Gebelikte Acil ve Onkolojik Cerrahi Yaklaşım Prensipleri
Özet
Gebelik süresince obstetrik olmayan acil cerrahi gereksinimleri, gebelik nedeniyle ertelenmemeli; elektif prosedürler ise doğum sonrasına bırakılmalıdır. En sık karşılaşılan nonobstetrik cerrahi endikasyonları akut apandisit ve safra kesesi hastalıklarıdır. Cerrahi operasyonların ve anestezi maruziyetinin ilk trimesterde yapısal anomali riskini artırmadığı gösterilmiş olsa da gebelik kaybı riskini minimize etmek adına acil olmayan batın cerrahileri için ikinci trimester en ideal dönem kabul edilir. Laparoskopik yaklaşım; daha kısa ameliyat süresi, azalan hastanede kalış süresi ve daha düşük komplikasyon oranları ile laparatomiye kıyasla güvenli bir alternatif sunar. Operasyon sırasında batın içi basıncın 8-12 mmHg arasında tutulması ve 16. haftadan büyük gebeliklerde vena cava basısını önlemek için hastaya sol lateral pozisyon verilmesi kritiktir. Gebelikte adneksiyal kitlelerin büyük çoğunluğu benign karakterde olup ikinci trimesterde geriler; ancak 10 cm'den büyük, solid veya septalı persiste kitleler torsiyon ve malignite riski nedeniyle çıkarılmalıdır. Malignite şüphesinde vertikal orta hat insizyonu ile laparatomi tercih edilmeli, ileri evre over kanserlerinde sitoredüktif cerrahi ve platin bazlı kemoterapi yaklaşımları anne ile fetüsün durumuna göre bireyselleştirilmelidir.
Non-obstetric emergency surgical requirements during pregnancy should not be delayed due to gestation, whereas elective procedures must be postponed until the postpartum period. The most common non-obstetric surgical indications are acute appendicitis and gallbladder diseases. Although surgical operations and anesthesia exposure in the first trimester have not been shown to increase the risk of structural anomalies, the second trimester is considered the most ideal period for non-emergency abdominal surgeries to minimize the risk of pregnancy loss. The laparoscopic approach offers a safe alternative compared to laparotomy, associated with shorter operative times, decreased hospital stays, and lower complication rates. Maintaining intra-abdominal pressure between 8-12 mmHg during surgery and placing the patient in a left lateral position for pregnancies greater than 16 weeks to prevent vena cava compression are critical steps. The vast majority of adnexal masses in pregnancy are benign and regress in the second trimester; however, persistent masses larger than 10 cm, solid, or septated should be removed due to the risk of torsion and malignancy. In case of suspected malignancy, laparotomy with a vertical midline incision is preferred, and cytoreductive surgery and platinum-based chemotherapy approaches in advanced ovarian cancers should be individualized based on maternal and fetal conditions.
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