.png){kind=small}
.png){kind=small}
BackTable / OBGYN / Article
Improving Laparoscopic Surgery in Pregnancy: Patient Selection, Tools & Techniques
Evangeline Adjei-Danquah • Updated Jul 20, 2025 • 34 hits
Laparoscopic surgery during pregnancy has evolved from relative obscurity to a safe, effective option for managing both gynecologic and non-gynecologic conditions during pregnancy. With modern instruments and advancements in technique, surgeons can now perform laparoscopic cerclage procedures and ovarian cystectomies with relatively little risk. With careful positioning, minimal tissue exposure and close coordination with the anesthesia team to account for respiratory and vascular changes, those risks can be even further minimized.
Successful outcomes rely on thoughtful surgical techniques and planning, appropriate patient selection, and a collaborative, evidence-based approach. Laparoscopic procedures offer clear benefits, including reduced venous thromboembolism (VTE) risk, quicker recovery, and minimized surgical trauma. With appropriate risk management in place, laparoscopic alternatives to open procedures can provide both maternal and fetal safety in complex cases.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable OBGYN Brief
• Early research on laparoscopy in pregnancy, especially studies on pneumoperitoneum safety, helped establish its role as a safe and effective surgical option for pregnant patients.
• Scheduling surgery for the early second trimester minimizes risks, balancing ease of surgical access with physiologic safety.
• Physiologic changes in pregnancy require special considerations, such as patient positioning to avoid vena cava compression and careful management of pneumoperitoneum pressure.
• Laparoscopic pregnancy surgery is safe and effective when performed with proper technique, offering benefits like reduced VTE risk and faster recovery compared to open surgery.
• Standard surgical principles such as safe energy use, infection prophylaxis, and VTE prevention remain applicable with minor pregnancy-specific adjustments.
• Successful outcomes depend on coordinated care with anesthesia, thoughtful entry techniques, and evidence-based monitoring, tailored to gestational age and patient risk factors.
Table of Contents
(1) Advent of Laparoscopic Surgery in Pregnancy
(2) Considerations for Pregnancy Physiology in Laparoscopic Surgery
(3) Laparoscopic Techniques in Pregnant vs Non-Pregnant Patients
Advent of Laparoscopic Surgery in Pregnancy
The evolution of laparoscopic surgery in pregnancy highlights how once-controversial approaches have become standard practice. Dr. Sobolewski shares how early pioneers, like general surgeon Steve Eubanks at Duke, conducted groundbreaking animal studies on the safety of pneumoperitoneum during pregnancy—work that laid the foundation for the laparoscopic techniques now accepted as safe and beneficial in pregnancy.
This emphasizes that although laparoscopic pregnancy surgery was once seen as risky or experimental, it is now valued for its benefits, including reduced risks of complications like venous thromboembolism. Today gynecologic and non-gynecologic surgeries, such as appendectomies and cholecystectomies, remain the most common laparoscopic procedures performed on pregnant patients, making this research critical for both OB/GYNs and general surgeons.
[Dr. Mark Hoffman]
It's a fun time to be a part of. There's a lot happening where we are, so I'm excited. I know we had Jamal on recently talking a little bit about robotics specifically in pregnancy, but you had given a talk at AGL, and I was really excited to have you come chat with us about laparoscopy and pregnant patients and physiologic differences and those kinds of things. I wanted to hear a little bit about how you got interested in that, and where all that came out of.
[Dr. Craig Sobolewski]
Yes, thanks. I think it's something that we all needed to, at some point in our careers, whether we're a generalist or a specialist or subspecialist, have some experience with and have to think about. What's really been interesting over a long career is what at one point was pretty avant-garde is now considered routine, and that's just the evolution of life and certainly the evolution of medicine. I think that we really used to have to be very thoughtful about who were appropriate patients to consider this approach in and who were not.
Interestingly, when I came here in the early 2000s, general surgeon Steve Eubanks was the division director for the MIS portion of the general surgery department here at Duke. If you look at publications on the effects of pneumoperitoneum on pregnant fetuses, he did a lot of that work. Here at Duke, there's a big vivarium. He did pregnant use, so pregnant sheep studies, looking at the effects of pneumoperitoneum and safety. A lot of the groundbreaking research was laparotomy on a pregnant sheep, invasive monitoring of both mother and fetus, close the sheep back up, do pneumoperitoneum for an hour, monitor PO2, PCO2, uterine blood flow, those kinds of things.
Thankfully, to pioneers like him and others, we've learned a lot, and we know that done properly, it's incredibly safe. All of the standard advantages of laparoscopy that we talk to all of our patients about certainly pertain to pregnant patients, and in many ways are even more important, like lower risk for VTE, for example, things like that. Yes, it was pretty interesting to meet him and hear about the work that he was doing when I first got here.
[Dr. Mark Hoffman]
It's incredible to think about being a physician and scientist like that. Again, I know there's a lot of folks doing research out there, but so much about academic medicine these days. In many places, it's productivity. It's really, you have to decide clinical practice or focus on research. There's so many hours in the day, and to think about some of these guys that were doing, I'm sure he was a busy surgeon. Then in his spare time operating on sheep, it just seems--
Yes, it is. It is an amazing testament to the guys who were able to do these things so long ago, it wasn't that long ago, I guess, that allowed us to do these things that you said. You said we take it for granted. Oh, yes, well, obviously, laparoscopy is the right thing to do in these situations, but there were times-- I talked to Arnie about this. I heard all the stories in Michigan, and it was like malpractice, we'll call them peer review if you consider doing these crazy things. To be a pioneer, it takes guts.
[Dr. Craig Sobolewski]
Yes, definitely need some cowboys out there, for sure. He did that. I think at first, I was like, "Well, gosh, you're a general surgeon. Why are you interested in this?" The reality is the overwhelming majority of abdominal surgeries on pregnant patients are done for non-gynecologic indications. The majority of them are acute appendicitis or acute cholecystitis. In retrospect, it made perfect sense that he was interested in doing that research at that time.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Considerations for Pregnancy Physiology in Laparoscopic Surgery
Laparoscopic surgery in pregnancy requires careful attention to maternal physiology and procedural timing. The early second trimester is often the ideal window for intervention, balancing accessibility and safety. To minimize vena cava compression by the gravid uterus, surgical strategies like lateral table tilt are used. Achieving optimal exposure while preserving uterine safety is critical, often creatively aided by tools such as liver retractors.
Pregnancy also brings significant respiratory changes like increased tidal volume and minute ventilation to compensate for diaphragm elevation and respiratory alkalosis. Collaboration with anesthesiologists experienced with pregnant patients is crucial to manage these physiologic shifts, particularly when adjusting ventilation. Using alternative trocar entry points, such as Palmer’s point, can help ensure safe access and effective laparoscopic surgery during pregnancy.
[Dr. Craig Sobolewski]
…If you'd like to get back to the physiology piece of things because, ideally, there is definitely a sweet spot when you're thinking about doing these operations in pregnancy. That early second trimester is really ideal because it's scary to be touching the uterus, that you can imagine something's kicking back at you when you're in there. What's important to remember about the gravid uterus is that as it gets bigger in the supine position, it's going to cause venous compression on the vena cava. One of the things that we do in that case and others is routinely, we'll tilt the table in a left lateral position. We'll have anesthesia airplane the table.
[Dr. Mark Hoffman]
Certain number of degrees or just enough.
[Dr. Craig Sobolewski]
Yes, just enough. As a former obstetrician many, many years ago, it was always tilt them to the left. I'll put a pillow under them so that they're tilted to the left, because it does. It gets the uterus a little bit more easily off of the vena cava. The same thing happens if you tilt them to the right. If we're putting the suture in on the right side of the patient, we'll tilt the patient to her left if we're doing-
[Dr. Mark Hoffman]
Oh, that's interesting.
[Dr. Craig Sobolewski]
-it on the other side, then we airplane the table the other way. Whatever you can do because-- The residents hear me say this all the time, there's only two things that you have to do to be a good surgeon. It's, you have to know anatomy, so you have to have the knowledge of anatomy and you have to have exposure. If you have one without the other, you are up the proverbial creek.
If you know what you need to see, but you can't figure out a way to see it, you can't progress the surgery forward. In these patients, there's a liver retractor that we use, which is a 5-millimeter long snake-like device that as you turn it, it shapes itself into almost like a curved metal triangle. It's got a big space in the center of it. We can put that underneath the uterus and scoop it up a little bit and still only have a small surface area that's in contact with the uterus. We'll use that liver retractor.
…Yes. Physiology of pregnancy is really fascinating because the way that the body has to compensate for all of these things is really pretty interesting. The rib cage gets bigger. Even though the diaphragm goes up, the rib cage gets bigger. Your tidal volumes will go up, but because these other pulmonary functions decrease, patients will respond.
Essentially you get a respiratory alkalosis because of the physiology of pregnancy. The way that the pregnant patient compensates for that is by increased minute ventilation. I know you're a father. I know that you had a wife who's been pregnant, and by the end of their pregnancy, their minute ventilation is up there, man. They're huffing and puffing just so that they don't get too alkalotic.
[Dr. Mark Hoffman]
That's interesting. No, those are the kinds of things I would imagine that make you want to be a little bit more efficient in the OR. Having a plan, all those things, these are not great positions for pregnant patients to be in.
[Dr. Craig Sobolewski]
Yes. The work, honestly, falls all on our anesthesia colleagues because they're the ones that have to understand that physiology and make the appropriate changes in the vent settings in order to compensate for that. The pulmonary function part, we need to be good colleagues and make sure that we're operating on the lowest bias, so no more than 15 millimeters of mercury. If you can see as well as you need to at 12, that's probably going to make our anesthesia friends a little nicer when you're having a cup of coffee at the end of the case.
[Dr. Mark Hoffman]
Are you actively trying to minimize the pressure, or is it only if they're complaining across the drape?
[Dr. Craig Sobolewski]
We'll start at 15 to get in. It just depends. First of all, any entry technique that you're comfortable using is safe in pregnancy. You clearly need to understand that you might need to think of an alternate site. If you normally go in with a Veress at the umbo, you might want to reconsider that if your patient's 16 weeks pregnant or something like that. They've all been described in literature, they've all been demonstrated to be safe. Whether it's Veress, followed by a trocar, whether it's optical trocar without a Veress, whether it's openness on, they're all perfectly safe.
[Dr. Mark Hoffman]
What's your technique?
[Dr. Craig Sobolewski]
We'll universally go in left upper quadrant at Palmer's point. I typically go in Veress up there, followed by an optical trocar, but I don't know, depending on my mood, sometimes I'll just go direct optical. Then, we'll get in at 15 just to do our initial survey, and then we'll decrease it a bit. If we can still see sufficiently well, then we just stay there. I will say that for our pregnancy cerclages, we almost always just keep it at 15 just because the view is already so obscured by the size of the uterus because they're never early second trimester. They're always right around 14, 15 weeks, and that's a challenge.
I think it's not a bad idea to try to operate on. If your standard is 15, if you can get by with a little bit lower, that's probably in your patient's best interest, and certainly makes life a little bit easier for anesthesia.
Laparoscopic Techniques in Pregnant vs Non-Pregnant Patients
When performing laparoscopic surgery on pregnant patients, standard electrosurgical devices (typically monopolar or harmonic) can be used safely given the surgeon maintains awareness of surrounding structures, especially the gravid uterus. Close visualization and mindful use of instruments are essential to avoid unintended injury. Just as with any surgery, understanding anatomy and ensuring appropriate exposure remain key principles.
While pregnancy introduces unique physiologic changes, most surgical protocols including VTE prophylaxis and infection prevention do not require significant adjustment from standard care in non-pregnant patients. However, in pregnant patients fetal monitoring varies based on gestational age, with pre- and post-procedure checks often performed. Entry techniques, patient positioning, and anesthesia collaboration are critical considerations for pregnant patients compared to non-pregnant patients. Postoperatively, aside from gestational-specific monitoring, standard recovery practices typically apply.
[Dr. Mark Hoffman]
Yes. Talk to me about energy in pregnant patients. Do you think much about that? Does it matter, or is it–
[Dr. Craig Sobolewski]
I don't think it should matter. I think you have to be careful to understand things like direct coupling and ways that if-- I like to operate in the near field. I like to have my laparoscope pretty close to whatever it is that I'm operating on. I think you just see better detail. If you are doing that and you forget that there's a big, huge uterus behind the tip of the laparoscope that you can't see, and you've got an energy instrument in there, if it's laying on the uterus or something, God forbid it.
I just feel like if you're going to use some energy, make sure you understand, as is always appropriate, what's nearby. Now you're going to have this big old mass there in the middle that you really don't want to burn if you can avoid it.
[Dr. Mark Hoffman]
No reason to avoid monopolar, no reason to avoid anything specifically using harmonic or whatever. It's all good surgical technique-
[Dr. Craig Sobolewski]
Yes.
[Dr. Mark Hoffman]
-avoiding touching things you don't want to touch.
[Dr. Craig Sobolewski]
When I think about it, if I think about what's different about operating in a pregnant patient compared to a non-pregnant patient, I think there are some things that when you are making the decision to operate, whether any day of the week, you're in your clinic and you see a patient and you're making a decision to operate, and now you've made that decision, then you go through your list of what you do to plan for that procedure. All that's going to be the same in a pregnant patient, but there's going to be some things that might be a little bit different. Pregnancy is a hypercoagulable state. Do I need to do anything differently about my VTE prophylaxis? The answer is no, it really isn't.
Even though there are physiologic changes in terms of the coagulable factors, most of the increased PTE risk comes from venous stasis. I think being efficient in the OR, SCDs, if the patient-- if you have a scoring system that you use to determine VTE risk and that person scores at a level that would require perioperative heparin is safe in a pregnant patient. Whatever your VTE management is, it shouldn't change based on a pregnant patient. You're going through your order list. Do you have to prophylax them against infection differently? The answer there is no. You use standard guidelines for whatever antibiotic prophylaxis based on the procedure that you're doing.
When they're in the hospital in pre-op, there are some things you might do differently. At least we do. If it's a pre-viable pregnancy, we'll get fetal hearts by Doppler, and that's it. We'll do that both pre- and post-procedure. We don't do anything for tocolysis. There's no evidence to support routine tocolytics in any manner. If it's a viable pregnancy, they should have both electronic fetal heart monitoring as well as monitoring for contractions, both pre- and post-procedure. That's different. That's not going to be in your ERAS order set for whatever procedure you're doing.
Think about your trocar entry or your site of entry, how you're going to get in. Think about how you're going to position the patient throughout the operation. Make sure you have an anesthesiologist who's comfortable managing a patient during pregnancy. Post-operatively, other than fetal hearts, and based on gestational age, with whichever way you're going to do it, there's really no guidelines or need to manage those patients differently in the immediate post-operative timeframe.
[Dr. Mark Hoffman] Are you keeping them overnight? You're sending them home?
[Dr. Craig Sobolewski]
Yes, sending them home. There's no evidence to support this necessarily, but for our cerclages, we just document the deepest amniotic fluid pocket in pre-op and post-op. We do just a quick bedside ultrasound, look at fluid, and then we do a quick bedside ultrasound and look at fluid afterwards just because we're putting a needle that sometimes goes into the stroma of the uterus, just to document that we didn't rupture them so that if three or four days later, God forbid, they rupture, we know–
[Dr. Mark Hoffman]
You know that they ruptured three or four days later or not?
[Dr. Craig Sobolewski]
We know that it didn't happen as a consequence of the procedure that we did, yes.
[Dr. Mark Hoffman]
Cerclage loose enough that you can do a DNC?
[Dr. Craig Sobolewski]
Yes, that's the–
[Dr. Mark Hoffman]
Afterwards, that was something that we talked about.
[Dr. Craig Sobolewski]
I don't know how you ensure that that's the case. Part of our consent is that the patient might need a hysterotomy for an IUFD. Ideally, it would be nice if you could do that, but the flipside of this is, what's the purpose of the procedure? The purpose of the procedure is to retain the pregnancy. I haven't figured out a way to gauge the degree of constriction at the cervix. It's all done by eye and gestalt mostly. I will say it's part of the reason that we like doing these standard laparoscopic is just because you can get a little bit better tactile appreciation of how tight you're tying the knot.
Podcast Contributors
Dr. Craig Sobolewski
Dr. Craig Sobolewski is a minimally invasive GYN surgeon at Duke University in Durham, North Carolina.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2025, March 11). Ep. 79 – Laparoscopy in Pregnancy: Key Considerations for Surgeons [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Vaginal vs Abdominal Cerclage: Sustaining Second Trimester Pregnancies
Treating Trafficked Patients: Focus on Trauma-Informed Care
How to Identify Human Trafficking in Healthcare Settings & How to Respond
Isthmocele Repair: Counseling, Surgical Techniques & Complications