During pregnancy and the postpartum period, high levels of progesterone increase a woman's vulnerability to gallstone formation. Up to 10 percent of pregnant patients are believed to have gallstones. Biliary tract disease is the second most common nonobstetric surgical problem during pregnancy and the postpartum period. There are concerns that laparoscopic gall bladder surgery may be complicated in the postpartum period because of changes in the biliary tract itself as well as the presence of an enlarged uterus and other intra-abdominal changes. In particular, laparoscopic surgery has been questioned in patients who have undergone a recent cesarean delivery. Diettrich and Kaplan conducted a prospective study to document special considerations for successful laparoscopic biliary surgery in postpartum patients.
The study included 1,100 consecutive patients presenting to a surgical practice with biliary tract disease. Thirty-four of these women had undergone biliary surgery within six weeks of childbirth. All patients had gallstones with symptomatic cholecystitis that met the criteria for surgery. In addition, in 10 (29 percent) of the patients, stones were documented in the ductal system, including one patient who had gallstone pancreatitis. Eight of the women had had a recent cesarean delivery. In these patients, a modified technique was used to obtain pneumoperitoneum, and the intra-abdominal pressure was limited to 10 mm Hg.
Initially, cholangiography was performed selectively but was routinely performed later in the series and led to the diagnosis of two patients with common duct stones who had none of the traditional risk factors. Choledocholithiasis was documented in 50 percent of patients who had preoperative indications for cholangiography and in 18 percent of patients who had no signs or symptoms of stones in the collecting system. Apart from the morbidity caused by common duct stones that were missed early in the study, there was no increase in surgical morbidity, and the average length of hospital stay was 2.6 days. No delayed complications were detected during a mean follow-up of 3.2 years.
The authors conclude that laparoscopic biliary surgery is safe and can be successful in the postpartum period, even in patients who recently delivered by cesarean section. The authors strongly recommend routine cholangiography for postpartum patients because of the high incidence of choledocholithiasis, which may not be clinically apparent.