What is the optimal time for gallbladder (cholecystectomy) removal in a pregnant patient?

From the Guidelines

The optimal time for gallbladder removal (cholecystectomy) during pregnancy is the second trimester, specifically between weeks 13 and 26, as it balances maternal and fetal risks while addressing the patient's gallbladder disease. This recommendation is based on the most recent and highest quality study available, which suggests that laparoscopic cholecystectomy is safe during pregnancy and is the standard of care regardless of trimester, but ideally in the second trimester 1.

Key Considerations

• Surgery during the first trimester should be avoided when possible due to the higher risk of spontaneous abortion and concerns about anesthetic effects during critical fetal organ development.
• Third trimester surgery becomes technically more challenging due to the enlarged uterus limiting surgical exposure, and carries increased risks of preterm labor.
• If a pregnant patient presents with acute cholecystitis or other severe gallbladder disease requiring urgent intervention, surgery should proceed regardless of gestational age, as the risks of untreated disease may outweigh surgical risks.
• Laparoscopic cholecystectomy is generally preferred over open surgery due to shorter hospital stays, less postoperative pain, and quicker recovery, as supported by a study that found a significantly lower mean number of cumulative hospitalizations in patients who underwent cholecystectomy during the index hospitalization 1.
• During the procedure, the patient should be positioned slightly on her left side to minimize uterine compression of the vena cava, and fetal monitoring should be employed before and after surgery.

Additional Recommendations

• Conservative management with antibiotics and pain control may be appropriate for mild cases, particularly if the patient is near term, with definitive surgery performed postpartum.
• The Society of American Gastrointestinal and Endoscopic Surgeons guidelines recommend that after the first trimester of pregnancy, patients should be placed in the left lateral or partial left lateral decubitus position for laparoscopy to minimize compression of the inferior vena cava 1.
• A study of 1245 pregnant women with biliary pancreatitis found a significantly higher 30-day readmission rate in patients who did not undergo index cholecystectomy, highlighting the importance of timely surgical intervention 1.

From the Research

Optimal Time for Gallbladder Removal in Pregnant Patients

The optimal time for gallbladder removal in pregnant patients is a topic of discussion among medical professionals. Several studies have investigated the outcomes of cholecystectomy during different trimesters of pregnancy.

• A study published in the Journal of the American College of Surgeons in 2021 found that cholecystectomy can be performed in the first trimester without significantly increased risk of maternal and fetal complications, compared to the second trimester 2.
• However, the same study found that cholecystectomy during the third trimester was associated with a higher rate of preterm delivery and overall maternal and fetal complications 2.
• Another study published in Surgical endoscopy in 2021 suggested that delay of cholecystectomy should be discussed in the third trimester due to an increased risk for preterm delivery 3.
• A study published in the Journal of gastrointestinal surgery in 1997 recommended that laparoscopic cholecystectomy should be performed either in the second trimester or early in the third trimester, if possible 4.
• A nationwide register-based study published in the International journal of surgery in 2024 found no significant differences in outcomes when comparing cholecystectomy among the different trimesters 5.

Trimester-Specific Outcomes

The outcomes of cholecystectomy during different trimesters of pregnancy are as follows:

• First trimester: No significant increase in maternal and fetal complications compared to the second trimester 2.
• Second trimester: Considered the ideal time for cholecystectomy, with low rates of complications 2, 6.
• Third trimester: Associated with a higher rate of preterm delivery and overall maternal and fetal complications 2, 3.

Safety of Cholecystectomy During Pregnancy

Several studies have confirmed that cholecystectomy is safe for both the mother and the fetus during pregnancy, regardless of the trimester 6, 4, 5.

• A study published in Surgical laparoscopy & endoscopy in 1994 found no maternal or fetal morbidity or mortality in four patients who underwent laparoscopic cholecystectomy during the second trimester 6.
• A study published in the Journal of gastrointestinal surgery in 1997 found no fetal deaths or premature births related to the procedure in 22 patients who underwent laparoscopic cholecystectomy during pregnancy 4.
• A nationwide register-based study published in the International journal of surgery in 2024 found that cholecystectomy, ERCP, and combinations thereof are safe during pregnancy, with no significant differences in outcomes compared to nonpregnant patients 5.