.7) when compared with expected rates
in non- surgical women. Neonatal deaths
were associated with prematurity, but
preterm births did not occur from delivery
immediately after the operation but with
an average delay of 21, 7 and 5 weeks
in the rst, second, and third trimester
respectively. The relationship between
the condition necessitating surgery in
pregnancy and adverse outcomes of
pregnancy was not investigated and could
be a confounding factor.
Reedy et al. (1997) looked at 20-year period
of health registry data (a proportion also
included in Mazze et al. (1989) and compared
open (n=1522) to laparoscopic (n=2181)
surgery in pregnancy at gestations between
four weeks and twenty weeks. When these
women, who had undergone either open or
laproscopic surgery, were compared to the
normal pregnant population they had no
increased risk of fetal malformations (open
surgery versus total studied population risk
ratio 1.08, 95% CI 0.85-1.11; laparoscopic
surgery versus total studied population risk
ratio 1.09, 95% CI 0.9-1.11).
No developmental or physical abnormalities
were seen in children born to mothers
who had laparoscopic surgery between
16 and 28 weeks’ gestation (including
cholecystectomy, appendicectomy and
surgery for small bowel obstruction) (Rizzo,
2003). The follow-up ranged from 1 to 8
years.
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What are the maternal benets to laparoscopic
compared to open surgery?
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10 Facts Views Vis Obgyn
A case report details the rupture of uterine
varicocele at laparoscopic appendectomy
at 33 weeks, followed by conversion to
emergency caesarean section, with good
maternal and neonatal outcome (Holzer et
al., 2011).
6. Anaesthesia
complications (8% versus 24%, p=0.04),
with no difference in gestational age at
delivery, Apgar scores, and rates of preterm
delivery or fetal loss.
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What are the maternal risks from laparoscopy in
pregnancy?
General laparoscopic surgical risks such
as haemorrhage and herniation at the
port site also apply to laparoscopy during
pregnancy.
Due to enlargement of the uterus and
subsequent limitations to visual field
and surgical access there is an increased
risk of vascular and organ trauma, in
particular uterine perforation, although
this risk has not been quantied.
Clinicians should counsel women about
consequences of uterine perforation,
which include subsequent uterine
rupture, infections, preterm delivery, and
laceration of the fetus or the placenta.
The size of the perforation is likely to be
of importance.
Clinicians should be aware that there is
increased risk of bleeding due to increased
vascularity of uterus and adnexae, but
this risk is currently not quantied.
A systematic review on cholecystectomy
in pregnancy (Nasioudes et al., 2016)
gives a narrative account of non-pregnancy
specic complications such as haemorrhage
and herniation at the port site after
laparoscopy. Another systematic review
on cholecystectomy in pregnancy reports a
maternal death associated with laparoscopic
cholecystectomy in 767 cases (Sedaghat et
al., 2017). Details of this death are missing
despite contacting the authors.
There are only case reports on trauma to the
uterus. Case series of less than ve cases
were not included in the guideline, with the
exception of this section, where no other
evidence was available. In one case the
uterus was laparoscopically repaired after
Veress needle and trocar injury. PROM
occurred at 32 weeks. The child was well
at 12 months (Joumblat et al., 2012).
In a second case, inadvertent pneumo-
amnion occurred at 21 weeks’ gestation
during a negative laparoscopy, resulting in
miscarriage (Friedman et al., 2002).
No studies were identied which examined
the maternal risks of anaesthesia for women
undergoing laparoscopic surgery in pregnancy.
Recommendations regarding the maternal
anaesthetic risks for non-obstetric laparoscopic
surgery in pregnancy have been extrapolated from
both non-pregnant women having laparoscopy,
and the delivery of anaesthesia in the pregnant
population.
What are the maternal anaesthetic risks of
laparoscopy in pregnancy and how can these
specic risks be safely managed?
The pre-operative anaesthetic review
should include relevant features related
to the pregnancy such as gestation and
pregnancy related co- morbidities as well
as the routine anaesthesia history and
examination.
There should be early involvement of
an obstetric anaesthetist, or at the very
least consultation with an obstetric
anaesthetist.
Aspiration prophylaxis should be
administered, and a strategy for airway
management should be made. General
anaesthesia and endotracheal intubation
are essential, and the use of a laryngeal
mask airway is not recommended.
Creation of the pneumoperitoneum
should be gradual, as should alterations
in maternal positioning.
Pregnant woman undergoing non-
obstetric surgery are at an added risk
for venous thromboembolism. Their risk
for venous thromboembolism should be
stratied and prophylaxis considered as
per the Royal College of Obstetricians
and Gynaecologists Green-Top Guidance.
An anaesthetic assessment should include a
thorough evaluation of the patient, including timely
pre-operative resuscitation if necessary. Aspiration
prophylaxis should be administered as part of the
premedication, and an early strategy for airway

EVIDENCE-BASED GUIDELINE ON LAPAROSCOPY IN PREGNANCY – BALL Et al. 11
No anaesthetic agents have yet been proven
to be teratogenic in humans when used in
clinical doses and when normal physiology
is maintained (Kuczkowski, 2006).
Utero-placental blood ow is essential for
oxygen delivery to the fetus and impairment
to this can threaten fetal viability (Chestnut
et al., 2009). When maternal blood pressure
is maintained close to baseline and end-tidal
CO2 controlled between 3.7-4.3 kPa, no
adverse outcomes were reported (Steinbrook
et al., 1996; Bhavani-Shankar et al., 2000;
Rajmohan et al., 2013).
ETCO2 can be used as a surrogate marker
for maternal arterial CO2 monitoring, and
invasive arterial monitoring is not routinely
required in otherwise healthy and stable
women, however the decision should be
made on a case by case basis (Bhavani-
Shankar et al., 2000).
Uterine displacement can improve cardiac
output and uteroplacental ow and should
be used unless it adversely impacts on the
ability to carry out the surgery in a timely
and effective manner, when gestational age
is greater than 18 weeks (Cluver et al., 2013).
Establishment of pneumoperitoneum can
be accompanied by marked changes in
cardiovascular and respiratory physiology
(Struthers and Cuschieri, 1998). Alterations
in positioning and the creation of the
pneumoperitoneum should be gradual, with
vigilance and monitoring of the woman’s
haemodynamic status.
Non-obstetric surgery during pregnancy
is associated with an increased risk of
venous thromboembolism (VTE). As
a minimum, the RCOG classifies any
surgical procedure as an intermediate risk,
whereby pharmacological prophylaxis with
low molecular weight heparin should be
considered (RCOG, Guideline No 37a and
37b, 2015).
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management should be formulated. A rapid sequence
induction should be considered to minimise the risk
of pulmonary aspiration.
What are the fetal risks associated with anaesthesia
and what strategies can be employed to increase the
safety for the fetus, when pregnant women require
non-obstetric laparoscopic surgery?
Modern anaesthetic agents, muscle
relaxants and opioids are not thought to
be teratogenic when used in therapeutic
clinical doses and when the maternal
physiology is maintained.
Clinicians should ensure the utero-
placental blood ow is maintained by
avoiding maternal hypotension.
Maternal arterial CO2 should be
controlled, avoiding hypo- and
hypercapnia, to maintain optimal utero-
placental flow and thus avoid fetal
acidosis.
End-tidal CO2 (ETCO2) can be used as a
surrogate marker for arterial CO2.
No primary studies were identied that selectively
investigated the fetal anaesthetic risks of
laparoscopic surgery separately from the risks of the
surgical intervention. There are no primary studies
that distinguish the effects of anaesthetic factors
from surgical factors with regard to fetal risks.
The risks of anaesthesia for the fetus of pregnant
women undergoing non-obstetric laparoscopic
surgery can broadly be divided into two. Firstly,
the risks related to pharmacological agents used in
anaesthesia and the risk of teratogenicity. Secondly,
the risks related to a reduction in uteroplacental blood
ow, secondary to changes in maternal mean arterial
pressure, partial pressure of arterial carbon dioxide
(PaCO2), oxygenation, aorto-caval compression and
increased intra-abdominal pressure.
What type of anaesthesia should be used?
In most cases general anaesthesia should
be employed.
There is limited evidence on the use of regional
anaesthesia for laparoscopy in pregnancy. The
benets of general anaesthesia include securing the
airway to reduce the risk of aspiration, good muscle
relaxation to allow excellent surgical conditions
and controlled ventilation to regulate maternal
PaCO2. In addition, general anaesthesia can avoid
any discomfort that an awake woman may endure,
related to either a high neuraxial sensory block
level for an adequate pneumoperitoneum, or steep
positioning.
7. Peri- and intra-operative laparoscopic
management of non-obstetric emergencies
Who should be involved in the management
of pregnant women requiring laparoscopy for
abdominal non-obstetric conditions?

12 Facts Views Vis Obgyn
When deciding on the route of surgery
clinicians should be aware that recent
small series have shown good maternal
and fetal outcomes for laparoscopic
appendicectomy, cholecystectomy and
adnexal surgery up to 34 weeks gestation,
which extends historical recommendation
to limit laparoscopic surgery to the second
trimester.
Any surgery in pregnancy is associated
with maternal and fetal risks. Non-urgent
surgery should be postponed until after
pregnancy.
According to previous American College
of Obstetrics and Gynecology (ACOG)
committee opinion, the second trimester is the
best time to carry out non-urgent laparoscopic
surgery, because preterm contractions and
miscarriage are least likely (Committee
Opinion No. 696, 2017). Furthermore, access
to pelvic organs and the gallbladder is easier
because the uterus is smaller than in the
third trimester. However, there is emerging
evidence showing good maternal and fetal
outcomes outside the second trimester.
A series of third trimester cases managed
laparoscopically included ve cholecystectomies,
four appendicectomies, and two adnexal
operations (Upadhyay et al., 2007). One
patient went into labour at 34 weeks following
appendicectomy complicated by peritonitis.
Another patient (29 weeks) was converted to
open salpingo-oophorectomy for torsion after
diagnostic laparoscopy due to operator preference
but required emergency laparotomy and caesarean
section due to bleeding from the ovarian pedicle.
The two complications are not likely to be due to
the laparoscopic approach.
Another observational study compared 117
laparoscopic operations (adnexal torsion,
persistent cysts, cholecystitis and appendicitis)
in the rst trimester (n=71, mean gestational
age 7.7 ± 1.9 weeks) with laparoscopic
surgeries in the second and third trimesters
(n= 46, mean gestational age 18.1 ± 4.3 weeks,
11 cases in third trimester, up to 34 weeks)
(Weiner et al., 2015). No difference was found
between the two groups regarding surgical
complications and pregnancy outcomes. In
both groups half of the deliveries were before
37 weeks.
A multi-disciplinary team should be in
charge of the care of pregnant women
requiring laparoscopy. Depending
on the individual case this team
may include gynaecologists, general
surgeons, anaesthetists, obstetricians and
neonatologists.
Laparoscopic surgery in pregnancy
should be performed by advanced
laparoscopic surgeons with appropriate
training and competencies in order to
reduce complications and operating
times.
Pregnancy should not be a reason to delay
urgent surgery.
If the expertise to undertake laparoscopic
approach in pregnancy is lacking, then the
open route is acceptable since maternal
and fetal outcomes are good.
Both laparoscopic and open routes are
acceptable, depending on circumstances,
since maternal and fetal outcomes are
equally acceptable.
General surgeons with a large caseload (top
quartile of participating surgeons in annual
number of cholecystectomies) experienced
fewer maternal (1% versus 14%, p<0.0001),
fetal (4% versus 10%, p<0.0001) and surgical
(10% versus 13%, p<0.05) complications
than other surgeons. Their patients also had
a shorter length of stay (4 versus 5 days,
p<0.0001) in a retrospective cohort study of
9714 predominantly laparoscopic surgeries
(89% cholecystectomies) in pregnancy
(p<0.0001) (Kuy et al., 2009).
The maternal benefits of laparoscopy
(shorter operating time and hospital stay,
minor complications) were not observed
in cases of perforation of appendix or
gallbladder (Cox et al., 2016). Timely
surgical intervention is important in order
avoid the risk of perforation and subsequent
sepsis. Higher rates of perforation were
observed when surgery was delayed for
more than 24 hours after onset of symptoms
(Tamir et al., 1990).
Maternal and fetal outcomes are satisfactory
in both open and laparoscopic interventions
(Aylin et al., 2016), therefore open surgery
in experienced hands is preferable to delayed
laparoscopic treatment.
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At what gestation should laparoscopic surgery in
pregnancy be performed?

EVIDENCE-BASED GUIDELINE ON LAPAROSCOPY IN PREGNANCY – BALL Et al. 13
surgery on ovarian cysts using a routine
laparoscopic approach with less than 12
mmHg pneumoperitoneum (Candiani et al.,
2012).
Intra-operative monitoring may be
required only in selected cases and
when emergency delivery of the fetus is
being considered. According to ACOG
the following items need to be present
before considering fetal monitoring:
fetal viability, technical feasibility for
intraoperative electronic fetal monitoring,
an obstetrician willing to intervene for
fetal indications, maternal consent for
Caesarean section (CS) (desirable) and
feasibility to interrupt laparoscopic surgery
for emergency CS (Committee Opinion
No. 696, 2017). Intraoperative monitoring
during laparoscopy can be achieved by
trans-vaginal or trans-abdominal ultrasound
scanning with a steep left tilt to overcome
the pneumoperitoneum.
If there is a risk of preterm delivery of a viable
fetus, antenatal corticosteroids between
24±0 and 35±6 weeks and magnesium for
fetal neuro protection should be used up
to 33±6 in accordance with existing NICE
guidance (NICE, 2015). Urgent surgery
should not be delayed for administrating
corticosteroids.
A systematic review showed no difference
in the preterm delivery rate between women
who received prophylactic tocolysis and
those who did not (Walsh et al., 2008).
Laparoscopic surgery is generally not
considered a sensitising event and therefore
routine administration of prophylactic anti D
is not required (Qureshi et al., 2014).
Laparoscopic surgery in pregnancy
should be carried out in settings where
adequate time, laparoscopic expertise and
monitoring facilities are available.
After the age of fetal viability pregnant
women undergoing laparoscopic surgery
should be treated in a unit with adequate
obstetric and neonatal facilities in case
the immediate delivery of the baby is
indicated.
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Where should laparoscopic surgery in pregnancy be
performed?
The studies which informed this guideline originated
mainly from tertiary care units in developed
countries and so the recommendations cannot be
extrapolated to all settings.
What interventions are needed when planning
laparoscopic surgery in pregnancy?
Fetal heart Doppler ultrasound
monitoring may be done before and after
surgery to conrm fetal wellbeing and
reassure the mother. There is no need for
routine intraoperative monitoring.
If there is a risk of pre-term delivery
antenatal corticosteroids for fetal lung
maturation and magnesium sulphate
for fetal neuro-protection should be
administered dependent upon the
gestation of the fetus.
Anti-D administration is not deemed
necessary according to guidelines since
laparoscopic surgery is not included in
the list of potentially sensitising events.
Routine tocolysis for women undergoing
laparoscopic or open surgery in
pregnancy is not recommended because it
has not been shown to improve outcomes.
Caution needs to be exercised in steroid
administration in maternal sepsis.
In the past intraoperative fetal heart
monitoring, especially with open surgery,
was seen as mandatory. Newer large case
series have shown good outcomes without
routine intra-operative fetal heart monitoring
during laparoscopy (Kirshtein et al., 2009;
Chung et al., 2013).
A small quasi-experimental study showed
no Doppler anomalies of the fetal heart or
the maternal uterine arteries (measured
trans-vaginally) during laparo scopic
8. Intraoperative considerations
The following section discusses intraoperative
issues relating to laparoscopy in pregnancy. Specic
conditions (appendectomy, gallbladder disease and
adnexal surgery) will be discussed in section 9.
Clinicians would be aware that
intrauterine manipulation is
contraindicated in pregnancy. Hence
collaboration with the anaesthetic team
(positioning, tilting) and experienced
operating assistance is required.
In order to improve surgical access without an
intrauterine manipulator, alternative strategies

14 Facts Views Vis Obgyn
In order to avoid uterine perforation
and restricting views from having the
camera port too close to the uterus, it is
recommended to adjust the port location
according to the fundus (Jeong et al., 2011).
Therefore, the fundus should be palpated
before insufation. In very obese women
transabdominal ultrasound and obstetric
guidance may be required. Upadhyay et al.
(2007) reported 11 laparoscopies between
26-28 weeks’ gestation (appendicectomy,
cholecystectomy and adnexal surgery) using
1-2 cm below the costal margin on the left
or right mid-clavicular line using Veress’
insufation in 10 cases and Hasson’s in one
case with no access-related complications.
include digital vaginal manipulation, planning the
placement of surgical ports according to pathology
and uterine size, tilting of the surgical table and
consideration of thirty-degree laparoscope. Bearing
in mind that uterine surface in pregnancy is more
friable and can bleed more easily on contact even
with blunt instruments, a ‘no touch’ approach should
be adopted.
8.1 Ports
How should the primary and secondary ports be
placed?
For generic entry techniques refer to the RCOG
recommendations preventing entry-related
gynaecological laparoscopic injuries for non-
pregnant women (Green-top Guideline No 49, 2008).
This section will address the issues specically
relevant to laparoscopy in pregnancy.
Where should the primary port be placed in
pregnancy?
The location of the primary port will
depend on the level of the uterine fundus.
The uterine size should be determined by
palpation or ultrasound.
In the absence of RCTs clinicians should
choose their primary port location including
umbilical, supra-umbilical / sub-xiphoid
and Palmers’ point (left upper quadrant
in the mid- clavicular line) according to
uterine size, location of pathology and
operator experience.
It has been suggested that in the late
second and the third trimesters primary
port sites could include 1-2cm below
costal margin in the left (Palmers’ point)
or right mid-clavicular line or 3-6 cm
above the umbilicus in the midline.
Insertion of an orogastric tube for gastric
decompression maybe helpful when
Palmer’s point is used for access.
No study was identified that randomised
for location of the primary port, thus no
recommendations can be made for one location
over another.
Researchers describe a variety of different
locations for primary ports depending on
gestational age (Lyass et al, 2001; Lenglet et al.,
2006; Machado et al., 2009; Bani Hani, 2007;
Kirshtein et al., 2009; Balthazar et al., 2011;
Jeong et al., 2011; Wilasrusmee et al., 2012; Koo
et al., 2012; Peng et al., 2013; Chen et al., 2014;
Nasioudis et al., 2016; Sedaghat et al., 2017).
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Should the Veress or Hasson technique be used for
primary port placement?
The Hasson technique has been reported
inside or above the umbilicus in the
midline.
With either approach clinicians should be
mindful of the possibility of uterine injury.
The benets of the Hasson technique may
include reducing the risk of uterine trauma
and spillage of contents of ovarian cysts.
Clinicians should be aware that in
experienced hands direct (gasless) entry
may be an alternative, but there is
insufcient information in late pregnancy
to suggest this as a routine approach.
Although there are no studies randomised
for Hasson’s and Veress’ entry techniques,
a number of authors have recorded case
series using these approaches throughout all
gestations for cholecystectomy (Bani Hani,
2007), appendicectomy (Lyass et al., 2001),
and adnexal surgery without entry-related
complications (Balthazar et al., 2011). The
Hasson technique has been reported inside
or above the umbilicus in the midline.
Chen et al. (2014) reported direct entry
in 33 laparoscopies for ovarian cysts in
second trimester (mean gestation 16.8)
without entry-related complications. The
direct entry technique was described as
placing an optical trocar under visual
control in the umbilicus, whilst elevating
the umbilicus with a towel forceps. Park
et al. (2010) described direct entry via
Palmer’s point (left upper quadrant in
the mid-clavicular line) in n=8 cases of

EVIDENCE-BASED GUIDELINE ON LAPAROSCOPY IN PREGNANCY – BALL Et al. 15
women (RCOG, Green-top Guideline No
49, 2008). Since these pressures are only
maintained for a short duration until the
primary port is placed, they are unlikely to
harm the fetus.
No adverse changes to feto-maternal
perfusion or adverse pregnancy events
were recorded at less than 12 mmHg
pneumoperitoneum in a quasi- experimental
setting using intraoperative Doppler studies
(Candiani et al., 2012). This was backed
up by numerous case reports showing no
adverse effects on the fetus at operating
pressures at or below 12 mmHg (Lyass et
al., 2001; Mathevet et al., 2003; Yuen et al.,
2004; Lenglet et al., 2006; Kirshtein et al.,
2009; Jeong et al., 2011; Koo et al., 2012;
Peng et al., 2013; Chung et al., 2013; Chen
et al., 2014; Minig et al., 2016).
8.3 Choice of laparoscope
pregnancy appendicectomies (2 in rst
trimester, 5 in second trimester, one in third
trimester) using a 5 mm trocar. No maternal
of fetal complications were observed. The
incidence of port entry complications is very
low, and the studies above are too small to
detect entry related complications.
Where should secondary ports be placed?
Secondary port placement will be dictated
by uterine size, pathology and operative
approach.
Pre-surgical planning is paramount
due to the challenges of accessing the
pathology, given the limited degrees of
freedom in laparoscopic surgery and the
added obstacle of the size of the pregnant
uterus. Ipsilateral port placement may
circumvent this obstacle.
A systematic search returned no randomised
control trials, but authors of case series of
appendicectomy (Kirshtein et al., 2009;
Jeong et al., 2011; Miloudi et al., 2012),
and cholecystectomy in pregnancy stated
that secondary port placement is dictated by
uterine size and pathology (Sungler et al.,
2014).
Secondary port placement should be
considered on the same side (ipsilateral port
placement) as the identied pathology as
this technique prevents the surgeon from
having to instrument across the pregnant
uterus.
8.2 Pneumoperitoneum in pregnancy
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What insufflation pressures and operative
pressures should be used in laparoscopic surgery
in pregnancy?
An intraabdominal pressure of 20-25
mmHg should be used for gas insufation
before inserting the primary trocar .
Clinicians should be aware that current
evidence supports operating pressures of
12 mmHg.
Current recommendations on operating
pressures in pregnancy are in keeping with
recommendations for the non-pregnant state.
There are no studies on insufation pressure
during port insertions in pregnancy. The
recommendation for an insufation pressure
of 20-25 mmHg is extrapolated from the
RCOG recommendation in non-pregnant
What diameter laparoscope is preferred for
laparoscopic procedures during pregnancy?
Both 5 and 10 mm diameter laparoscopes
have been used in pregnancy and
choice of diameter depends upon the
surgical requirements and availability of
equipment.
The benets of using a 10 mm diameter
laparoscope include better quality of image
and the possibility of removing a larger
specimen through the camera port. The
benets of a smaller 5 mm laparoscope
include the need for smaller incisions with
better cosmesis and the ability to insert them
through secondary ports to gain different
views. Although numerous authors describe
their use of 5 and 10 mm laparoscope, no
data specifically comparing laparoscope
diameter during pregnancy were identied.
What degree of laparoscope is preferred for
laparoscopic procedures during pregnancy?
The choice of degree of laparoscope
depends upon the preference of the
surgeon and the surgical situation. Skilful
use of a 30-degree laparoscope might
improve the visual eld in the presence of
a large uterus.
There are no studies evaluating the optimal
degree of laparoscope that should be
used in pregnancy. Traditionally, many

16 Facts Views Vis Obgyn
Ultrasound, bipolar and monopolar
energy sources are safe to use during
laparoscopy in pregnancy.
The operating surgeon should choose
energy modality based on his or her
own preference. The surgeon should
be mindful of the principles of safe
electrosurgery in laparoscopy.
gynaecologists use 0 degree and general
surgeons more often use 30 degree
laparoscopes. However, extrapolating from
non-pregnant laparoscopic surgery on large
broid uteri, a 30 degree scope can improve
visibility in the pelvis in trained hands.
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What retrieval technique should be used to remove
surgical specimens during laparoscopic surgery in
pregnancy?
The choice of extraction method for
surgical specimens during laparoscopic
surgery in pregnancy should be in
accordance with the preference of the
operating surgeon.
Infected and potentially dangerous
specimens should be contained in a tissue
bag.
D
Consideration should be given to the use of a tissue
bag to avoid peritoneal spill of cystic contents,
bearing in mind the likely preoperative diagnosis. For
example, care should be taken not to spill contents
of dermoid cysts to avoid chemical peritonitis and
spillage of potentially malignant cysts as clinical
assessment cannot absolutely preclude malignancy
(RCOG, Green-top Guideline No 62, 2011).
A systematic search identied 10 case series
that mention techniques of tissue removal at
laparoscopy during pregnancy between 5-34
weeks’ gestation (Lee et al., 2004; RCOG,
Green-top Guideline No 49, 2008; Kirshtein et
al., 2009; Machado and Machado, 2009; Koo
et al., 2011a; Chung et al.,2013; Scheib et al.,
2013; Chen et al., 2014; Minig et al., 2016).
The indications for surgery included
appendicectomy, cholecystectomy and
adnexal surgery. The devices used included
endobag, endocatch, endopouch and sterile
condoms.
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Bearing in mind the likely diagnosis of the specimen,
consideration should be given to carrying out the
dissection within the bag as well as using it for
removal.
No comparative data to guide preferred techniques
for tissue extraction specimen were identied. There
was no data on power morcellation, which should be
discouraged in pregnancy due to the risk of uterine
trauma.
What energy modalities should be used during
laparoscopic surgery in pregnancy?
D
No papers were available that investigated energy
use during laparoscopic procedures in pregnant
women as their main research question. There is no
evidence that electrosurgery in a pregnant woman
is harmful to the fetus or embryo. When monopolar
energy is used it is recommended that the return
plate should not be placed such that the uterus is
between the electrode and the plate.
Amniotic uid, which is electrolyte rich, protects
the fetus from concentration of current and there
is no neuromuscular stimulation at the output
frequency of electrosurgical generators. Whilst
there is a discrepancy between advice from different
manufacturers, published literature does not suggest
increased risk of energy related complications with
any type of energy devices including monopolar
during pregnancy.
Nine case series’ reported on the use of
energy modalities but this was not the main
topic under investigation (Mathevet et al.,
2003; Kirshtein et al., 2009; Park et al.,
2010; Lee et al., 2010; Jeong et al., 2011;
Chung et al., 2013; Peng et al., 2013; Chen
et al., 2014; Takeda et al., 2014). The range
of energy sources, which were used without
complications, include ultrasonic, bipolar,
and monopolar energy. Monopolar energy
was reported as being used by Lee et al.
in 2010. Lee et al. (2004) used monopolar
scissors during 29 ovarian cystectomies
between 6-16 weeks’ gestation without
any operative complications. Mathevet et
al. (2003) also used monopolar scissors in
addition to bipolar diathermy in 48 pregnant
women undergoing laparoscopic adnexal
surgery (17 in rst trimester, 27 in second
and 4 in the third trimester). There were no
intraoperative complications but one woman
suffered a miscarriage at 17 weeks three
days after surgery, which was not ascribed
to the operating technique after review of
the operative video. The use of Harmonic
scalpel® reported in 2 case series (Chung
et al., 2013; Park et al., 2010). Chung
et al. (2013) carried out 22 laparoscopic
appendicectomies (6 in rst, 13 in second
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EVIDENCE-BASED GUIDELINE ON LAPAROSCOPY IN PREGNANCY – BALL Et al. 17
8.6 Post-operative care
What maternal care and fetal monitoring should be
offered post-operatively?
The literature search did not return any studies that
investigated fetal monitoring after surgery. Fetal
heart Doppler ultrasound monitoring may be done
after surgery to conrm fetal wellbeing and reassure
the mother.
and 3 in third trimester). No intra-operative
complications occurred. Park et al. (2010)
reported the use of Harmonic scalpel® in 8
cases of appendicectomy during pregnancy
(2 in rst trimester, 5 in second trimester,
one in third trimester) with no operative
complications.
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Given the restricted access and visibility in
laparoscopy in pregnancy the surgeon needs to
respect electrosurgical principles to avoid trauma.
General safety rules for monopolar diathermy apply
(avoiding indirect thermal damage, pedicle effect,
avoid coupling, checking for faulty insulation).
8.4 Closure Techniques
What wound closure techniques are recommended
in pregnancy?
The risk of hernia formation is 1-2% in
incisions greater than 10 mm, therefore
the fascia should be closed.
No data were identied for port closure after
laparoscopy in pregnancy. In non-pregnant
women ports greater than 10 mm should
be closed by formal sheath closure with a
port closure system, such as Endoclose®
(with pneumoperitoneum maintained) or
by using a J-needle, unless the Hasson
entry technique has been used, in which
case previously placed stay sutures are tied
together. The risk of postoperative hernia
formation is greater at the lateral port sites,
especially taking into account the impact
of the enlarging uterus on the abdominal
wall stretch, which may further increase the
risk of herniation. The skin can be closed
by a variety of techniques e.g. subcuticular
polyglactin and skin glue.
8.5 Use of drains
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Should an abdominal drain be inserted peri-
operatively on completion of laparoscopic
procedures in pregnancy?
The operating surgeon should decide
whether it is necessary to use a drain
based on their preference and assessment
of the individual case.
Drain placement has been only described
in the context of laparoscopic appendicitis
in pregnancy, not for cholecystectomy or
adnexal surgery. Comparative data between
routine placement (Park et al., 2010; Chung
et al., 2013), and selective placement (Jeong
et al., 2011), is lacking.
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Antibiotics should be used if there is an
infective process. The choice of antibiotic
should be based upon local anti-microbial
guidance and drug safety in pregnancy.
In the case of elective surgery for adnexal
masses, antibiotics would not be routinely
required.
Good analgesia, adequate rehydration
to maintain euvolaemia and measures
to prevent postoperative nausea and
vomiting should be integrated into
maternal postoperative care.
In a prospective case series of adnexal cysts
operated on electively in the rst trimester in
12 women no routine antibiotics were given
and there were no complications including
infections (Minig et al., 2016).
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9. Management of the commonest laparoscopically
treatable abdominal emergencies in pregnancy
9.1 Appendicitis
Is there a role for expectant management of
appendicitis in pregnancy?
In suspected appendicitis in pregnancy
timely surgical intervention is preferable
as delay may be associated with adverse
maternal and fetal outcomes.
Two large retrospective studies were
identified comparing conservative to
operative approach for suspected appendicitis
in pregnancy. Abbasi et al. (2014) reported
a higher rate of complications in women
who had antibiotics only compared to open
or laparoscopic appendicectomy. This study
also showed higher rates of septic shock
(OR=6.3, CI=1.9-20.8), peritonitis (OR=
1.6, CI=1.3-2.1) and increase in venous
thromboembolic disease (OR=2.5, CI=0.9-
7.4), when comparing pregnant women
who underwent treatment with antibiotics
(n=412) with those who underwent open
(n=3421) or laparoscopic surgery (n=3279).
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18 Facts Views Vis Obgyn
experienced laparoscopists should carry
out these procedures and outcomes
should be monitored.
A systematic review of 11 non-randomised
comparative studies of open (n=2816) and
laparoscopic (n=599) cases for suspected
appendicitis in pregnancy was identified
(Wilasrusmee et al., 2012). Most cases were
from the second trimester, but cases from
all trimesters were included. There was no
data on complexity of cases in either group.
Fetal loss was signicantly increased in the
laparoscopy group (RR=1.91, CI=1.31-2.77).
The adverse ndings reported by Wilasrusmee
et al. (2012) were inuenced by a single
study by McGory et al. (2007) without which
there would be no increase in fetal loss
associated with laparoscopy. McGory et al.
(2007) studied retrospective administrative
hospital records of pregnant (n=3133)
and non-pregnant women (n=91656) who
underwent open (n=73269) or laparoscopic
appendicectomy (n= 24214) and reported a
higher rate of fetal loss compared with open
appendicectomy (OR=2.31, CI=1.51-3.55).
A small retrospective study was
published after the systematic review by
Wilasrusmee et al. (2012). Laustsen et al.
(2016) compared 19 laparoscopic with
25 open appendicetomies and reported no
miscarriages, no differences in Apgar score,
weight, length and gestational age birth and
improved maternal outcomes.
A large retrospective UK study on hospital
data included 3061 appendicectomies
(Aylin et al., 2016; Balinskaite et al.,
2017). Laparoscopic appendicectomies
were associated with an increased risk
of spontaneous miscarriage (RR=2.36,
CI=1.71-4.41), but very few (1.8%) occurred
during immediately after laparoscopic
appendicectomy. No differences were
observed in risk of in preterm delivery <37/40,
maternal death, long inpatient stay and low
birth weight <2500 g. They reported that in
the rst trimester laparoscopic procedures
were nearly 5 times more common than open
ones. Conversely, in the third trimester open
procedures were 2.5 times more common
than laparoscopic ones.
Both studies have a large risk of a systematic
distortion in measuring the true frequency
of miscarriage due to laparoscopy because
Cheng et al. (2015) investigated outcomes
in pregnant women with appendicitis and
antibiotic conservative treatment (n=78),
open (n=653) and laparoscopic (n=128)
surgery and compared outcomes with
pregnant women without appendicitis
(n=3436) from a national database. Pregnant
women who had conservative treatment
for appendicitis had a higher incidence of
preterm labour (OR=2.47, CI=1.17-5.24)
and pregnancy loss (OR=31.37, CI=13.12-
75.01) than pregnant women who did not
have appendicitis. Compared to pregnant
women without appendicitis, women with
open appendicectomy had significantly
increased rates of preterm labour (OR=2.76,
CI=2.06-3.70), pregnancy loss (OR=14.34,
CI=7.70-26.71) and caesarean delivery
(OR=1.24, CI=1.05-1.48). In contrast,
women who underwent laparoscopic
surgery had no statistically increased rates of
preterm labour (OR=1.26, CI=0.57- 2.73), or
caesarean delivery (OR=1.31, CI=0.91-1.88)
compared to women without appendicitis.
The risk of miscarriage was increased in all
women who had appendicitis in pregnancy
compared to pregnant women without
appendicitis with conservative treatment
11.5% (OR=31.37, CI=13.12-75.01), open
appendicectomy 5.7% (OR=14.34, CI=7.70-
26.71), laparoscopic appendicectomy 5.5%
(OR=13.88, CI=5.50-35.04). There was no
direct comparison between the antibiotic and
the surgical groups. All three outcomes were
similar when the two surgical approaches
were compared.
Tamir et al. (1990) reported that a 24-
hour delay in operating (laparotomy) in
suspected appendicitis in pregnant women
led to a 66% increase in perforation.
Retrospectively, laparotomy occurred
within 24 hours of symptom onset in 19/54
(35%) cases. Perforation was seen in 23/54
(42%) women, all of whom had symptoms
exceeding 24h (p<0.0005).
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Should the laparoscopic approach to appendicectomy
be preferred over laparotomy in pregnancy?
Whilst maternal outcomes are
good, controversy exists regarding
the association of laparoscopic
appendicectomy and miscarriage.
Further research is needed to distinguish
between association and causality. In view
of this, it is not possible to recommend
one approach over the other and only
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EVIDENCE-BASED GUIDELINE ON LAPAROSCOPY IN PREGNANCY – BALL Et al. 19
and laparoscopic) and showed no signicant
difference in the incidence of preterm
delivery (3.5% versus. 6.0%, p=0.33) or
fetal mortality (2.2% versus 1.2%, p=0.57)
(Caspi et al., 2000). There was no case of
maternal or fetal mortality in 20 reports
of laparoscopic cholecystectomy and 9
reports of ERCP. In 12 reports of gallstone
pancreatitis, fetal mortality was 6/75 versus
1/38 (p=0.28) in conservative and surgical
groups respectively.
of the over-representation of rst trimester
pregnancies in the laparoscopy group.
Hence the risk of spontaneous miscarriage
associated with appendicectomy during
pregnancy should be interpreted with caution.
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9.2 Gallbladder disease (Symptomatic gallstones
and acute cholecystitis)
Is there a role for expectant management of
cholecystitis in pregnancy?
A conservative approach to gallbladder
disease (symptomatic gallstones and acute
cholecystitis) in pregnancy is associated
with higher maternal morbidity than
surgery.
Clinicians should be vigilant about
complications of gallbladder disease such
as gallstone pancreatitis, since this may
be associated with a high risk of fetal
mortality.
In pregnant women with biliary colic,
supportive care will lead to resolution of
symptoms in most cases. Complicated
gallstone disease requires a more proactive
approach.
The search identified one systematic
review of moderate quality (Date et al.,
2008), and a retrospective case series
(Othman et al., 2012), that compared
conservative, endoscopic retrograde
cholangiopancreatography) and laparoscopic
management. 112 pregnant women (rst
29, second 43 and third trimester 40) were
analysed retrospectively according to their
approach to treatment. In the rst and third
trimester there were more conservative
than active (laparoscopic and ERCP)
treatments, but outcomes were not reported
by gestation. Conservative treatment was
associated with more recurrent biliary
symptoms (30/50 versus 4/31, p=0.0002)
mean visits to the emergency department
(1.7 versus 1.1, p=0.0006) and mean days
spent in hospital (1.5 versus 1.2, p=0.034)
and caesarean section delivery (15/43 versus
2/25, p=0.04), but the duration of hospital
stay (5 days versus 6.5 days, p=0.07) and the
mean fetal birth weight (2752 g versus 2999
g, p=0.1) were not signicantly different.
Date et al. (2008) systematically reviewed
six case series, comparing conservative with
surgical management of cholecystitis (open
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Should the laparoscopic approach to
cholecystectomy be preferred over laparotomy in
pregnancy?
Laparoscopic cholecystectomy appears
to be associated with better composite
maternal and fetal outcomes than open
approach, fewer surgical complications
and shorter hospital stay.
The search identified a systematic
review comparing laparoscopic and open
cholecystectomy in pregnancy (Sedaghat
et al., 2017). Sedaghat et al. (2017)
reviewed eleven studies including 10632
pregnant women with gallbladder disease
or symptomatic gallstones who underwent
open or laparoscopic cholecystectomy. All
studies were retrospective, comparative and
non-randomised. Seven studies reported the
patients’ trimester at the time of surgery
(161 cases). The rst and second trimester
predominated (first trimester 44/161,
second trimester 102/161, third trimester
15/161) but outcomes were not stratied
by trimester. One maternal death was
reported in connection with laparoscopic
cholecystectomy at 20 weeks for chronic
cholecystitis 2 weeks postoperatively due
to intra-abdominal haemorrhage from a
non- identified source. Composite fetal
complications (OR=0.42, CI=0.28-0.63,
p<0.001), composite maternal complications
(OR=0.42, CI=0.33-0.53, p<0.001),
and composite surgical complications
(OR=0.45, CI=0.25-0.82, p<0.01) were all
less frequent in the laparoscopy group. There
was no signicant difference in fetal mortality,
(OR=0.39, CI=0.07-2.19, p=0.29), or preterm
delivery before 27/40 (OR=1.35, CI=0.41-5.14,
p=0.59) between the open and laparoscopic
group. Operation time was not signicantly
different in four studies that reported it (86.2
min versus 85.9 min, p=0.98). Length of
hospital stay was reported in 5/11 studies and
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20 Facts Views Vis Obgyn
was required. Expectant management of
ovarian cysts in pregnancy appeared to
be safe with a low intervention rate of
4.2% (one evacuation of retained products
of conception (ERPC) and laparoscopic
cystectomy, three cystectomies at term
section, two laparotomies in second
trimester, aspiration in second trimester), 3%
underwent torsion but only 0.13% of women
required emergency surgery (laparotomy in
second trimester, cystectomy at term section
and second trimester cyst aspiration).
Zanetta et al. (2003) followed up 72 women
with ovarian cysts in pregnancy greater
than 3cm (after excluding those who were
scanned in acute pain and required emergent
surgery for torsions at presentation). Only
two women required intervention (one had a
cystectomy at caesarean section at 37 weeks
for torsion, and one trans-cutaneous cyst
aspiration for pain). All other pregnancies
carried on to term. Two women required
a caesarean section because cysts were
obstructing labour. A high proportion of
cyst resolution and decrease in size >50%
was observed (27/39 simple cysts, 7/9
endometrioma, no dermoids, 8/15 cysts with
borderline appearance).
Caspi et al. (2000) followed up 68
pregnancies with ultrasound-diagnosed
dermoid cysts smaller than 6 cm, all treated
conservatively. Cysts did not increase in size
and no cyst accidents were observed. There
were no fetal or maternal complications
attributable to the presence of dermoid cysts
in this group.
Katz et al. (2010) compared outcomes in
pregnant women with (n=93) and without
ovarian cysts (n=212017). Twenty-two
women were diagnosed before or during
pregnancy by ultrasound and 71 were
diagnosed at CS. Among women with
ovarian cysts three cases of ovarian torsion
and one of haemorrhage were diagnosed. In
the ovarian cyst group 15 women needed
hospitalisation due to abdominal pain, but
no data is provided for the control group.
Fetal outcomes (rate of preterm delivery,
low birth weight, APGAR<5 and perinatal
mortality) did not differ statistically.
Majeed et al. (2011) reported 16 women
diagnosed with persistent ovarian cysts
and followed them up conservatively with
was signicantly shorter in the laparoscopic
group (mean 3.2 versus 6.0 days p=0.02). EviDENCE
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9.3 Ovarian cysts and masses
Should surgery for ovarian cysts be preferred over
the conservative approach in pregnancy?
Women with asymptomatic simple cysts may
be managed conservatively in pregnancy
provided that symptoms are absent or
acceptable to the woman.
Women with large, non-torted
symptomatic cysts who wish to avoid
surgery may be offered aspiration under
ultrasound guidance during pregnancy,
with denitive cystectomy after delivery
if required.
The risk of torsion of ovarian cysts
requiring emergency surgery in
pregnancy is low and, in most cases,
surgery may be delayed until the woman
becomes symptomatic, with good fetal
outcomes.
A systematic search identied a retrospective
series that observed the rate of torsion and
malignancy by adnexal mass size in 470
women who underwent surgery for adnexal
masses during all trimesters of pregnancy
between 2002-2009 (Koo et al., 2011b).
Fifty-ve women (11.7%) had torsion and
28 women (31.8%) had emergency surgery
for this indication. Torsion was more likely
to occur when cysts were between 6-10cm
than if they were smaller or larger than that
(OR=2.68, CI=1.35-5.40, p<0.006). More
than half of the torsions occurred in the rst
trimester and corpus luteum was the most
common cyst type. Risk of torsion was not
directly proportional to the cyst size.
A systematic search identified four
retrospective and two prospective case series
that evaluated conservative management
of ovarian cysts in pregnancy (Condous
et al., 2003). No evidence was found that
recommended conservative treatment when
an acute cyst accident was suspected.
Condous et al. (2004) followed up one
hundred and sixty-one women with 166
ovarian cysts diagnosed by rst trimester
ultrasound (43% asymptomatic, 56.3%
had pain or vaginal bleeding) throughout
pregnancy with serial scans every 4-6 weeks
until either the cyst resolved or intervention
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EVIDENCE-BASED GUIDELINE ON LAPAROSCOPY IN PREGNANCY – BALL Et al. 21
with open approach for persistent or torted
ovarian cysts were identied (Koo et al.,
2012). These studies conrmed that maternal
outcomes were better and fetal outcomes
were similar in the laparoscopic compared
to the laparotomy group. However, the case
number of rst and third trimester pregnancies
and large cysts (>6 cm) were small. The fact
that most reports were retrospective and from
specialist centres could lead to the risk of
reporting bias, with better outcomes for the
reported techniques than could be expected
in non-specialist settings.
Cyst aspiration with or without
concurrent cystectomy may be a safe
alternative.
Chung et al. (2001) reported a technique
of extra-corporeal cystectomy or
oophorectomy after aspiration of the cyst, in
four obese second trimester women. Dohi et
al. (2012) reports two cases of ultrasound-
guided culdotomy for cysts incarcerated in
the pouch of Douglas after needle aspiration
via scan probe. There were no operative
complications and both women had vaginal
deliveries. Duic et al. (2002) describes a
technique of trans-vaginal ultrasound guided
cyst aspiration in 1st and of percutaneous
ultrasound guided cyst aspiration in second
trimester with good outcomes. Hutt et al.
(2000) also reports aspiration of two cases
of large ovarian cysts, one twice after
re-accumulation with normal pregnancy
outcome.
Kitade et al. (2008) reports a 2 puncture
extra-corporeal method of cyst aspiration
including a specialised retractor and balloon
to bring the cyst to a 3 cm suprapubic
incision in a case series of n=18.
ultrasound scan (frequency not stated) until
they became symptomatic. Four women had
emergency laparotomy due to ovarian cyst
torsion and rupture, two women had elective
laparotomy in second trimester due to large
cyst size (>20 cm) and ten women had a
laparotomy in the post- partum period. Fetal
outcomes included one miscarriage and all
remaining women had a term delivery.
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Should the laparoscopic approach to ovarian cysts
be preferred over the open approach in pregnancy?
When surgery is indicated, laparoscopic
cystectomy is associated with better
maternal outcomes than laparotomy in
the second trimester, with similarly good
fetal outcomes.
Good maternal and fetal outcomes have
also been reported for laparoscopic
surgery for the rst and third trimester,
however the number of reported cases is
small. More research is needed to prove
the superiority of one approach over the
other outside the second trimester. In the
interim, choice of approach should be
decided based on local circumstances and
expertise.
A Cochrane database review from 2013 did
not identify any RCTs (Bunyavejchevin et
al., 2013). A newer systematic review (Liu et
al., 2017) of one RCT (Chen et al., 2014), and
three non-randomised comparative studies
investigated laparoscopic and open surgery
for suspected adnexal masses in the second
trimester in 240 women. Laparoscopic
surgery was associated with a reduced risk
of post-operative complications (RR=0.20,
CI=0.06–0.72); there was no difference
in the risk of post-operative miscarriage
(p=0.26). Laparoscopy was associated
with lower estimated intra-operative blood
loss, lower post-operative pain scores,
and a shorter hospitalisation, readmission
and immobilisation. Laparoscopy was
associated with a longer operation duration
compared with laparotomy (mean difference
13.7 min, CI=12.58–14.82, p<0.001). In
one of the reviewed studies signicantly
fewer adhesions at the time of caesarean
section were observed in women who had
undergone laparoscopy.
In addition, three further retrospective studies
(Carter et al., 2004, Koo et al., 2012 and
Martynov et al. 2014) comparing laparoscopic
B
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10. Safety of imaging in pregnancy
Guidance on ionising radiation in pregnancy can be
found in Health Protections Agency & Royal College
of Radiologists & College of Radiographers’
guidance (RCR, 2009). Recommendations on
contrast media in pregnancy can be found in
the European Society of Urogenital Radiology
guidelines (Webb et al., 2005). For the conditions
included in this guideline Magnet Resonance
Imaging (MRI) with gadolinium is usually not
required, since there are alternative modalities,
such as MRI without gadolinium and ultrasound.
Indications for MRI with gadolinium include the

22 Facts Views Vis Obgyn
laparoscopic surgery in pregnancy. Anesthesiology.
2000;93(2):370-3.
Borgfeldt C, Andolf E. Transvaginal sonographic ovarian
ndings in a random sample of women 25-40 years old.
Ultrasound Obstet Gynecol. 1999;13(5):345-50.
Bunyavejchevin S, Phupong V. Laparoscopic surgery for
presumed benign ovarian tumor during pregnancy.
The Cochrane database of systematic reviews.
2013;(1):Cd005459.
Candiani M, Maddalena S, Barbieri M et al. Adnexal masses
in pregnancy: fetomaternal blood flow indices during
laparoscopic surgery. J Minimally Invasive Gynecol.
2012;19(4):443-7.
Carter JF, Soper DE. Operative laparoscopy in pregnancy.
JSLS. 2004;8(1):57–60.
Caspi B, Levi R, Appelman Z et al. Conservative management
of ovarian cystic teratoma during pregnancy and labor. Am
J Obstet Gynecol. 2000;182(3):503-5.
Chen L, Ding J, Hua K. Comparative analysis of laparoscopy
versus laparotomy in the management of ovarian cyst during
pregnancy. J Obstet Gynaecol Res. 2014;40(3):763-9.
Cheng HT, Wang YC, Lo HC et al. Laparoscopic appendectomy
versus open appendectomy in pregnancy: a population-
based analysis of maternal outcome. Surg Endosc.
2015;29(6):1394-9.
Chestnut DH WC, Tsen LC, Ngan Kee WD et al. Obstetric
anesthesia: principles and practice. 4th ed. ed. London:
Elsevier Mosby; 2009.
Chung JC, Cho GS, Shin EJ et al. Clinical outcomes compared
between laparoscopic and open appendectomy in pregnant
women. Can J Surg. 2013;56(5):341-6.
Chung MK, Chung RP. Laparoscopic extracorporeal
oophorectomy and ovarian cystectomy in second trimester
pregnant obese patients. JSLS. 2001;5(3):273-7.
Cluver C, Novikova N, Hofmeyr GJ et al. Maternal position
during caesarean section for preventing maternal and
neonatal complications. Cochrane Database Syst Rev. 2013;
28;(3):CD007623.
Committee Opinion No. 696. American College of
Obstetricians and Gynecologists. Nonobstetric surgery
during pregnancy. Obstet Gynecol. 2017;129(777-8).
Condous G, Okaro E, Bourne T. The Conservative
Management of Early Pregnancy Complications: a
Review of the Literature. Ultrasound Obstet Gynecol.
2003 Oct;22(4):420-30.
Cox TC, Huntington CR, Blair LJ et al. Laparoscopic
appendectomy and cholecystectomy versus open: a study
in 1999 pregnant patients. Surg Endosc. 2016;30(2):593-
602.
Date RS, Kaushal M, Ramesh A. A review of the management
of gallstone disease and its complications in pregnancy.
Am J Surg. 2008;196(4):599-608.
Dohi S, Yamazaki R, Sagawa T et al. New ultrasound-
guided culdotomy of vaginal ovarian cystectomy for
pregnant women incarcerated ovarian dermoid cysts
in recto -uter ine po uc h: cas e repo rts. E ndoscop y.
2012;44(10):44 - A26.
Duic Z, Kukura V, Ciglar S et al. Adnexal masses in
pregnancy: a review of eight cases undergoing surgical
management. European journal of gynaecological
oncology. 2002;23(2):133-4.
Erekson EA, Brousseau EC, Dick-Biascoechea MA et al.
Maternal postoperative complications after nonobstetric
antenata l su rge ry. J Matern Feta l Ne onatal Med.
2012;25(12):2639-44.
Friedman JD, Ramsey PS, Ramin KD et al. Pneumoamnion
and pregnancy loss after second-trimester laparoscopic
surgery. Obstet Gynecol. 2002;99(3):512-3.
Hasson J, Tsafrir Z, Azem F et al. Comparison of adnexal
torsion between pregnant and nonpregnant women. Am J
Obstet Gynecol. 2010;202(6):536 e1-6.
Holzer T, Pellegrinelli G, Morel P et al. Appendectomy
during the third trimester of pregnancy in a 27-year old
characterization of liver and brain lesions when
suspecting a new malignancy, if treatment would
make a difference.
The smallest possible dose of one of the most
stable gadolinium contrast agents may be given
to the pregnant mother if there is a very strong
indication for enhanced MRI. No mutagenic and
teratogenic effects have been described after
maternal administration of gadolinium based on the
limited data available (Webb et al., 2005). Webb et
al. (2005) states that no additional neonatal tests are
required.
11. Conclusions
There is mounting evidence that appendicitis,
gallbladder disease and symptomatic adnexal
cysts can be safely managed laparoscocpically in
pregnancy. Most evidence is from specialist centers.
Only adequately trained laparoscopists should carry
out these procedures and adequate peri- operative
preparations are paramount.
Especially outside the second trimester most
included papers are from small case series and more
high-grade evidence is needed. Because it is difcult
to perform RCTs for these conditions, creation and
analysis of national large databases appears to be a
way forward.
Declarations: Disclaimer from BSGE (See appendix 1)
Funding: this was an unfunded project .
Acknowledgements: Librarian Genny Franklin supported
the systematic searches. Librarians Genny Franklin and
Lisa Xue obtained the original articles.
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APPENDIX 1
Clinical guidelines are systematically developed
statements which assist clinicians and women in
making decisions about appropriate treatment for
specific conditions’. These recommendations
are not intended to dictate an exclusive course of
management or treatment. They must be evaluated
with reference to individual woman’s needs,
resources and limitations unique to the institution
and variations in local populations. It is hoped
that this process of local ownership will help to
incorporate these guidelines into routine practice.
Attention is drawn to areas of clinical uncertainty
where further research may be indicated.
The evidence used in this guideline was graded
using the scheme below and the recommendations
formulated in a similar fashion with a standardised
grading scheme.

EVIDENCE-BASED GUIDELINE ON LAPAROSCOPY IN PREGNANCY – BALL Et al. 25
Classication of evidence levels
1++ High-quality meta-analyses, systematic reviews of
randomised controlled trials or randomised controlled trials
with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of
randomised controlled trials or randomised controlled trials
with a low risk of bias
1– Meta-analyses, systematic reviews of randomised
controlled trials or randomised controlled trials with a high
risk of bias
2++ High-quality systematic reviews of case– control or
cohort studies or high-quality case–control or cohort studies
with a very low risk of confounding, bias or chance and a
high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with
a low risk of confounding, bias or chance and a moderate
probability that the relationship is causal
2- Case–control or cohort studies with a high risk of
confounding, bias or chance and a signicant risk that the
relationship is not causal
3 Non-analytical studies, e.g. case reports, case series
4 Expert opinion
At least one meta-analysis, systematic review or
randomised controlled trial rated as 1++ and di-
rectly applicable to the target population; or
A systematic review of randomised controlled tri-
als or a body of evidence consisting principally of
studies rated as 1+ directly applicable to the target
population and demonstrating overall consistency
of results
A body of evidence including studies rated as 2++
directly applicable to the target population, and
demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or
1+
A body of evidence including studies rated as 2+
directly applicable to the target population and dem-
onstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Recommended best practice based on the clinical
experience of the guideline development group
Grades of recommendations
A
B
C
D
Good practice point