UPDATED TOPICS IN MINIMALLY INVASIVE ABDOMINAL SURGERY

Laparoscopic Cholecystectomy in High Risk Patients 33
Leone et al [16] presented their cases between January 1994 and December 2000 where there
were 1,100 laparoscopic cholecystectomies for symptomatic gallbladder diseases. They
reported that there were 24 cirrhotic patients who had well-compensated cirrhosis (Child’s
class A or B). The authors reported that there were no operative mortality and the
postoperative complication rates were 20.8%. They estimated that the intraoperative blood
loss was 37.08 ml in average. Their average hospital stay 3.61 days. The authors concluded
that laparoscopic cholecystectomy in patients with compensated cirrhosis is safe and should
be the treatment of choice for these patients. They further stated that laparotomy should be
applied only if the surgeon considers the operation inadequate to be continued
laparoscopically.
7. Patients who are pregnant
Diseases in the abdomen requiring surgical intervention during pregnancy present unique
challenges to their diagnosis and management [17]. These are said to be due to the changes in
physiology and abdominal anatomy characteristic of pregnancy. These changes make
laparoscopic surgery technically more difficult, the obstetrician must determine the status of
pregnancy such as gestational age, viability and inform the patient about the risks related to
pregnancy and surgery itself [18].
There are several mechanisms that have been proposed by specialists for increased fetal
morbidity and mortality associated with laparoscopic surgery during pregnancy including
direct uterine trauma, fetal trauma, intraamniotic CO2 insufflation, trauma to maternal
abdominal organs and vessels, decreased uterine blood flow and oxygen delivery,
teratogenic effects of anesthetic drugs, fetal acidosis due to CO2 pneumoperitoneum,
adverse effects of anesthesia on maternal hemodynamic and acid-base balance, increased
risk of thromboembolic disease, the effect of underlying abdominal pathology, manipulation
during surgery and effects of postoperative medications [18,20] Therefore laparoscopic
cholecystectomy has been used cautiously in pregnant women. This is due to the possible
mechanical problems related to the pregnant uterus and the other is fear of fetal injury
resulting from instrumentation or the pneumoperitoneum.
7.1 Cases
To assess the effects of laparoscopic cholecystectomy on both the mother and the unborn
fetus, Abuabara et al [19] reviewed their surgical experience over a 5-year period where 22
patients ranging from 17 to 31 years underwent laparoscopic cholecystectomy during
pregnancy. They noted that the gestational ages ranged from 5 to 31 weeks where there are
two patients who are in their first trimester, 16 in the second and four in the third. Their
indications for surgery were persistent nausea, vomiting, pain, and inability to eat in 17
patients, acute cholecystitis in three and choledocholithiasis in two. The surgeons
established pneumoperitoneum in all patients and their results were all 22 patients survived
the surgical procedure without complications and there were no fetal deaths or premature
births related to the procedure. The authors concluded that laparoscopic cholecystectomy
during pregnancy is safe for both the mother and the unborn fetus and if at all possible,
when laparoscopic cholecystectomy is indicated, it should be performed either in the second
trimester or early in the third.
Wishner et al [21], members of the Norfolk Surgical Group, gathered their data for the
laparoscopic cholecystectomy cases from May 1991 to June 1994 where they performed the