Presentation on theme: "SAGES Guidelines for Laparoscopic Surgery During Pregnancy Steven J. Heneghan MD FACS Director Mithoefer Center for Rural Surgery Surgeon in Chief Bassett."— Presentation transcript:
SAGES Guidelines for Laparoscopic Surgery During Pregnancy Steven J. Heneghan MD FACS Director Mithoefer Center for Rural Surgery Surgeon in Chief Bassett Healthcare
The SAGES Guidelines for the Diagnosis, Treatment, and Use of Laparoscopy for Surgical Problems During Pregnancy Heidi Jackson MDSteven Granger MD Raymond R. Price MD Vice-Chairman Dept of Surgery Intermountain Medical Center Intermountain Healthcare Adjunct Assistant Clinical Professor of Surgery University of Utah Michael Rollins MD Robert Fanelli MDWilliam Richardson MDDavid Earle MD
Guidelines There is a considerable amount of effort toward standardizing guidelines –Rating the evidence –Rating the recommendations Avoiding using guidelines to reduce professional competition and a move to having them a resource for both patients and clinicians There is an effort to have agreement between organizations with regard to guidelines.
Guidelines for Diagnosis, Treatment, and use of Laparoscopy for Surgical Problems During Pregnancy* Guidelines for Diagnosis, Treatment, and use of Laparoscopy for Surgical Problems During Pregnancy* Guidelines for Laparoscopic Surgery During Pregnancy* Guidelines for Laparoscopic Surgery During Pregnancy* 1996 2007 SAGES * 8 guidelines * 23 guidelines 22 References 175 References
Levels of Evidence Level 1Evidence from properly conducted randomized, controlled trials Level IIEvidence from controlled trials without randomization Cohort or case-control studies Multiple time series, dramatic uncontrolled experiments Level IIIDescriptive case series, opinions of expert panels
Scale for Evidence Grading Grade A High-level (level I or II), well-performed studies with uniform interpretation and conclusions by the expert panel Grade B High-level, well-performed studies with varying interpretation and conclusion by the expert panel Grade C Lower level evidence (level II or less) with inconsistent findings and/or varying interpretations or conclusions by the expert panel
Guidelines Imaging 1Ultrasonographic imaging during pregnancy is safe and useful in identifying the etiology of acute abdominal pain in the pregnant patient Level II Grade A 2Expeditious and accurate diagnosis should take precedence over concerns for ionizing radiation. Radiation dosage should be limited to 5 to 10 rads Level III Grade B 3CT delivers 2-4 rads which falls below the limit and may be considered an appropriate test Level III Grade B
Guidelines Imaging 4MR Imaging can be performed without IV Gadolinium Level III Grade B 5Nuclear medicine administration of radio nucleotides can generally be done at safe levels Level III Grade C 6Intraoperative Cholangiography exposes the mother and fetus to minimal radiation and may be uses selectively during surgery. Level III Grade B
Changes in Recommendations 19962007 Second trimester deferment 2 nd Monitoring Fetus Trimester Pneumoperitoneum Intra-operative Monitoring Abdominal Access 1 st, 2 nd, 3rd 8-12 mm Hg10-15 mm Hg Open (Hasson) Open (Hasson) or Closed (Verres) ETCO2 30-40 Serial maternal ABG/ ETCO2 Intra-operative Pre- and post- operative
24 yo female 12 weeks pregnant –RUQ abdominal pain every 3-4 days –Occurs after fatty meals –US: multiple stones, no wall thickening –Normal LFT’s, amylase, lipase Clinical Scenario “I was told by another surgeon that because I was pregnant, I could not have laparoscopic surgery.”
Questions? Should I offer her a cholecystectomy? –Timing of surgery? –Open or laparoscopic? –Monitoring of fetus intraoperatively? If laparoscopic: –What entry technique should be used? –Port placement? –Appropriate level of pneumoperitoneum? –Patient positioning? –Need for OB consultation? –ERCP or intraoperative cholangiogram?
Tocolytics Guideline 23: Tocolytics should not be used prophylactically, but should be considered peri- operatively when signs of preterm labor are present in coordination with obstetric consultation (Level I, Grade A). $94.8 million awarded to mother of 8 year-old boy. Failure to use tocolytics.
Fetal Heart Monitoring Guideline 21: Fetal heart monitoring should occur pre and postoperatively in the setting of urgent abdominal surgery during pregnancy (Level III, Grade B). No intra-operative fetal heart rate abnormalities reported.
Laparoscopy and Trimester of Pregnancy Guideline 9: Laparoscopy can be safely performed during any trimester of pregnancy (Level II, Grade B). Abortion Rate? Preterm Delivery Rate? Long term effects on the children?
Gallbladder Disease Guideline 15: Laparoscopic cholecystectomy is the treatment of choice in the pregnant patient with gallbladder disease regardless of trimester (Level II, Grade B). Symptom recurrence 1 st - 92%2 nd – 64%3 rd – 44% Non-operative Management Hospitalizations Spontaneous Abortions Pre-term Labor
Initial Port Placement Guideline 11: Initial access can be safely accomplished with an open or Hassan, Verres needle or optical trocar if the location is adjusted according to fundal height, previous incisions and experience of the surgeon (Level III, Grade B).
8 12 16 20 26 32 36 40 Fundal Height by Gestational Age in Weeks Rollins MD, Price RR. Laparoscopic surgery during pregnancy. In: Inderbir SG ed. Textbook of laparoscopic urology. New York: Informa Healthcare USA, Inc., 2006:983-986.
2 1 3 1 2 3 2 1 3 1st Trimester3 rd Trimester2 nd Trimester Rollins MD, Price RR. Laparoscopic surgery during pregnancy. In: Inderbir SG ed. Textbook of laparoscopic urology. New York: Informa Healthcare USA, Inc., 2006:983-986. Trocar Placement for Laparoscopic Appendectomy Changes by size of gravid uterus.
Insufflation Pressure Guideline 12: CO2 insufflation of 10-15 mmHg can be safely used for laparoscopy in the pregnant patient. Intra-abdominal pressure should be sufficient to allow for adequate visualization (Level III, Grade C). Maternal Fetal Pulmonary Acidosis Visualization
Maternal Pulmonary Growing fetus Pressure on diaphragm Residual Volume Functional Residual Capacity Pressures of 15 mmHg – no increased adverse outcomes to the patient or fetus PaO 2
Fetal Acidosis No evidence to support long term detrimental effects resulting from CO 2 pneumoperitoneum in humans Tachycardia Hypertension Hypercapnia Animal Studies CO 2 Pneumoperitoneum Devon’s Racing Rams (photo Rick Turner)
Intra-operative CO2 monitoring Guideline 13: Intra-operative CO2 monitoring by capnography should be used during laparoscopy in the pregnant patient (Level III, Grade C). Maternal arterial blood gas (PaCO 2 ) vs. End-tidal CO 2 (EtCO 2 ) Capnography adequately reflects maternal acid/base status in humans.
ER physician calls you to see a 27 year old 8 week pregnant patient with 8 hours of R lower quadrant pain. She has been nauseated for 8 wks. –Abdomen only mildly tender RLQ to deep palpation –WBC 16 Clinical Scenario Possible options: US abdomen CT scan Exploratory laparoscopy
Ultrasound Guideline 1: Ultrasonographic imaging during pregnancy is safe and useful in identifying the etiology of acute abdominal pain in the pregnant patient (Level II, Grade A). 1. Radiographic test of choice for most gynecologic causes of abdominal pain 2. Useful 1 st line diagnostic study for many non-gyn causes
Risk of Ionizing Radiation Guideline 2: Expeditious and accurate diagnosis should take precedence over concerns for ionizing radiation. Radiation dosage should be limited to 5-10 rads in the first 25 weeks of pregnancy (Level III, Grade B). * Fetal age at exposure 1 st week of conception - mortality 10-17 weeks gestation – CNS teratogenesis Later pregnancy – hematologic cancer * Radiation dosage < 5 rads minimal fetal risk
Fetal Radiation Exposure from Diagnostic Imaging Studies Chest radiograph<0.001 Abdominal series0.245 Pelvic radiograph0.04 Upper gastrointestinal series0.05-0.1 Barium enema0.3-4 HIDA scan0.15 Chest CT scan0.01-0.2 Abdominal CT scan0.8-3 Pelvic CT scan2.2 StudyRads Rollins MD, Price RR. Laparoscopic surgery during pregnancy. In: Inderbir SG ed. Textbook of laparoscopic urology. New York: Informa Healthcare USA, Inc., 2006:983-986.
Computed Tomography Guideline 3: Contemporary multi-detector CT protocols deliver a radiation dose to the fetus below detrimental levels and may be considered as an appropriate test during pregnancy depending on the clinical situation (Level III, Grade B). Practitioners should be aware of the radiation doses delivered by the CT scanners in their facilities. CT abdomen and pelvis 2-4 rads Early identification Rate of perforation
Laparoscopic Appendectomy Guideline 17: Laparoscopic appendectomy may be performed safely in any patients with suspicion of appendicitis (Level II, Grade B).
Conclusions Guidelines are a moving process and when published they are a point in time rather than a completed process Guidelines are much more difficult than most people realize Guidelines should give the references for the conclusions the rating of the references and grading of the recommendations www.sages.com