In Reply:—

I appreciate the thoughtful comments expressed by Drs. Pennington and Stein about the Clinical Concepts and Commentary article concerning management of surgery for the pregnant patient. Because of imposed limitations on the number of references, the only referenced article about laparoscopy and pregnancy was from the Swedish Health Registry;1however, mention was made in my article about “several case reports of success in the late second and early third trimesters” using laparoscopic techniques. Not mentioned were case reports of problems with the technique, including trocar injuries resulting from the limited operative space and respiratory acidosis resulting from carbon dioxide insufflation. 2Currently, techniques of gasless laparoscopy during pregnancy are being used at some institutions. 3 

The precautions recommended were not from the Swedish Health Registry data, which did not address the use of low intraabdominal pressure, the use of pneumatic stockings, or the choice of gas for creating pneumoperitoneum. The precautions represented suggestions from case reports in the literature. I agree that carbon dioxide has become the gas of choice in creating pneumoperitoneum and has the benefit of noncombustibility. Nitrous oxide can be a useful alternative to avoid the respiratory acidosis reported with use of carbon dioxide. I use carbon dioxide when electrocautery is employed, with attention to end-tidal carbon dioxide (ETCO2) and arterial carbon dioxide tension (PaCO2), maintaining the normally reduced values during pregnancy, to avoid acidosis.

Reedy MB, Kallen B, Kuehl TJ: Laparoscopy during pregnancy: A study of five fetal outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol 1997; 177:673–9
Bhavani-Shankar K, Steinbrook RA, Mushlin PS, Freiberger D: Transcutaneous PC02monitoring during laparoscopic cholecystectomy in pregnancy. Can J Anaesth 1998; 45:164–9
Tanaka H, Futamura N, Takubo S, Toyoda N: Gasless laparoscopy under epidural anesthesia for adnexal cysts during pregnancy. J Reprod Med 1999; 44:929–32.