Minimally invasive surgery in pregnancy is here

MANILA, Philippines - Five years ago, on her first pregnancy, I diagnosed Mrs. J., with a 7x7 cm ovarian cyst. On her fourth month, an exploratory laparotomy was contemplated for the removal of the ovarian cyst. Her abdomen was cut open, way bigger than the usual, to be able to expose the pregnant uterus and at the same time, manipulate the ovarian mass located behind the uterus. The scar stretched as the pregnancy grew to term. The pregnancy progressed without any problem and she had a spontaneous vaginal delivery to a healthy baby boy. The surgery, however, left the mother with a midline scar running up to her umbilicus, and going around it.

Mrs. J. refers an acquaintance, also pregnant for the first time at 16 weeks, with a 7x7 cm. ovarian cyst. By this time, the technology of minimally invasive therapy through laparoscopy had come of age. I convinced the patient that laparoscopic removal was the best to do in this case. Three 1-cm. incisions were made on the abdomen above the level of the umbilicus, the mass was visualized, excised, and later evacuated by slightly enlarging the right hole where the instruments were being inserted. It was almost like removing a tennis ball through a keyhole.  (See photos.) This was the first time a laparoscopic surgery in a pregnant woman was ever performed at Asian Hospital. On the team to assist for any surgical complications which may occur were Dr. Miguel Mendoza, section chief of laparoscopic surgery and Dr. Orlando Diomampo, chairman of surgery. The patient was discharged the following day in good condition, extremely grateful for her small incisions and remarkable post-op recovery.

What is minimally invasive surgery or laparoscopy?

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

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

 Here are the advantages of laparoscopy:

1) Dramatically smaller scar, therefore, less post-operative pain and less need for pain medications.

2) Less hemorrhage, thus reducing the chances of blood transfusion.

3) Less chances for wound infection due to reduced exposure of internal organs to possible external contaminants and due to a smaller skin area traumatized and exposed to skin bacteria.

4) Less chances of incisional hernias.

5) Increased chances of early mobilization because of minimal pain. The patient can usually go home the following day or even on the same day.

6) Since there is less or no manipulation of the uterus, which contains the developing baby, this leads to less uterine irritability and thus less chances of abortion or premature labor.

7) Due to decreased need for narcotic pain medications post-operatively, there is less chance of depressing the heart rate and placental perfusion and metabolism of the fetus.

8) The patient can go back to work sooner.

9) No growth or developmental delay was found in 11 children followed up till eight years after lap surgery on the mother.

Advanced technology has made minimally invasive surgery a preferred mode of intervention particularly for removal of benign ovarian cysts. In pregnancy, it becomes even a superior procedure compared to open surgery because of the reduced discomfort for the mother post-operatively, the minimal to absence of manipulation of the uterus plus the tinier scars that are left with the patient as a reminder of her surgery during pregnancy.

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(Rebecca B. Singson is a fellow of the American College of Surgeons and of the Philippine Obstetric Society. She is the chairwoman of the Ob-Gyn Department of St. Luke’s Medical Center, Bonifacio Global City and also practices at the Makati Medical Center and the Asian Hospital and Medical Center.)