Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 476 - файл
.pdf
22
Symptomatic Cholelithiasis in
Pregnancy
VANCE L. SMITH and PAUL M. MAGGIO
Presentation
A 32-year-old woman, 28 weeks pregnant with her
second child, with no significant past medical history
presents to the emergency department with a 2-day
history of right upper-quadrant (RUQ) abdominal pain
and nausea. Her obstetrician-gynecologist, who had
evaluated her earlier in the day, thought it was unlikely
that her symptoms were related to her pregnancy. In the
emergency department, she is afebrile and her vital
signs are remarkable for mild tachycardia of 102. Her
pain is episodic, lasting approximately 90 minutes after
eating. On abdominal exam, the fundal height
measures 29 weeks, consistent with her pregnancy.
She has focal tenderness in the RUQ and reports that
the pain radiates through to her back on the same side.
She is anorexic but has been able to keep liquids
down.
Differential Diagnosis
Symptomatic cholelithiasis is a common cause of RUQ
abdominal pain and is second only to appendicitis as a
https://t.me/med1917
abdominal pain and is second only to appendicitis as a
cause of abdominal emergencies during pregnancy.
Although gallstones have been reported in up to 10% of
patients during pregnancy, the incidence of gallstonerelated diseases causing complications during pregnancy
is <1%. Contributing factors include hormonal changes
associated with increased bile stone formation and altered
gallbladder contractility.
Diagnosing symptomatic cholelithiasis during
pregnancy can be a challenge for any physician particularly
when compounded by efforts to limit radiologic exposure.
The presenting signs and symptoms of symptomatic
cholelithiasis may be nonspecific and difficult to distinguish
from those associated with pregnancy itself, and the
changing position of intra-abdominal contents during
pregnancy may complicate the examination of the gravid
abdomen. For example, the appendix is typically located at
McBurney’s point early in pregnancy but is later displaced
laterally and upward into the RUQ by the enlarging uterus
(Figure 1). As a consequence, appendicitis may present
as RUQ pain in the pregnant patient, especially in patients
late in their pregnancy. Less common causes of RUQ pain
during pregnancy include peptic ulcer disease,
pancreatitis, pyelonephritis, HELLP syndrome (syndrome
of hemolysis, elevated liver enzymes, and low platelets),
acute fatty liver, and hepatitis.
https://t.me/med1917
FIGURE 1 • As the uterus grows, there is upward displacement of the
https://t.me/med1917
appendix in counterclockwise fashion.
Workup
Laboratory evaluation including a complete blood count
and liver function tests was obtained. The white blood cell
count was mildly elevated at 13 × 103/μL. Liver and
pancreatic enzymes were normal (total bilirubin 1.0 mg/dL,
indirect bilirubin 0.5 mg/dL, alkaline phosphatase 90 U/L,
lipase 35 U/L). A RUQ abdominal ultrasound was
performed (F i g u r e 2) and demonstrated a normal
gallbladder wall with multiple hyperechoic shadowing
consistent with gallstones. The common bile duct
measured 0.7 cm.
FIGURE 2 • RUQ abdominal ultrasound revealing cholelithiasis.
https://t.me/med1917
Diagnosis and Treatment
The imaging modality of choice in diagnosing symptomatic
cholelithiasis is ultrasonography. Transabdominal
ultrasound is sensitive (>95% for gallstones), inexpensive,
and safe without exposing the patient to radiation. For the
diagnosis of acute cholecystitis, it yields a sensitivity of
88% and a specificity of 80%.
When choledocholithiasis is suspected (e.g., bilirubin or
alkaline phosphatase is elevated), endoscopic retrograde
cholangiopancreatography can be safely performed with
minimal radiation exposure as long as proper shielding is
used. Magnetic resonance cholangiopancreatography
(MRCP) is an alternative, but it is only diagnostic and its
safety in regard to the fetus has not been well established.
The timing of surgical intervention for symptomatic
cholelithiasis in the pregnant patient remains controversial.
Historical recommendations were to delay surgical
intervention until the second trimester. In the intervening
time, these patients were managed with intravenous fluids,
bowel rest, narcotics, broad-spectrum antibiotics, and a fatrestricted diet. More recent evidence suggests that an
operation can be performed safely during any trimester of
pregnancy. In fact, some surgeons have argued that
delaying surgery may have devastating consequences for
the fetus. When managed nonoperatively, symptomatic
cholelithiasis has a high recurrence rate and its associated
complications, such as gallstone pancreatitis, can lead to
https://t.me/med1917
spontaneous abortion and preterm labor. Recurrence rates
for symptomatic patients have been reported to be as high
as 92% in the first trimester, 64% in the second trimester,
and 44% in the third trimester.
Once the decision to perform an operative intervention
has been made, laparoscopic cholecystectomy is the
preferred approach. It carries the same benefits of
laparoscopy performed in the nonpregnant patient.
Specifically, laparoscopic surgery results in a decreased
requirement for narcotics, a lower rate of wound
complications, shorter hospital stays, and a decreased risk
of venous thromboembolism secondary to early
ambulation. An obstetric consultation should be obtained
for all cases involving a viable fetus (>24 weeks gestation)
and will typically include preoperative and postoperative
monitoring of fetal heart rate and uterine activity.
Surgical Approach for Laparoscopic
Cholecystectomy
The patient is placed supine on the operating table. For the
gravid patient, she can lie in the left lateral recumbent
position to decrease compression of the vena cava.
Access to the abdomen is obtained via an open Hasson,
Veress needle, or optical trocar, depending on surgeon
preference and level of experience. While there is no
evidence that any of the above options is superior to
others, many surgeons would opt to enter via an open
Hasson technique. This allows direct visualization of the
https://t.me/med1917
abdominal wall and intra-abdominal viscera prior to trocar
insertion. Port location should be adjusted for fundal height,
which should be measured before and after induction of
general anesthesia. More recent advances such as singleport laparoscopy should be reserved for high-volume
centers with surgeons experienced in this technique, and
only in pregnant patients whose fundal height permits entry
at the umbilicus.
Pneumoperitoneum can usually be achieved by CO
2
insufflation of 10 to 15 mm Hg, although it is important to
remember that some pregnant patients may demonstrate
restrictive lung physiology due to elevation of their
diaphragm. These patients are prone to arterial
desaturation and may be better managed with insufflation
pressures <12 mm Hg. In all cases, adequate visualization
of the gallbladder and biliary anatomy must be maintained.
Once all ports are placed, the fundus of the gallbladder
is retracted toward the abdominal wall and superiorly over
the liver, and the peritoneum is dissected from the
gallbladder neck. Dissection should be carried out from the
gallbladder neck to the common bile duct in order to gain
the critical view of safety (Figure 3). The critical view is
achieved by clearing all fat and fibrous tissue in Calot’s
triangle, after which the cystic structures can be clearly
identified, occluded, and divided. This helps to avoid bile
duct injuries and failure to successfully create this view is
an indication for conversion to an open cholecystectomy.
https://t.me/med1917
FIGURE 3 • Critical view during laparoscopic cholecystectomy. Note the
clear delineation of the junction of the cystic duct with the gallbladder as
well as the clear space between the gallbladder and liver, devoid of any
other structure other than the cystic artery.
The cystic duct and artery are then clipped and divided,
and the gall bladder is removed from its fossa using
electrocautery or the Harmonic scalpel. If there is spillage
of bile from the gallbladder, the abdomen should be
irrigated and the fluid aspirated. The ports are withdrawn
under direct visualization and the abdomen desufflated.
Each incision is closed (Table 1).
https://t.me/med1917
TABLE 1. Key Technical Steps and Potential Pitfalls to Laparoscopic
Cholecystectomy in the Pregnant Patient
Surgical Approach for Open
Cholecystectomy
For patients in whom laparoscopic cholecystectomy cannot
be performed safely, an open cholecystectomy is indicated.
This is accomplished through a right subcostal incision.
After retractors are placed and the bowel and gravid uterus
packed away from the surgical field, the gallbladder is
https://t.me/med1917
grasped and dissection is performed via a top-down
approach. The cystic duct and artery are identified, ligated,
and divided. Once adequate hemostasis is obtained, the
viscera are returned to their normal anatomic position and
the incision is closed in two layers (Table 2).
TABLE 2. Key Technical Steps to Open Cholecystectomy in the Pregnant
Patient
Postoperative Management
After undergoing laparoscopic cholecystectomy, patients
are usually admitted overnight for observation. Fetal
monitoring is required in cases that involve a viable fetus to
evaluate fetal heart rate and uterine activity. An oral diet
can be started on the day of surgery and oral pain
medications shortly thereafter. Patients undergoing an
open cholecystectomy typically require a 3- to 5-day
hospital stay to achieve adequate pain control and
sufficient oral intake.
https://t.me/med1917
Соседние файлы в папке @xirurgi_2025