LAPAROSCOPY DURING PREGNANCY AND IN CHILDREN

The most common nonobstetric surgical procedures during pregnancy are adnexal surgery, appendectomy, and cholecystectomy, and they are amenable to laparoscopic surgery^[260] (see Chapter 58 and Chapter 60 ). Laparoscopy during pregnancy raises several concerns. Abdominal surgery increases the risk of miscarriage or premature labor. However, all the reports in the literature of laparoscopy carried out between 4 and 32 weeks of estimated gestational age have resulted in uncomplicated pregnancies.^{[261] [262] [263]} Another concern is the risk of damaging the gravid uterus. This can be avoided by alternative entry sites for the Verres needle and trocars. The effects of increased IAP and hypercarbia on the human fetus were also investigated. CO₂ pneumoperitoneum induced significant fetal acidosis. Fetal heart rate and arterial pressure increased, but these changes were minimal. ^[264] All these alterations resulted from hypercarbia, not from increased IAP, because N₂ O pneumoperitoneum did not affect blood-gas values, heart rate, or blood pressure. After desufflation, all variables quickly returned to normal.^[264] Provided maternal PaCO₂ is maintained at normal levels, fetal placental perfusion pressure and blood flow, pH, and blood gas tensions were unaffected by insufflation or desufflation.^[265] Capnography is adequate to guide ventilation during laparoscopy in pregnant patient. ^[266] Hemodynamic changes induced by pneumoperitoneum are similar in pregnant and nonpregnant women.^[267] The following recommendations^[261] are for safe laparoscopy in pregnant patients:

1. The operation should occur during the second trimester, ideally before the 23rd week of pregnancy, to minimize the risk of preterm labor and to maintain adequate intra-abdominal working room.
2. Tocolytics are beneficial to arrest preterm labor, but their prophylactic use is debatable.
3. Open laparoscopy should be used for abdominal access to avoid damaging the uterus.
4. Fetal monitoring may be performed using transvaginal ultrasonography.
5. Mechanical ventilation must be adjusted to maintain a physiologic maternal alkalosis.

Gasless laparoscopy is an alternative to avoid the potential side effects of CO₂ pneumoperitoneum and can sometimes be managed using epidural anesthesia.^{[268] [269]}

Laparoscopy is frequently performed in infants and children, and data concerning the ventilatory and hemodynamic tolerance of pneumoperitoneum by children are available. CO₂ pneumoperitoneum induces similar changes in respiratory mechanics to those reported in adults.^{[270] [271]} PaCO₂ and PETCO₂ increase during pneumoperitoneum, but PETCO₂ may sometimes overestimate PaCO₂ .^[272] CO₂ absorption may be more intense and faster in infants than in adults because the peritoneal surface area referred to body weight is greater in infants. ^[273] During brief laparoscopy (<15 minutes), peak airway pressure and PETCO₂ rise only slightly; no increase in ventilation is required.^[274] The hemodynamic changes observed in children are similar to those reported in adults. ^{[275] [276]} Good cardiorespiratory tolerance of laparoscopy has been reported in children.^{[275] [276] [277]} Controversy concerning the benefits (i.e., improved analgesia and postoperative recovery) of laparoscopy for appendectomy, the most frequent indication for laparoscopy in children, persists.^{[278] [279] [280]}