Pantelis Athanasios G, Machairiotis Nikolaos, Stavros Sofoklis, Potiris Anastasios, Karampitsakos Theodoros, Lapatsanis Dimitris P, Drakakis Petros
Surgical Department of Obesity and Metabolic Disorders, Athens Medical Group, Psychiko Clinic, Athens, GRC.
Third Department of Obstetrics and Gynecology, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC.
Cureus. 2024 Jun 30;16(6):e63521. doi: 10.7759/cureus.63521. eCollection 2024 Jun.
Accumulation of experience with minimally invasive surgery over the last three decades has rendered laparoscopic surgery the mainstay of management for surgical pathology during pregnancy. In the present meta-review, we compiled the available evidence on the safety of laparoscopic and robotic-assisted surgeries during pregnancy, based on relevant systematic reviews (SR) and meta-analyses (MA). A systematic review was performed for articles published until February 2024 in English using PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online) and Google Scholar based on predefined selection and exclusion criteria. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and included SRs and MAs examining women of childbearing age (population) who had undergone laparoscopic surgery or robotic-assisted laparoscopic surgery during pregnancy (intervention). The presence of comparison to open surgery was desirable but not mandatory (comparator). The included studies should necessarily report on fetal loss (outcome), and optionally on other metrics of fetal, maternal, or operative performance. We considered SRs/MAs analyzing randomized trials, observational studies, case reports, and case series (study design). The methodological quality of SRs/MAs not exclusively including case reports and case series was assessed with the Assessment of Multiple Systematic Reviews (AMSTAR) 2 instrument. A total of 1229 articles were screened, of which 78 were potentially eligible. Of these, 33 articles met our inclusion criteria, 18 containing SRs only and 15 SRs with MA. The examined disciplines were laparoscopic appendectomy (10 studies, 30.3%), laparoscopic cerclage for cervical insufficiency (eight studies, 24.2%), adnexal-ovarian laparoscopic surgery (five studies, 15.2%), laparoscopic cholecystectomy and biliary tree exploration (three studies, 9.1%), laparoscopic myomectomy (two studies, 6.1%), and one study each for laparoscopic surgery regarding pancreatic indications, adrenal indications, and bariatric complications (3.0%). The odds ratio/relative risk for fetal loss rate ranged from 0-1.9, with variable statistical significance depending on the discipline. Twenty-three out of the 33 studies were submitted to quality evaluation with the AMSTAR 2 instrument, with three being of "low quality" (13.0%) and the remaining 20 of "critically low quality" (87.0%). In conclusion, the widespread acceptance of laparoscopic surgery for treating surgical pathology during pregnancy is substantiated by heterogeneous and low-quality evidence. Literature mainly revolves around laparoscopic appendectomy, whereas other disciplines that may commonly arise during pregnancy, such as cholecystectomy and the acute abdomen following bariatric surgery, are underrepresented in the literature. Factors such as anatomical alterations that may affect surgical access, surgeon's expertise, and the biological course of the underlying pathology should be taken into consideration when selecting the appropriate mode of operating during pregnancy.
在过去三十年中，微创手术经验的积累使腹腔镜手术成为孕期外科病理学治疗的主要手段。在本次荟萃综述中，我们基于相关系统评价（SR）和荟萃分析（MA），汇总了孕期腹腔镜手术和机器人辅助手术安全性的现有证据。使用PubMed/MEDLINE（医学文献分析与检索系统在线）和谷歌学术，根据预先定义的纳入和排除标准，对截至2024年2月发表的英文文章进行了系统评价。我们采用了系统评价和荟萃分析的首选报告项目（PRISMA）指南，纳入了对孕期接受腹腔镜手术或机器人辅助腹腔镜手术的育龄妇女（人群）进行研究的SR和MA（干预）。与开放手术进行比较是理想的，但不是必需的（对照）。纳入的研究必须报告胎儿丢失情况（结局），也可选择报告胎儿、母亲或手术操作的其他指标。我们考虑了分析随机试验、观察性研究、病例报告和病例系列的SR/MA（研究设计）。使用多重系统评价评估（AMSTAR）2工具对并非仅包含病例报告和病例系列的SR/MA的方法学质量进行评估。共筛选了1229篇文章，其中78篇可能符合条件。其中，33篇文章符合我们的纳入标准，18篇仅包含SR，15篇为SR与MA。所研究的学科包括腹腔镜阑尾切除术（10项研究，30.3%）、宫颈机能不全的腹腔镜宫颈环扎术（8项研究，24.2%）、附件 - 卵巢腹腔镜手术（5项研究，15.2%）、腹腔镜胆囊切除术和胆道探查术（3项研究，9.1%）、腹腔镜子宫肌瘤切除术（2项研究，6.1%），以及关于胰腺疾病、肾上腺疾病和减肥手术并发症的腹腔镜手术各1项研究（3.0%）。胎儿丢失率的比值比/相对危险度范围为从0至1.9，根据学科不同，统计学意义各异。33项研究中的23项使用AMSTAR 2工具进行了质量评估，其中3项为“低质量”（13.0%），其余20项为“极低质量”（87.0%）。总之，孕期腹腔镜手术治疗外科病理学的广泛接受是由异质性和低质量的证据所证实的。文献主要围绕腹腔镜阑尾切除术，而孕期常见的其他学科，如胆囊切除术和减肥手术后的急腹症，在文献中的代表性不足。在选择孕期合适的手术方式时，应考虑可能影响手术入路的解剖改变、外科医生的专业技能以及潜在病理状况的生物学进程等因素。
