and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
licensing copies, or posting to personal, institutional or third party
websites are prohibited.
In most cases authors are permitted to post their version of the
article (e.g. in Word or Tex form) to their personal website or
institutional repository. Authors requiring further information
regarding Elsevier’s archiving and manuscript policies are
encouraged to visit:
Review
Gasless
laparoscopic
surgery
during
pregnancy:
evaluation
of
its
role
and
usefulness
Francesco
Sesti
*
,
Adalgisa
Pietropolli,
Franz
Federico
Sesti,
Emilio
Piccione
AcademicDepartmentofBiomedicine&PreventionandClinicalDepartmentofSurgery,SectionofGynecology,TorVergataUniversityHospital,Rome,Italy
Contents
1. Introduction... 8
2. Methods... 9
3. Results... 9
3.1. Generalsurgicalprocedures... 9
3.1.1. Cholecystectomyandappendicectomy... 9
3.2. Gynecologicprocedures... 9
3.2.1. Adnexaldisorders... 9
3.2.2. Gaslesslaparoscopyforuterinediseases... 10
4. Discussion ... 10
5. Conclusion... 11
References... 11
1. Introduction
Surgicaldiseasesinthepregnantwomanremainadiagnostic and therapeutic challenge. General surgical procedures are requiredinapproximately1in635pregnancies,acuteappendicitis and symptomatic biliary disease being the most common indications [1]. Among the gynecologic conditions requiring
ARTICLE INFO Articlehistory:
Received19December2011 Receivedinrevisedform10April2013 Accepted30April2013 Keywords: Gaslesslaparoscopy Pregnancy Ovariancystectomy Salpingo/oophorectomy Uterinemyomectomy Cholecystectomy ABSTRACT
Theminimallyinvasivelaparoscopicapproachinthesurgicaltreatmentofdiseasesduringpregnancy hasbecomeprogressivelymoreacceptedandapplied.Inanattempttoovercomethepotentialadverse effectsofpneumoperitoneumonthefetus,gaslesslaparoscopicsurgery(GLS)hasbeendeveloped.This articlereviewstheevidenceavailablefortheroleandeffectivenessofGLSinpregnancy.Acomputerized literaturesearchwasconductedonMedline,ScienceCitationIndex,CurrentContents,Embase,and PubMeddatabasesforEnglishlanguagepublicationsfromthefirstreportofGLSinpregnancyin1995to June2012.Elevencasereportsorretrospectiveserieswereidentified.Atotalof44pregnantwomen underwentGLSforvarioussurgicalindications.Inallcases,theprocedureswerecarriedoutwithout complication,andthewomenweredischargedfromhospitalwithacontinuingpregnancy.GLS in pregnancyhascomparableoutcomestoconventionalCO2laparoscopy,butitisassociatedwithsome
advantages.HypercarbiaandincreasedintraperitonealpressureduetoCO2insufflationareavoided.The
useofhigh-pressurecontinuoussuctionmaypreventtheproblemsthatarepotentiallyassociatedwith intra-abdominalsmokegeneratedbyelectrosurgery,whichcanincreasetheriskoffetalexposureto elevatedlevelsoftoxicgases.Becausethisproceduremaybeperformedunderregionalanesthesia, avoidinggeneralanesthesia,thereisaminimaltransplacentalpassageofanestheticdrugstothefetus. Thesurgeonmustbeexpertinadvancedlaparoscopicprocedures.
ß2013ElsevierIrelandLtd.Allrightsreserved.
* Corresponding author at: School of Medicine, Academic Department of Biomedicine & Prevention and Clinical Department of Surgery, Tor Vergata UniversityHospital,VialeOxford,81-00133Rome,Italy.
Tel.:+390620902921;fax:+390620902921. E-mailaddress:Francesco.Sesti@uniroma2.it(F.Sesti).
ContentslistsavailableatSciVerseScienceDirect
European
Journal
of
Obstetrics
&
Gynecology
and
Reproductive
Biology
j o urn a l hom e pa ge : ww w. e l s e v i e r. c om/ l o ca t e / e j ogr b
0301-2115/$–seefrontmatterß2013ElsevierIrelandLtd.Allrightsreserved.
surgery during pregnancy, ovarian cysts, adnexal masses or torsions are the most frequent. Adnexal surgery accounts for one-thirdoflaparoscopicproceduresperformedduringpregnancy, and56%oftheseoperationsareperformedinthesecondtrimester
[2].
Allthesedisordersareroutinelytreatedusingcarbondioxide (CO2)laparoscopictechniquesin the non-pregnantpatient.The
advantagesofCO2laparoscopicproceduresoveropenprocedures
in the general population are well described and include diminished postoperative pain, shorter length of hospital stay, quickerrecovery,areducedoccurrenceofthromboembolicevents, and shorterlengthofpostoperativeileus[3].Despitethis,some surgeons are reluctant to utilize this method when treating a pregnantwoman,especiallyafterthefirsttrimester,becausethere arefewdatashowingthesafetyofoperativelaparoscopyduring pregnancy[4].Thisisprobablybecauseofthepotentialrisktothe fetusduetotrocarinsertion,CO2insufflation,andaninadequate
surgicalfield.Inaddition,potentialriskstothemotherconsistof altered physiologyofpneumoperitoneumand decreasedvenous return tothe heart,withpossiblecompromise of the uteropla-cental perfusion as a result of augmented intra-abdominal pressure,andfetalacidosisgeneratedbyCO2absorption[3].
Althoughmanytechnicalimprovementsandadjustmentshave been developed to improve security and efficiency of CO2
laparoscopy,numerousstudieshavereportedpathophysiological or clinical problems related to CO2 laparoscopy in pregnancy.
Indeed, CO2 laparoscopy may create diminution of pulmonary
function, increased pulmonary wedge pressure, ventilation– perfusion mismatch, visceralvasoconstriction, augmented dead space, increase oftotalperipheral resistance, effects oncardiac outputandincreaseinPaCO2[5].
Inanattempttoovercometheadverseeffectsof pneumoper-itoneum, many techniques have been developed to lift the abdominal wall withoutgas.With gasless laparoscopicsurgery (GLS)thepotentialdetrimentaleffectsofCO2pneumoperitoneum
on the fetus can be avoided, while theadvantages of reduced postoperativepainand improvedrecoveryareretained[6].The proceduresinvolvetheuseoftwowireloopsplacedthroughthe abdominalwallandpulledupwardbyamechanicaldevice.The first generation of abdominal wall lifting devices provided an intraperitoneallift[7].Analternativeapproachwasfirstdescribed by Hashimoto et al. [8]: abdominal lifting was provided by subcutaneous wires.Thisconceptwasthen developedwiththe introductionofnewsubcutaneousliftingsystemsforlaparoscopic surgery[9].Themethodwidelyusedtodayistheplanarliftingof theabdominalwall.
Somedatasuggestthatclinicaloutcomesofgaslesslaparoscopy areequivalenttothoseofconventionallaparoscopictechniques, while providing improved safety. In this paper the published evidence regarding the use of gasless laparoscopy during pregnancyisreviewed,focusingongeneralsurgicaland gyneco-logicprocedures.
2. Methods
Acomputerized literaturesearchwasconductedonMedline, Science Citation Index, CurrentContents, Embase, and PubMed databasesforEnglishlanguagepublicationsfromthefirstreportof GLSinpregnancyin1995toJune2012.Elevencasesreportsor retrospectiveserieswereidentified.
3. Results
Forty-fourpregnantwomenunderwentGLSforvarioussurgical indications. The largestgroup of cases (n=40) wasof adnexal mass, andthereweretwo casesofadnexaltorsion, onecaseof
necrotic uterine leiomyoma and one ofacute cholecystitis. The procedures undertaken included ovarian cystectomy (n=38), salpingo-oophorectomy (n=2), salpingectomy (n=1), adnexal detorsion(n=1),uterinemyomectomy(n=1),and cholecystecto-my (n=1). In 25 cases the procedure was performed under epiduralanesthesia.Inallcases,theprocedureswerecarriedout withoutcomplication,andthewomenweredischargedfromthe hospitalwithacontinuingpregnancy.
3.1. Generalsurgicalprocedures
3.1.1. Cholecystectomyandappendicectomy
A recentretrospectivereview ofbothlaparoscopicand open procedures performed on pregnant women showed that CO2
laparoscopiccholecystectomy wasas safeand efficaciousasits respectiveopenprocedure[4].Infact,reducedratesofmiscarriage and preterm labor have been reported in association with laparoscopic cholecystectomy when compared to an open cholecystectomy[10].
A singlecase reportofgasless laparoscopiccholecystectomy was identified in our literature search. In order to avoid the potential problems related to CO2 insufflationwhile benefiting
fromthereducedpostoperativepainandimprovedrecoveryofCO2
laparoscopic cholecystectomy, Iafrati et al. [11] performed a gasless laparoscopic cholecystectomy. They used an abdominal wall-lifting device(Laparofit– OriginMedsystems,Menlo Park, CA)withJ-shapedliftingarmsona38-year-oldwomanwhowas 14 weeks pregnant and suffering from acute cholecystitis. The procedurewascarriedoutwithoutcomplication,andthewoman wasdischargedfromthehospitalin24hwithaviablefetus[11]. Traditionally, the surgical treatment of choice for acute appendicitis during pregnancy has beenopen appendicectomy. Arecentretrospectivereviewof65consecutivepregnantpatients, however,aimedtoevaluateCO2laparoscopicversusopensurgery
forsuspectedappendicitisduringpregnancyanddemonstratedno significant difference in fetal losses [12]. No cases of GLS appendicectomyduringpregnancywereidentifiedin our litera-turesearch.
3.2. Gynecologicprocedures
3.2.1. Adnexaldisorders
3.2.1.1. Adnexaltorsion. Severalcase reportshaveconfirmedthe safety andeffectivenessof CO2 laparoscopyinthetreatmentof
adnexaltorsionduringpregnancy[10,13,14].ThefirstcaseofGLS for adnexal torsion during a twin pregnancy was reported subsequently[15].In2001Schmidtetal.describedacaseofan acuteabdomenrelatedtorightovarianpedicletorsioninthefifth week of pregnancy. The authors performed GLS using the Laparofan (Origin, Menlo Park, CA), and the ovary wasrotated intoitsusualposition.Thepatientwaswell,andwasdischargedon theseventhpostoperativeday.
Another case of torted hematosalpinx in a woman in the thirteenth week of pregnancywas treated using theLaparofan fixed on Laparofit (Origin, Menlo Park, CA) [16]. Ro¨mer et al. performed GLS, detecting a torted 6cm hematosalpinx, and successfullycarriedout salpingectomyusing bipolardiathermy. Thepatientwaswell,andwasdischargedonthefifthpostoperative day.
3.2.1.2. Adnexal masses. Several case reports supportthe useof CO2laparoscopyinthetreatmentofsymptomaticadnexalmasses
ineachtrimesterofpregnancy[10].Aretrospectivecohortstudyof 101pregnantwomenat14weeksormoreofgestationundergoing laparoscopy(n=50)orlaparotomy(n=51)formanagementofa
persistentadnexalmassshowedshorterhospitalstay,decreased bloodloss,andfewerpostoperativecomplicationsinthe laparos-copy group compared with the laparotomy group, without seemingtohaveanegativeeffectonthepregnancy[17].
ThefirststudycomparingtheeffectivenessandsafetyofGLS ovariancystectomyduringpregnancywiththoseofconventional laparotomywasreportedin1999[6].GLSovariancystectomywas performed underepiduralanesthesia in17womenbetween 12 and16weeks’gestation.Theprocedurewascarriedoutwithout anyfetalloss.Thetotaldosesofanalgesicsandtocolyticagents usedafterGLSovariancystectomywerelowercomparedtothose usedafterlaparotomy.
Inanotherreport,sevenpregnantwomenwithadnexalcystsat 12–19 weeks of gestation were successfully treated without complications using GLS ovarian cystectomy under epidural anesthesia[18].
Anotherreportconcernedawomanwhowasaffectedbyaleft ovariancystinthefifteenthweekofpregnancy.Thecystwaslarger than60mmandwaslocatedinthepouchofDouglas.Anelective GLSovariancystectomywasperformedusingaLaparofitsystem (Tyco Healthcare Japan, Tokyo, Japan). A metreurynter, an inflatablebagfordilatingthecervicalcanal,wasinsertedthrough the left trocar site into the bottom of cul-de-sac. A volume of 250mLsalinewasextraperitoneallyinflatedintotheballoonof metreurynter.Theovariancystappearedspontaneouslyoutofthe cul-de-sac after ballooning the metreurynter in the pouch of Douglas. This allowed an extraperitoneal cyst enucleation and ovariansuturingafterhavingaspiratedthecystcontents,andthe left ovary was pulled out through theleft port site. Histologic diagnosiswasmaturecysticteratoma.Thesubsequentantenatal andintrapartumcoursewasuneventful[19].
Morerecently,twootherreportsofGLSovariansurgeryduring pregnancyhavebeenpublished.Inthefirstcasesseries,13women withadnexalcystsat10–17weeksofgestationweresuccessfully treated usingGLSovarian cystectomyunder general anesthesia
[20].Postoperativecomplicationscompriseduterinecontractions inthree womenandvaginalbleedingin fourwomen,butthese symptoms resolved rapidly after surgery. All the cases were delivered between 37 and 40 weeks of pregnancy. In another report, elective GLSsalpingo-oophorectomy due toa persistent voluminous left ovarian cyst was performed under general anesthesiaatthefourteenthweekofgestationwithout complica-tions. The subsequent antenatal and intrapartum course was unremarkable[21].
There are reports of the use of CO2 laparoscopy in the
management of heterotopic pregnancy [22,23]. More recently, thefirstcaseofheterotopictubalpregnancytreatedusingGLShas beenreported[24].Thewomanwassuccessfullymanagedunder general anesthesia at theseventh week of gestation using GLS salpingectomyofthetubalpregnancy.Thesubsequentantenatal coursewasuneventful.
3.2.2. Gaslesslaparoscopyforuterinediseases
3.2.2.1. Uterine myomas. Myomectomy performed during preg-nancy througha laparotomy [25] orconventional laparoscopy withpneumoperitoneum[26]hasbeendescribed.Todatethereis asinglepublishedreportofGLSmyomectomyduringpregnancy inawomanwithasubserosalmyomameasuring7cm7cmon theuterinefundusat24weeksofgestation[27].Shehadacute abdominalpainwithsuspectedtorsionornecrosisofthemyoma. GLSwasperformedusingtheLaparotenserdevice(LuciniSurgical Concept, Milan, Italy) under epidural anesthesia. A partially necrotic uterineleiomyomawasdetectedandthemyomawas removedandsuccessivelyextractedfromtheabdominalcavityby morcellation with a scalpel [28]. Monopolar and bipolar
electrosurgerywerenot used. Theuterine defectwasrepaired in a continuous one-layer closure using a conventional long needle holder. No intraoperative complications occurred, and therewerenoanesthesia-relatedcomplications.Thewomanwas dischargedonthefirstpostoperativedayandtheremainderofher pregnancywasunremarkable.
4. Discussion
Symptomaticgallbladderdiseaseisthemostfrequent indica-tionfornon-gynecologicproceduresduringpregnancy.Gallstones arepresentin12%ofallpregnancies,andmorethanone-thirdof thesymptomaticpatientsdonotrespondtoconservativemedical management [29]. CO2 laparoscopic cholecystectomy during
pregnancy is preferred because of thegood outcomesand low rate of complications [10]. The single case report of GLS cholecystectomy demonstratedthat theuseof abdominal wall-lifting devices couldbe supported, since both hypercarbia and increased intraperitoneal pressure are avoided [11]. Both wire suspensionandretractingarmdeviceshavebeenused[8].During thedevelopmentphaseof thesedevices,exposure for cholecys-tectomy has occasionally been problematic, although pelvic exposure was generally satisfactory. It is suggested that the additionofa J-shapedlifting armpermitsan exposureintothe right upper quadrant essentially equivalent to pneumoperito-neum,allowingasafecholecystectomytobeundertaken[11].
Theincidenceofadnexalmassesduringpregnancyis2%.Most adnexalmassesdiscoveredduringthefirsttrimesterofpregnancy are functional ovarian cyststhat resolve spontaneously by the secondtrimester.Expectantmanagementhasbeensuggestedfor adnexalmasses6cminpregnancybasedonan82–94%rateof spontaneous resolution. Persistent masses are most frequently functional cysts or mature cystic teratomas with malignancy reported in 2–6% [30]. In the event that surgery is indicated, various case reports support the use of laparoscopy in the management of adnexal masses in every trimester [31,32]. It was reported, however, that if maternal respiratory acidosis occurs,asinpneumoperitoneum,thediffusionofCO2cancause
fetalhypercarbiaandacidosis,andthatprematurelaborcanoccur fromtheincreasedintra-abdominalpressure[31].Indeed,several studiesofpneumoperitoneuminapregnantewemodelshowedan increaseinthefetalPaCO2andadecreaseinthefetalarterialpH
[33,34].
InadditiontothechemicaleffectsofabsorbedCO2,thepressure
effectofpneumoperitoneummaybedetrimentaltothemother andfetus;fetalhypoxiacanbegeneratedbyincreasedintrauterine pressure. CO2 insufflation in the pregnant ewe can result in a
reductionofuterinebloodflowandanincreaseinintra-amniotic pressure[34].Thesestudiessuggestthatpneumoperitoneummay have deleterious effects on the fetus. On the contrary, stable maternalPaCO2wasobservedinpatientsundergoingGLS[6].The
useofabdominalwall-liftingdevicesinthepregnantpatientmight beconsideredbecausebothhypercarbiaandincreased intraperi-tonealpressure are avoided withless significanthemodynamic and respiratorymaternaleffects [6,18]. Inparticular,theuseof subcutaneous lift systems [35] is recommended because they showseveraladvantagesoverthefull-thicknesswallliftdevices
[36].First,thesurgeoncan preventinjury tothegraviduterus. Second,thesubcutaneousliftsystemcanbeappliedtoallpatients, regardlessofanyhistoryofabdominalsurgeryoranyunexpected adhesions.
Fetal acid–base balance may also be affected adversely by reductioninthematernaldiaphragmaticexcursionandvenacaval flow, both of which may result from the increased maternal intraperitonealpressure[37].Anadditionalpotentialriskisthe fetalexposure tointra-abdominalsmoke,generated by
electro-surgeryandlasers,whichcanincreasethelevelsoftoxicgases,the most important of which is carbon monoxide [38]. GLS can facilitatetheuseofhigh-pressurecontinuoussuction,preventing thatproblem.
It has been proposed that GLS may extend the variety of gynecologic surgeries,particularly ontheadnexa inpregnancy. Indeed, there is norisk of injuringthe pregnantuterus witha Veress needle or cannula, and no increase in intra-abdominal pressure. Afurther advantageis theabilitytouseconventional instruments.Theuteruscanbecautiouslymanipulatedbymoving itwithaspongethatisheldbyaringforceps[16].
Surgicalmanagementofuterineleiomyomaduringpregnancy maybesuccessfullyperformedincarefullyselectedpatients,butit can becomplicated by injury tothe graviduterus,resulting in pregnancyloss.Thesurgeonmustthereforebeskillfulinadvanced techniquesoflaparoscopicsurgery,adoptingasafeprotocolforthe portplacementsystemconsideringthesizeofthepregnantuterus
[39]. An increasing number of reported cases have shown laparoscopy to be safe in the first two trimesters with good maternalandfetaloutcome.Itisrecommendedthatalaparoscopic myomectomycanbeconsideredaminimallyinvasivealternative totraditionallaparotomyforselectedpatientswhenmyomectomy duringpregnancyisunavoidable[26].
GLS myomectomy seems to offer several advantages over conventional laparoscopywithpneumoperitoneum.Becausethe peritonealcavitydoesnotneedtobesealedairtight,conventional long laparotomyinstruments,suchas tissueclamps,tenaculum clamps, needle holders, knives, and scissors can be used. This facilitates several steps of the procedure. One of the main advantagesisinuterinerepairbecauseapplyingtheconventional curved needle deeply intothemyometrium witha laparotomy needleholderiseasierandfaster.Aspreviouslyemphasized[40], the augmented vascularization and tissue impedance of the pregnantuteruscanamplifytherisk ofelectrosurgicaldamage. Itisthereforeimportanttoavoidtheuseofmonopolarandbipolar electrosurgeryinthemyomaresection,asoccurredintheonlycase ofgaslesslaparoscopicmyomectomyduringpregnancyreportedin theliterature[27].
5. Conclusion
During its early years, some argued that laparoscopy was contraindicated during pregnancy. The use of the minimally invasive laparoscopic approach in the surgical treatment of diseases during pregnancyhas, however,become progressively more accepted and applied as data supporting its safety and enhancements in use have accumulated. In an attempt to overcome the potential adverse effects of pneumoperitoneum on thefetus, many techniqueshave been developedto lift the abdominalwallwithoutgas.LimitedpublisheddataonGLSduring pregnancy show outcome measures comparable to those of conventional CO2 laparoscopy, but it is associated with some
potentialadvantages.Withthistechniquethepotentialdeleterious effects of carbon dioxide insufflationon thefetus are avoided, whilethebenefitsofdiminishedpostoperativepainandenhanced recovery areretained.The reported useof GLSin pregnancyis limitedandthesurgeonmustbeexpertinadvancedlaparoscopic proceduresbeforeconsideringGLSasasafealternativeforhis/her patient.
References
[1]AndreoliM,ServakovM,MeyersP,MannJrWJ.Laparoscopicsurgeryduring pregnancy.JAmAssocGynecolLaparosc1999;6:229–33.
[2]LachmanE,SchienfeldA,VossE,etal.Pregnancyandlaparoscopicsurgery.J AmAssocGynecolLaparosc1999;6:347–51.
[3]JacksonH,GrangerS,PriceR,etal.Diagnosisandlaparoscopictreatmentof surgicaldiseasesduringpregnancy:anevidence-basedreview.SurgEndosc 2008;22:1917–27.
[4]CorneilleMG,GallupTM,BeningT,etal.Theuseoflaparoscopicsurgeryin pregnancy:evaluationofsafetyandefficacy.AmJSurg2010;200:363–7.
[5]BaxterJN,O’DwyerPJ.Pathophysiologyoflaparoscopy.BrJSurg1995;82:1–2.
[6]AkiraS,YamanakaA,IshiharaT,TakeshitaT,ArakiT.Gaslesslaparoscopic ovariancystectomyduringpregnancy:comparisonwithlaparotomy.AmJ ObstetGynecol1999;180:554–7.
[7]ChinAK,MollFH,McCollMB,ReichH.Mechanicalperitonealretractionasa replacement forcarbon dioxidepneumoperitoneum. JAmAssocGynecol Laparosc1993;1:62–6.
[8]HashimotoD,NayeemSA,KajiwaraS,HoshinoT.Abdominalwallliftingwith subcutaneouswiring:anexperienceof50casesoflaparoscopic cholecystec-tomywithoutpneumoperitoneum.SurgToday1993;23:786–90.
[9]ChinAK,EatonJ,TsoiEK,etal.Gaslesslaparoscopyusingaplanarlifting technique.JAmCollSurg1994;178:401–3.
[10]PearlJ,PriceR,RichardsonW,FanelliR.SocietyofAmericanGastrointestinal EndoscopicSurgeons.Guidelinesfordiagnosis,treatment,anduseof laparos-copyforsurgicalproblemsduringpregnancy.SurgEndosc2011;25:3479–92.
[11]IafratiMD,YarnellR,SchwaitzbergSD.Gaslesslaparoscopiccholecystectomy inpregnancy.JLaparoendoscSurg1995;5:127–30.
[12]SadotE,TelemDA,AroraM,ButalaP,NguyenSQ,DivinoCM.Laparoscopy:a safeapproachtoappendicitisduringpregnancy.SurgEndosc2010;24:383–9.
[13]MageG,CanisM,ManhesH,PoulyJL,BruhatMA.Laparoscopicmanagementof adnexaltorsion.Areviewof35cases.JReprodMed1989;34:520–4.
[14]BassilS,SteinhartU,DonnezJ.Successfullaparoscopicmanagementof ad-nexaltorsionduringweek25ofatwinpregnancy.HumReprod1999;14: 855–7.
[15]Schmidt T,Nawroth F, Foth D, Rein DT, Ro¨mer T,Mallmann P.Gasless laparoscopyasanoptionforconservativetherapyofadnexalpedicaltorsion withtwinpregnancy.JAmAssocGynecolLaparosc2001;8:621–2.
[16]Ro¨merT,BojahrB,SchwesingerG.Treatmentofatorquedhematosalpinxin thethirteenthweekofpregnancyusinggasless laparoscopy.J AmAssoc GynecolLaparosc2002;9:89–92.
[17]BalthazarU,SteinerAZ,BoggessJF,GehrigPA.Managementofapersistent adnexalmassinpregnancy:whatistheidealsurgicalapproach.JMinim InvasiveGynecol2011;18:720–5.
[18]TanakaH, Futamura N,TakuboS, Toyoda N. Gaslesslaparoscopy under epidural anesthesia for adnexal cysts during pregnancy. J Reprod Med 1999;44:929–32.
[19]MurakamiT,NodaT,OkamuraC,TeradaY,MoritoY,OkamuraK.Cul-de-sac packing with a metreurynter in gasless laparoscopic cystectomy during pregnancy.JAmAssocGynecolLaparosc2003;10:421–3.
[20]OguriH,TaniguchiK,FukayaT.Gaslesslaparoscopicmanagementofovarian cystsduringpregnancy.IntJGynaecolObstet2005;91:258–9.
[21]PhupongV,BunyavejchewinS.Gaslesslaparoscopicsurgeryforovariancystin asecondtrimesterpregnantpatientwithaventricularseptaldefect.Surg LaparoscEndoscPercutanTech2007;17:565–7.
[22]BarrenetxeaG,Barinaga-RementeriaL,LopezDeLarruzeaA,AgirregoikoaJA, MandiolaM,CarboneroK.Heterotopicpregnancy:twocasesanda compara-tivereview.FertilSteril2007;87(417):e9–15.
[23]PasicRP,HammonsG,GardnerJS,HainerM.Laparoscopictreatmentofcornual heterotopicpregnancy.JAmAssocGynecolLaparosc2002;9:372–5.
[24]PhupongV,BunyavejchevinS.Successfultreatmentofaheterotopictubal pregnancy by gasless laparoscopic surgery. J Obstet Gynaecol Res 2010;36:686–9.
[25]UsifoF,MacraeR,SharmaR,OpemuyiIO,OnwuzurikeB.Successful myomecto-myinearlysecondtrimesterofpregnancy.JObstetGynaecol2007;27:196–7.
[26]SonCE,ChoiJS,LeeJH,JeonSW,BaeJW,SeoSS.Acaseoflaparoscopic myomectomyperformedduringpregnancyforsubserosaluterinemyoma.J ObstetGynaecol2011;31:180–1.
[27]MelgratiL,DamianiA,FranzoniG, MarzialiM,SestiF. Isobaric(gasless) laparoscopic myomectomyduring pregnancy. J MinimInvasive Gynecol 2005;12:379–81.
[28]DamianiA,MelgratiL,MarzialiM,SestiF.Gaslesslaparoscopicmyomectomy: indications,surgicaltechnique,andadvantagesofanewprocedurefor re-movinguterineleiomyomas.JReprodMed2003;48:792–8.
[29]SunglerP,HeinermanPM,SteinerH,etal.Laparoscopiccholecystectomyand interventionalendoscopyforgallstonecomplicationsduringpregnancy.Surg Endosc2000;14:267–71.
[30]Sherard3rdGB,HodsonCA,WilliamsHJ,SemerDA,HadiHA,TaitDL.Adnexal masses and pregnancy: a 12-year experience. Am J Obstet Gynecol 2003;189:358–62[discussion362–3].
[31]MathevetP,NessahK,DargentD,MellierG.Laparoscopicmanagementof adnexalmassesinpregnancy:acaseseries.EurJObstetGynecolReprodBiol 2003;108:217–22.
[32]YuenPM,NgPS,LeungPL,RogersMS.Outcomeinlaparoscopicmanagement ofpersistentadnexalmassduringthesecondtrimesterofpregnancy.Surg Endosc2004;18:1354–7.
[33]HunterJG,SwanstormL,ThomburgK.Carbondioxidepneumoperitoneum inducesfetalacidosisinapregnantewemodel.SurgEndosc1995;9:272–9.
[34]CruzAM,SoutherlandLC,DukeT,TownsendHG,FergusonJG, CroneLA. Intraabdominalcarbondioxideinsufflationinthepregnantewe.Uterineblood flow,intraamniotic pressure,andcardiopulmonaryeffects. Anesthesiology 1996;85:1395–402.
[35]NagaiH,KondoY,YasudaT.Anabdominalwall-liftmethodoflaparoscopic cholecystectomy without peritoneal insufflation. Surg Laparosc Endosc 1993;3:175–9.
[36]Smith RS,FryWR,Tsoi EK,et al.Gaslesslaparoscopy and conventional instruments: the next phase of minimally invasive surgery. Arch Surg 1993;128:1102–7.
[37]CalleryMP,SoperNJ.Physiologyofthepneumoperitoneum.BaillieresClin Gastroenterol1993;7:757–77.
[38]BeebeDS,SwicaH,CarlsonN,PalahniukRJ,GoodaleRL.Highlevelsofcarbon monoxideare produced by electro-cautery oftissue during laparoscopic cholecystectomy.AnesthAnalg1993;77:338–41.
[39]Al-FozanH,TulandiT.Safetyandrisksoflaparoscopyinpregnancy.CurrOpin ObstetGynecol2002;14:375–9.
[40]SestiF,CapobiancoF,CapozzoloT,PietropolliA,PiccioneE.Isobaricgasless laparoscopyversusminilaparotomyinuterinemyomectomy:arandomized trial.SurgEndosc2008;22:917–23.
