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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 5  |  Issue : 1  |  Page : 40-42

Surgical considerations of combined laparoscopic cholecystectomy and cesarean delivery


1 Department of Surgery, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Anesthesia, Dr. Sulaiman Al Habib Hospital, Riyadh, Saudi Arabia
3 Department of General Surgery, College of Medicine, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia

Date of Submission28-Jun-2020
Date of Acceptance03-Jul-2020
Date of Web Publication3-Oct-2020

Correspondence Address:
Dr. Khayal Al-Khayal
Department of Surgery, Faculty of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_6_20

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  Abstract 


A 32-year-old female, with history of two previous cesarean sections. She was scheduled for an elective cesarean section. The night before surgery, she hada spike of fever and abdominal pain in the epigastrium and felt nauseated. She was brought to the emergency room, and her ultrasound examination revealed edema n the peri- gallbladder area and cholecystitis. A general surgical consult was made, and the opinion was that she needs to be operated urgently. Laparoscopic cholecystectomy was done with initial port placement at Palmer's point with a 5-cm Covidien optical port. Procedure completed with no complication. The obstetric team then made a Pfannenstiel incision to deliver the baby. The delivery was completed in 10 min after the closure of the laparoscopic ports. The patient was in hospital for the next 3 days, and her puerperium was unremarkable. There were no further complications during her stay. The baby was discharged from NICU on the1stpostoperativeday.

Keywords: Acute calculous cholecystitis, cesarean section, laparoscopic cholecystectomy, laparoscopic surgery


How to cite this article:
Al-Khayal K, Ahmed Baig AM, Boustazastal C, Alaam S, Al Mukhlifi TS. Surgical considerations of combined laparoscopic cholecystectomy and cesarean delivery. Saudi J Laparosc 2020;5:40-2

How to cite this URL:
Al-Khayal K, Ahmed Baig AM, Boustazastal C, Alaam S, Al Mukhlifi TS. Surgical considerations of combined laparoscopic cholecystectomy and cesarean delivery. Saudi J Laparosc [serial online] 2020 [cited 2020 Oct 29];5:40-2. Available from: https://www.saudijl.org/text.asp?2020/5/1/40/296787




  Introduction Top


Pregnant women are at high risk of symptomatic gallstones due to hormonal changes during pregnancy.[1] Cholecystectomy is the most common surgical procedure performed during pregnancy.[2],[3] The incidental finding of gallstones has increased considerably due to many patients undergoing ultrasound imaging of the abdomen for a variety of conditions.[4] For patients who develop symptomatic gallstones during pregnancy, cholecystectomy is generally delayed until delivery for safety reasons.[1],[4],[5] Most patients are effectively managed with conservative, nonoperative therapy. However, in some patients, surgery is required for refractory symptoms or complications.[6] One appropriate approach could be to perform a combined cesarean section and cholecystectomy in one sitting.[7],[8],[9],[10] We report this interesting case report of combined laparoscopic cholecystectomy and cesarean delivery in one session.


  Case Report Top


We are presenting a 32 -year-old female, gravida 3 para 3 and with two live children delivered previously by cesarean section. Her weight was 86 kg bw and the height was 164 cm. She had no medical comorbidities. Her antenatal history revealed ultrasound gallstones. Her previous anesthetic experience under spinal anesthesia was uneventful. The airway assessment was normal. She was scheduled for an elective cesarean section. The night before surgery, she had a spike of fever and abdominal pain in the epigastrium and felt nauseated. She was brought to the emergency room, and her ultrasound examination revealed edema in the peri-gallbladder area and cholecystitis. Her biochemical analysis was normal. A general surgical consult was made, and the opinion was that she needs to be operated urgently to prevent the perforation of gallbladder. A decision for combining the cesarean section and laparoscopic cholecystectomy was conveyed to the family, which was accepted. Here, a surgeon informed an obstetrician that he/she would prefer to do laparoscopic procedure before the cesarean section. The obstetric team agreed with complete monitoring of the fetal heart sounds.

In the operation room (OR), an intravenous cannula 20G was inserted. All the monitoring according to the American Society of Anesthesiologists standards of monitoring was applied. An obstetric team was standby in the OR. They applied the cardiotocography (CTG) monitor that confirmed the normal fetal heart sounds. Under general anesthesia, capnoperitoneum was created by initial port placement at Palmer's point with a 5-cm Covidien optical port. After proper creation of capnoperitoneum, the intra-abdominal pressure was limited to 12 cmH2O to avoid hemodynamic effects of raised intra-abdominal pressure on the uteroplacental blood flow. No injury to bowel or gravid uterus was confirmed, and the dissection of the Calot's triangle was done. Cholecystectomy was performed in 45 min. Thorough wash and suction of the liver bed were done. Hemostasis was confirmed. CTG did not record any trace of uterine activity or fetal distress. The laparoscopic ports were then closed after the capnoperitoneum was drained out.

The obstetric team then made a Pfannenstiel incision to deliver the baby. The delivery was completed in 10 min after the closure of the laparoscopic ports. Apgar score at birth was 5 with respiratory depression. This was treated with constant physical stimulation and oxygen therapy. A neonatologist deemed appropriate to shift the baby to the neonatal intensive care unit (NICU) for further support. Later, it was confirmed that the baby was off the oxygen support the next day. The mother tolerated the procedure very well. After the confirmation of adequate hemostasis and mean blood pressure over 70 mmHg, the abdomen was closed in surgical layers.

The patient was in hospital for the next 3 days, and her puerperium was unremarkable. There were no further complications during her stay. The baby was discharged from NICU on the 1st postoperative day.


  Discussion Top


Although gallstone disease in pregnancy is uncommon, the potential maternal and fetal morbidity from both the disease and its surgical therapy is significant. After open cholecystectomy, the rate of preterm labor is about 7% overall and 40% in the third trimester.[11] The rate of spontaneous abortion is 0%–18%, and the rate of preterm delivery is 0%–22%, depending on the severity of the underlying disease and gestational age.[12] Most of the patients with symptomatic gallbladder disease in the pregnancy are effectively managed conservatively, and cholecystectomy is performed selectively during the postpartum period.[2]

There were five case reports before our report on combining the laparoscopic cholecystectomy and cesarean section.[13],[14],[15],[16],[17] Mushtaque et al. did a case series and described the benefits of combining the mini-laparotomy cholecystectomy with the cesarean section.[18] Another case series by Kosmidis et al.[19] also described the benefit of combining cesarean with cholecystectomy. However, in all of these reports, the cesarean section preceded the laparoscopic procedure. In our case, we have done the laparoscopic procedure before the cesarean section. Since cesarean section was planned, surgical team suggested to do cholecystectomy first as there will not be any effect to the uteroplacental flow. In the opposite, if the case was emergency cesarean section, delivering the baby would be our priority. They argued that many elective laparoscopic procedures have been performed in the third trimester safely without the risk to fetus. Another argument put forth by the surgical team was creation of capnoperitoneum after the cesarean section would increase the chance of wound dehiscence and future incisional hernia. It was concluded that, as long as there was fetal monitoring done with CTG, and it was nonproblematic, the surgical team would do the procedure first. At any sign of uterine irritability or fetal distress, they would stop and the obstetric team would deliver the baby.

Complex laparoscopic surgeries with capnoperitoneum have been safely performed in the pregnant women. Outcomes are generally very good and better than laparotomy, although physiological derangements such as hypoxemia, hypercarbia, and hypotension need management.[20]

The decrease in the placental blood flow as a result of raised intra-abdominal pressure secondary to the capnoperitoneum is well tolerated by the fetus. In general, the pressure should be kept to 10 mmHg.[21]

In conclusion, the combined procedure in selected patients, apart from having many advantages, is a cost-effective method of treatment. It avoids rehospitalization for separate cholecystectomy. With an additional small port, single anesthesia, and single hospital stay, the combined procedure confers valuable advantages for both patient and hospital in time, cost, and convenience, including avoiding the separation of mother from newborn entailed by reoperation. It also prevents the possibility of developing acute cholecystitis, while the patient is waiting for cholecystectomy. Our result indicates that the combination approach is safe, effective, and well accepted.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

This study was financially supported by Dr. Tapiwa Kundishora for helping in reviewing the discussion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Paramanathan A, Walsh SZ, Zhou J, Chan S. Laparoscopic cholecystectomy in pregnancy: An Australian retrospective cohort study. Int J Surg 2015;18:220-3.  Back to cited text no. 1
    
2.
Bouyou J, Gaujoux S, Marcellin L, Leconte M, Goffinet F, Chapron C, et al. Abdominal emergencies during pregnancy. J Visc Surg 2015;152(6 Suppl):S105-15.  Back to cited text no. 2
    
3.
Cox TC, Huntington CR, Blair LJ, Prasad T, Lincourt AE, Augenstein VA, et al. Laparoscopic appendectomy and cholecystectomy versus open: A study in 1999 pregnant patients. Surg Endosc 2016;30:593-602.  Back to cited text no. 3
    
4.
Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology. Radiol Clin North Am 2003;41:1203-16.  Back to cited text no. 4
    
5.
Ko CW, Beresford SA, Schulte SJ, Matsumoto AM, Lee SP. Incidence, natural history, and risk factors for biliary sludge and stones during pregnancy. Hepatology 2005;41:359-65.  Back to cited text no. 5
    
6.
Mendez-Sanchez N, Chavez-Tapia NC, Uribe M. Pregnancy and gallbladder disease. Ann Hepatol 2006;5:227-30.  Back to cited text no. 6
    
7.
Bolukbas FF, Bolukbas C, Horoz M, Ince AT, Uzunkoy A, Ozturk A, et al. Risk factors associated with gallstone and biliary sludge formation during pregnancy. J Gastroenterol Hepatol 2006;21:1150-3.  Back to cited text no. 7
    
8.
Griffin S, Abbassi N, Parveen Z, Zafar A, Ali J. Combined abdominal hysterectomy, cholecystectomy and appendectomy; a study of 25 cases in Abbottabad. J Ayub Med Coll Abbottabad 2006;18:57-9.  Back to cited text no. 8
    
9.
Bukovsky I, Schneider D, Weinraub Z, Arieli S, Schreyer P, Caspi E. Sterilization at the time of cesarean section: Tubal ligation or hysterectomy? Contraception 1983;28:349-56.  Back to cited text no. 9
    
10.
Gabriele R, Conte M, Izzo L, Basso L. Cesarean section and hernia repair: Simultaneous approach. J Obstet Gynaecol Res 2010;36:944-9.  Back to cited text no. 10
    
11.
Ochsenbein-Kölble N, Demartines N, Ochsenbein-Imhof N, Zimmermann R. Cesarean section and simultaneous hernia repair. Arch Surg 2004;139:893-5.  Back to cited text no. 11
    
12.
Kort B, Katz VL, Watson WJ. The effect of nonobstetric operation during pregnancy. Surg Gynecol Obstet 1993;177:371-6.  Back to cited text no. 12
    
13.
Pelosi MA, Pelosi MA, Villalona E. Laparoscopic cholecystectomy at cesarean section. A new surgical option. Surg Laparosc Endosc 1997;7:369-72.  Back to cited text no. 13
    
14.
Pelosi MA, Pelosi MA 3rd, Villalona E. Handassisted laparoscopic cholecystectomy at cesarean section. J Am Assoc Gynecol Laparosc 1999;6:491-5.  Back to cited text no. 14
    
15.
Bernard A, Butler L, Crump S, Meier J. Concurrent cesarean section and hand port-assisted laparoscopic cholecystectomy: A safe approach. Surg Laparosc Endosc Percutan Tec 2005;15:283-4.  Back to cited text no. 15
    
16.
Weber Sánchez A, García-Benítez CQ, Bravo Torreblanca C, Garteiz Martínez D, Carbo Romano R, Vega Rivera F, et al. Post cesarean section laparoscopic cholecystectomy for hydrocholecystitis. Gynecol Obstet Mex 2011;79:230-4.  Back to cited text no. 16
    
17.
Surgit O, Gumus II, Kilic MO. Laparoscopic cholecystectomy performed immediately after cesarean section without additional incisions: A new method. BJMMR 2016;13:1-5.  Back to cited text no. 17
    
18.
Mushtaque M, Guru IR, Malik TN, Khanday SA. Combined lower segment cesarean section and cholecystectomy in single sitting-our initial experience. J Turk Ger Gynecol Assoc 2012;13:187-90.  Back to cited text no. 18
    
19.
Kosmidis C, Efthimiadis C, Anthimidis G, Vasiliadou K, Kotsifa C, Stefanatos A, et al. Laparoscopic cholecystectomy during cesarean section: A case study. J Gynecol Surg 2013;29:254-56. doi:10.1089 /gyn.2012. 0136.  Back to cited text no. 19
    
20.
Palmer CM, D'Angelo R, Paech MJ. Obstetric Anesthesia. Handbook of Obstetric Anaesthesia: New York; Informed health care. 1st Ed. CRC press 2001.  Back to cited text no. 20
    
21.
Mishra RK, Mishra RK. Textbook of Practical Laparoscopic Surgery. 3rd Ed. Jaypee Brothers medical; 2013.  Back to cited text no. 21
    




 

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