First Trimester Laparoscopic Cholecystectomy Under Combined Spinal and Epidural Anesthesia: A Case for New Standard Care

Gabriel-Petre Gorecki, Department of Anesthesia and Intensive Care, CF2 Clinical Hospital, Bucharest, Romania, and colleagues detail the successful laparoscopic cholecystectomy of an 11-week pregnant woman performed under combined spinal and epidural anesthesia.

The case concerns a 37-year-old pregnant woman in the 11th week of pregnancy who presented with obstructive jaundice symptoms, including right hypochondrium pain, nausea, and vomiting. After an initial conservative treatment, her condition worsened, leading to the diagnosis of acute cholecystitis with hepatocytolysis syndrome. Given the risks associated with surgery during early pregnancy, a decision was made to proceed with laparoscopic cholecystectomy under combined spinal and epidural anesthesia (CSEA) after unsuccessful medical management.

This unique approach was chosen to minimize the risks to both mother and fetus, as general anesthesia posed higher risks. The patient underwent the procedure without complications, with intraoperative monitoring ensuring safety. The combined anesthesia technique allowed effective pain management and stability throughout the surgery. The patient received appropriate antibiotics and fluids, completing the procedure in 45 minutes.

Postoperative monitoring showed no complications and fetal health remained stable, with normal heart rates observed in Doppler ultrasound. The patient was discharged 24 hours after surgery, with her pregnancy progressing normally. Follow-up after childbirth via cesarean section revealed no long-term effects from the laparoscopy. This case highlights the feasibility and safety of laparoscopic surgery under CSEA for pregnant women in the first trimester, especially when conservative measures fail.

"This case demonstrates that laparoscopic cholecystectomy, compared to open surgery, is a safe and effective option even in the first trimester. To minimize fetal risk, combined spinal and epidural anesthesia was used, with ropivacaine 0.2% delivered through an epidural catheter for postoperative pain relief, reducing systemic drug exposure and enhancing patient comfort. We believe this approach could become the gold standard for laparoscopic surgery in pregnant patients. Additionally, monitoring end-tidal CO2 (ETCO2) during such surgeries can be beneficial due to the changes in respiratory mechanics that may occur from increased intra-abdominal pressure and surgical positioning," the researchers wrote.

"Combined spinal and epidural anesthesia could become a preferred option for laparoscopic surgeries in the first trimester of pregnancy due to its benefits in safety and analgesia," they concluded.

Reference:

Gorecki, G., Bodor, A., Kövér, Z., Comănici, M., Sima, R., Panaitescu, A., Comănici, A., Constantin, A., Pleș, L., Diaconescu, A. S., & Lungu, V. (2024). Laparoscopic Cholecystectomy Under Combined Spinal and Epidural Anesthesia in the First Trimester of Pregnancy—Case Report and Literature Review. Life, 14(11), 1492. https://doi.org/10.3390/life14111492