Transcript SAGES Guidelines for Laparoscopic Surgery During Pregnancy

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
Raymond R. Price MD
Vice-Chairman Dept of Surgery
Intermountain Medical Center
Intermountain Healthcare
Adjunct Assistant Clinical Professor of Surgery
University of Utah
Heidi Jackson MD
Robert Fanelli MD
Steven Granger MD
William Richardson MD
Michael Rollins MD
David 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.
SAGES
1996
Guidelines for Laparoscopic Surgery
During Pregnancy*
22 References
* 8 guidelines
2007
Guidelines for Diagnosis, Treatment,
and use of Laparoscopy for Surgical
Problems During Pregnancy*
175 References
* 23 guidelines
Levels of Evidence
Level 1
Evidence from properly conducted
randomized, controlled trials
Level II
Evidence from controlled trials
without randomization
Cohort or case-control studies
Multiple time series, dramatic
uncontrolled experiments
Level III
Descriptive 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
• 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
• 2 Expeditious 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
• 3 CT delivers 2-4 rads which falls below the
limit and may be considered an appropriate test
Level III Grade B
Guidelines Imaging
• 4 MR Imaging can be performed without IV
Gadolinium Level III Grade B
• 5 Nuclear medicine administration of radio
nucleotides can generally be done at safe levels
Level III Grade C
• 6 Intraoperative Cholangiography exposes the
mother and fetus to minimal radiation and may be
uses selectively during surgery.
Level III Grade B
Changes in Recommendations
1996
Monitoring Fetus
Trimester
Intra-operative
Second trimester
2nddeferment
2007
Pre- and postoperative
1st, 2nd, 3rd
Pneumoperitoneum
8-12 mm Hg
10-15 mm Hg
Intra-operative
Monitoring
Serial maternal
ABG/ ETCO2
ETCO2 30-40
Abdominal Access
Open (Hasson)
Open (Hasson) or
Closed (Verres)
Clinical Scenario
• 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
“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 perioperatively 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).
Non-operative Management
Symptom recurrence
1st - 92%
2nd – 64%
3rd – 44%
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).
Fundal Height
by Gestational
Age in Weeks
36
40 32
26
20
16
12
8
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.
1
2
1
2
2
1
3
3
3
1st Trimester
2nd Trimester
3rd 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.
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
Pulmonary
Visualization
Fetal
Acidosis
Maternal
Pulmonary
Residual
Volume
Growing
fetus
Pressure on
diaphragm
Functional
Residual
Capacity
PaO2
Pressures of 15 mmHg – no increased adverse
outcomes to the patient or fetus
Fetal
Animal Studies
CO2 Pneumoperitoneum
Acidosis
Tachycardia
Hypertension
Hypercapnia
Devon’s Racing Rams (photo Rick Turner)
No evidence to support long term detrimental effects
resulting from CO2 pneumoperitoneum in humans
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
(PaCO2)
vs.
End-tidal CO2
(EtCO2)
Capnography adequately reflects
maternal acid/base status in humans.
Clinical Scenario
• 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
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 1st 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).
* Radiation dosage
< 5 rads minimal fetal risk
* Fetal age at exposure
1st week of conception - mortality
10-17 weeks gestation – CNS teratogenesis
Later pregnancy – hematologic cancer
Fetal Radiation Exposure from Diagnostic
Imaging Studies
Study
Chest radiograph
Abdominal series
Pelvic radiograph
Upper gastrointestinal series
Barium enema
HIDA scan
Chest CT scan
Abdominal CT scan
Pelvic CT scan
Rads
<0.001
0.245
0.04
0.05-0.1
0.3-4
0.15
0.01-0.2
0.8-3
2.2
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).
Early identification
Rate of perforation
CT abdomen and pelvis
2-4 rads
Practitioners should be aware of the
radiation doses delivered by the CT
scanners in their facilities.
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