Laparoscopic appendectomy during pregnancy: between personal experiences and scientific evidence

A Safe Laparoscopic Approach for Ovarian Tumors during Pregnancy

Objectives

Surgery for pregnant women with ovarian tumors poses the risk of uterine irritation. We aimed to demonstrate the superiority of our laparoscopic technique over conventional methods and to compare the outcomes of laparoscopy with those of laparotomy for ovarian tumors during pregnancy.

Materials and Methods

This retrospective study included 50 patients undergoing procedures for ovarian tumors during pregnancy at the Tokushima University Hospital between January 2005 and December 2021. We compared surgical outcomes between laparoscopic procedures and laparotomy, along with complications. In addition, we compared the frequency of uterine stimulation with the conventional trocar position to that with the currently used trocar position in laparoscopic surgery.

Results

Forty patients in the laparoscopy group and 10 in the laparotomy group underwent procedures. The laparoscopy group had less bleeding (16.4 ± 28.8 vs. 58 ± 72.2 mL, P < 0.05) and shorter hospital stays (7.6 ± 1.7 vs. 12.8 ± 13.1 days, P < 0.05) compared with those of the laparotomy group. The outcomes showed no significant differences between groups. All laparoscopies and laparotomies were successful and without complications. Furthermore, the current trocar position tended to stimulate the uterus less frequently.

Conclusion

The results suggested that, compared to laparotomy, laparoscopy for ovarian tumors during pregnancy had better outcomes. The trocar position in our technique allows for easy operation of ovarian tumors without interference by forceps or cameras, resulting in minimal irritation of the uterus. Our original laparoscopic method may be safer with superior outcomes over the conventional method.

Laparoscopic management of ovarian cysts during pregnancy under urgent situations

BACKGROUND

Majority of adnexal masses are incidental findings during pregnancy and resolve spontaneously. They may complicate pregnancy due to haemorrhage, cyst rupture and ovarian torsion. Laparoscopy is the preferred surgical intervention owing to shorter operative time, quicker recovery and lower post-operative pain. However, safety and feasibility of laparoscopic surgery in the management of ovarian cysts in pregnant women is challenging especially at advanced gestational ages and in urgent situations.

METHODS

In this retrospective study, a total of 48 cases of urgent laparoscopic surgeries were evaluated in the first and second trimesters of pregnancy between March 2018 and March 2021 in Al-Zahra Hospital, Tabriz, Iran.

RESULTS

The operations were ended in all patients successfully. The mean operation time was 45 min. There were no foetal maternal complications. All pregnancies had been terminated after 37 weeks of gestation. Oophorectomy had been performed in six patients and six other patients needed blood transfusion. Ovarian torsion was the most common reason for emergency surgery and mature teratoma was the most commonly reported pathology. Tocolytic therapy was required in six patients, and all of the patients were prescribed 50 mg of injectable progesterone twice daily for 10 days after surgery. The mean intra-abdominal pressure was equal to 15 mmHg and the mean end-expiratory carbon dioxide (CO 2 ) pressure was 36 mmHg. Intravenous paracetamol was used to relieve post-operative pain. The mean hospitalisation time was 1.63 days.

CONCLUSION

Most of the ovarian cysts can be managed laparoscopically with ensured safety and lower morbidity even in emergency situations at advanced gestational ages.

Analysis of 190 Female Patients after Appendectomy

This study is a retrospective cohort review carried out at a single, private tertiary center. We included 190 female patients who underwent surgery for acute appendicitis between January 2016 and December 2018. Two groups of patients were analyzed based on the pregnancy. The main outcome measures were complication rate and risk of abortion during or after surgery. Out of 190 female patients, eight of them were pregnant (4.2%). The pregnant group more significantly underwent ultrasound investigation compared to the nonpregnant group. Complicated appendicitis present in two pregnant patients at advanced gestational age was not statistically significant from nonpregnant. Laparoscopic appendectomy was performed in 6/8 (75%) of pregnant compared to 158/182 (87%) in nonpregnant (p = 0.415). Compared to the nonpregnant, the pregnant group has a more fecolith, positive peritoneal fluid culture, and wound infection, with E. coli more frequently isolated in 25%. None of the pregnant patients had an abortion, preterm labor, or mortality during or after surgery. In conclusion, laparoscopic appendectomy is a low-risk operation for pregnant with acute appendicitis.

Updated Evaluation of Laparoscopic vs. Open Appendicectomy During Pregnancy: A Systematic Review and Meta-Analysis

To explore the updated evaluation about the obstetrical and perioperative outcomes of laparoscopic appendicectomy (LA) for pregnancy appendicitis compared with open appendicectomy (OA). Two reviewers independently searched the PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science databases to screen eligible studies up to December 2020. Only clinical researches, no < 10 cases for LA and OA group were included. Twenty retrospective studies with 7,248 pregnant women, evaluating LA and OA in surgical and obstetrical outcomes, were included. The weighted mean difference (WMD) with 95% CI and odds ratio (OR) was used to compare continuous and dichotomous variables. It seems LA was connected with significantly shorter hospital time and lower wound infection [mean difference (MD), −0.57 days; 95% CI, −0.96 to −0.18; p = 0.004 and OR, 0.34; 95% CI, 0.18 to 0.62; p = 0.0005, respectively]. The incidence of fetal loss after LA was higher than OA (OR,1.93; 95% CI, 1.39–2.69; p < 0.0001). It was almost similar in the rate of preterm delivery (OR, 0.80; 95% CI, 0.48 to 1.34; p = 0.40) and other perioperative and obstetrical complications (p > 0.05). Our results indicated that the occurrence of fetal loss after LA should not be ignored. Caution, skillful operation, and thoroughly informed consent about the advantages and disadvantages of laparoscopy are necessary.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42021233150.

Tubectomy of Pregnant and Non-pregnant Female Balinese Macaques (Macaca Fascicularis) With Post-operative Monitoring

Worldwide, primates, and humans increasingly share habitats and often enter in conflict when primates thrive in human-dominated environments, calling for special management measures. Reproductive control is increasingly used to manage population growth but very few monitoring data are available. Therefore, the efficiency and implications of such programs require a careful examination. In the context of a contraception program in wild female long-tailed macaques in Ubud, Bali, conducted over four successive campaigns between 2017 and 2019, including 140 females (i.e., 41.9% of the reproductive females of the population in 2019), modifications of an endoscopic tubectomy procedure, a permanent sterilization method, clinical evaluation of this method, and the post-operative monitoring results of the neutered females after release are described. This surgical approach was applicable for pregnant females: 28.6% of the treated females were pregnant at the time of the surgery. The procedure used a single lateral port to reach and cauterize both oviducts in non-pregnant as well as in early to mid-term pregnant females. Pregnant females nearer to term required a second lateral port to access both oviducts masked by the size of the gravid uterus. Moreover, bipolar thermocauterization was utilized successfully without resection to realize the tubectomy. The average duration of the laparoscopic surgery was 14 min for non-pregnant females and 22 min for pregnant females. Animals were released 3 h 22 min in average following their capture. This short holding time, recommended for free-ranging primates, was made possible by the minimal invasiveness of the sterilization approach. A laparoscopic post-operative evaluation conducted on two patients during the following campaign confirmed that the oviducts were definitely disrupted and no longer patent. Moreover, no new pregnancies in sterilized females were recorded during the 3-year observation period. The survival rate of the treated females 6 months after sterilization was high (96.3%) with no major post-operative complications clinically recorded. Among females that were pregnant during surgery, 81.1% were confirmed to experience term delivery. This study demonstrates the safety and efficiency of endoscopic tubectomy, even for pregnant females, as a mean of wild macaques' population control.

Laparoscopic treatment for appendicitis during pregnancy: Retrospective cohort study

Background

Acute appendicitis is the most frequent non-obstetric surgical emergency during pregnancy. The benefits of laparoscopy during pregnancy are well known, but complications can occur, and these can affect both the mother and/or the foetus.We present results of laparoscopic surgical treatment of acute appendicitis in pregnant women, analysing the occurrence of adverse postoperative, obstetric and foetal outcomes and reviewing literature.

Materials and methods

Retrospective observational study on pregnant women with a preoperative diagnosis of acute appendicitis.

Results

n = 63, mean age 28.4 years, average gestational age of 17.7 weeks (3-30 weeks). 6.4 % exploratory laparoscopies, 92 % laparoscopic appendectomies and one right colectomy were performed. Conversion rate was 3.2 %. When symptoms begun within 48 hours prior to surgery, a perforated appendicitis was found in 11 %; whereas when the time from symptom onset to surgery was greater than or equal to 48 hours, it was evident in 31 % of the cases (p 0.008). The only independent variable associated with the presence of postoperative complications was symptom duration prior to surgery greater than or equal to 48 hours (OR 4.8; 95 % CI 1.1-16.2; p 0.04). Seven minor and 2 mayor postoperative complications were observed. Patients with complications spent, on average, twice as many days hospitalized (p < 0.001); and had 8 times more risk of preterm delivery (p 0.03). Obstetric complications were more frequent in pregnant women operated during the first trimester. Foetal mortality was 1.6 %.

Conclusion

Surgical morbidity of acute appendicitis in pregnant women is linked to the delay in the diagnosis and treatment of the inflammatory condition. Laparoscopic appendectomy during pregnancy is not exempt from postoperative, obstetric and foetal complications. It is necessary to standardize the definitions of "complication" in order to collate reliably the outcomes presented in the literature.

Laparoscopy versus open surgery for adnexal masses in pregnancy: a meta-analytic review

PURPOSE

The objective of this meta-analysis is to investigate and compare the pregnancy outcomes of laparoscopy and open surgery in the treatment of ovarian tumors during pregnancy.

METHODS

Search was conducted using MEDLINE, EMBASE, and Cochrane Databases from January 1990 to November 2018. A broad search strategy was used to identify studies comparing laparoscopy and open surgery in pregnancy. Inclusion criteria included comparative studies with the quantitative outcome data on gravida. Two authors independently reviewed and assessed for the quality of included studies according to the Newcastle-Ottawa Scale. Data were extracted for fetal loss, preterm delivery, duration of surgery, blood loss and length of hospital stay.

RESULTS

Nine retrospective trials were identified involving 985 patients. No statistical significance was found in fetal loss between laparoscopy and open surgery (P value = 0.334). The pooled estimate for preterm labor statistically significantly decreased for laparoscopy group (P value = 0.014). Reduced operative blood loss was found in laparoscopy group by 83.81 ml (P value = 0.015). Duration of operation may be longer in the laparoscopy group, but without statistical significance (P value = 0.346). Length of hospital stay was shorter in the laparoscopy group with reduction of 1.95 days (P value < 0.001).

CONCLUSIONS

The available low-grade evidence suggests that laparoscopic surgery might be a feasible alternative for pregnant women with adnexal masses.

Evaluation of management and surgical outcomes in pregnancies complicated by acute cholecystitis

OBJECTIVE

To evaluate the management of pregnancies complicated by acute cholecystitis (AC) and determine whether pregnant women are more likely to have medical and surgical complications.

METHODS

We carried out a population-based matched cohort study using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2011. Pregnant women with AC were age matched to non-pregnant women with AC on a 1:5 ratio. Management and outcomes were compared using descriptive analysis and conditional logistic regression.

RESULTS

There were 11,835 pregnant women admitted with AC who were age matched to 59,175 non-pregnant women. As compared to non-pregnant women, women with AC were more commonly managed conservatively, odds ratio (OR) 6.1 (5.8-6.4). As compared to non-pregnant women, pregnant women with AC more commonly developed sepsis [OR 1.4 (1.0-1.9)], developed venous thromboembolism [OR 8.7 (4.3-17.8)] and had bowel obstruction [OR 1.3 (1.1-1.6)]. Among pregnant women with AC, surgical management was associated with a small but significant increased risk of septic shock and bile leak.

CONCLUSION

AC, in the context of pregnancy, is associated with an increased risk of adverse outcomes. Although the literature favors early surgical intervention, pregnancies with AC appear to be more commonly managed conservatively with overall comparable outcomes to surgically managed AC. Conservative management may have a role in select pregnant women with AC.

Outcomes after open and laparoscopic appendectomy during pregnancy: A meta-analysis

OBJECTIVES

Acute appendicitis is the most prevalent cause of non-obstetrical surgical disease during pregnancy. There is no consensus on the optimal surgical management of acute appendicitis in pregnancy. Our aim is to identify surgical and obstetrical outcomes of laparoscopic (LA) and open approach (OA) in pregnant patients with acute appendicitis.

STUDY DESIGN

Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases were searched for articles published up to May 2017, along with the references of all articles. Prospective and retrospective trials reporting outcomes among pregnant women undergoing laparoscopic and open appendectomy were included. Of the 493 records screened, 20 were eligible for meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Statistical meta-analysis was performed using the RevMan 5.3 software.

RESULTS

A total of 6210 pregnant women from twenty studies were included in meta-analysis. Laparoscopic appendectomy was associated with significantly lower overall complication rates and shorter hospital stays (1835 patients OR 0.48 95% CI 0.29, 0.80 p = 0.005). While the open appendectomy group showed prolongation of gestational age for term deliveries, laparoscopic appendectomy patients had higher rates of fetal loss (543 patients MD -0.46 weeks 95% CI-0.87 to -0.04, p = 0.03 and 4867 patients OR 1.82 95% CI 1.30 to 2.57, p = 0.0006, respectively).

CONCLUSIONS

Current literature remains inconclusive on the optimal approach of appendectomy in pregnant women. Further larger-volume studies are needed in order to elucidate the critical effect of laparoscopic appendectomy on fetal loss rates.

Appendectomy in Pregnancy: Appraisal of the Minimally Invasive Approach

BACKGROUND

The optimal surgical approach to acute appendicitis in pregnancy remains controversial. Our aim was to compare perioperative and obstetric outcomes associated with laparoscopic and open appendectomy in a large contemporary cohort of pregnant women.

METHODS

Retrospective review of all women who underwent appendectomy during pregnancy in a single hospital during 2000-2014.

RESULTS

Ninety-two patients met the study criteria. Fifty (54%) underwent laparoscopic appendectomy and 42 (46%) open appendectomy. The laparoscopy group had a lower median gestational age at surgery (16 weeks versus 24 weeks, P < .001), a shorter median hospital stay (5 days versus 3 days, P < .001), and a lower rate of postoperative complications (8% versus 24%, P = .04). There were no significant between-group differences in the rates of gestational age at delivery, Apgar scores, preterm delivery, and fetal loss.

CONCLUSIONS

Laparoscopic appendectomy during pregnancy is safe and associated with better surgical outcomes than open appendectomy, with no difference in obstetric outcomes.

Management of gynecological cancers during pregnancy

The diagnosis of a gynecological malignancy during pregnancy is rare but not uncommon. Cancer treatment during pregnancy is possible, but both maternal and fetal interests need to be respected. Different treatment plans may be justifiable and multidisciplinary treatment is advised. Clinical trials are virtually impossible, and current evidence is mainly based on small case series and expert opinion. Individualization of treatment is necessary and based on tumor type, stage, and gestational age at time of diagnosis. Termination of pregnancy is not necessary in most cases. Surgery and chemotherapy (second trimester and onwards) are possible types of treatment during pregnancy. Radiotherapy of the pelvic area is not compatible with an ongoing pregnancy. This article discusses the current recommendations for the management of gynecological malignancies (cervical, ovarian, and vulvar cancers) during pregnancy.

Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients

BACKGROUND

When pregnant patients require surgery, whether to perform an operation open or laparoscopic is often debated. We evaluated the impact of laparoscopy for common general surgical problems in pregnancy to determine safety and trends in operative approach over time.

METHODS

Pregnant patients undergoing appendectomy or cholecystectomy were identified using the National Surgical Quality Improvement Program (NSQIP) database. We analyzed demographics, operative characteristics, and outcomes. Univariate comparison and multivariate regression analysis (MVA) were performed adjusting for confounding factors: age, body mass index (BMI), diabetes, and smoking, and an additional MVA was performed for perforated cases.

RESULTS

A total of 1999 pregnant patients between 2005 and 2012 were evaluated. Of 1335 appendectomies, 894 were performed laparoscopically (LA) and 441 open (OA). For 664 cholecystectomies, 606 were laparoscopic (LC) and 58 open (OC). There were no deaths. For LA versus OA, patient characteristics were not different {age: 27.7 vs. 28.2 years, p = 0.19; diabetes: 1.8 vs. 0.9%, p = 0.24; smoking: 19 vs. 16.1%, p = 0.2} except for BMI (27.9 vs. 28.4 kg/m(2); p = 0.03). LA had shorter operative times (ORT), length of stay (LOS), and fewer postoperative complications compared to OA. In MVA, difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.01), and wound complications (<0.01). MVA was performed for perforated cases alone: LA had equal ORT (p = 0.19) yet shorter LOS (p = <0.001). The majority of LA were performed in the last 4 years versus the first 4 years (61 vs. 39%, p < 0.001). For LC versus OC, patient characteristics were not different: age (28.3 vs. 28.7 years; p = 0.33), BMI (31.4 vs. 33.2 kg/m(2), p = 0.25), diabetes (2.8 vs. 3.5%, p = 0.68), and smoking (21.1 vs. 25.9%, p = 0.4). LC had a shorter ORT, LOS, and fewer postoperative complications than OC. In MVA, the difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.0001), and minor complications (<0.01). In MVA for cholecystitis with perforation, no difference was seen for LOS, ORT, or postoperative complications (p > 0.05). The percentage of LC cases appeared to increase over time (89 vs. 93%, p = 0.06).

CONCLUSION

While fetal events are unknown, LA and LC in pregnant patients demonstrated shorter ORT, LOS, and reduced complications and were performed more frequently over time. Even in perforated cases, laparoscopy appears safe in pregnant patients.

Abdominal surgery in pregnancy--an interdisciplinary challenge

BACKGROUND

Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach.

METHOD

This review is based on pertinent articles retrieved by a selective search in the PubMed database.

RESULTS

The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth.

CONCLUSION

Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.

Management of cancer in pregnancy

A multidisciplinary discussion is necessary to tackle a complex and infrequent medical problem such as cancer occurring during pregnancy. Pregnancy does not predispose to cancer, but cancers occurring in women of reproductive age are encountered during pregnancy. Ultrasonography and magnetic resonance imaging are the preferred staging examinations, but also a sentinel node staging procedure is possible during pregnancy. Standard cancer treatment is aimed for. Operations can safely be performed during pregnancy, but surgery of genital cancers can be challenging. The observation that chemotherapy administered during the second or third trimester of pregnancy, that is, after the period of organogenesis, has little effect on the long-term outcome of children adds to the therapeutic armamentarium during pregnancy. Cancer treatment during pregnancy adds in the continuation of the pregnancy and the prevention of prematurity.

Laparoscopic appendicectomy in pregnancy: a systematic review of the published evidence

Surgical intervention for acute appendicitis during pregnancy carries significant risk to both mother and foetus. The safety of Laparoscopic Appendicectomy in pregnancy has been a matter of debate among clinicians. We have critically reviewed the available published evidence in regards with this debate.

CONCLUSION

There is no strong current evidence as to the preferred modality of appendicectomy; open or laparoscopic, during pregnancy from the prospect of foetal or maternal safety. However, low grade evidence shows that laparoscopic appendicectomy during pregnancy might be associated with higher rates of foetal loss.

Laparoscopic appendectomy versus open appendectomy in pregnancy: a population-based analysis of maternal outcome

BACKGROUND

Laparoscopic appendectomy (LA) is the standard treatment of acute appendicitis for the general population; however, there is still some doubt regarding its safety for pregnant patients. Therefore, the purpose of this study is to investigate and compare the maternal outcome of pregnant patients with acute appendicitis following either an open appendectomy (OA) or LA from a population-based database.

METHODS

This study is based on the National Health Insurance Research Database. Patients with both ICD-9-CM codes for appendicitis (540.9, 540.0, and 540.1) and pregnancy (V22) in the same admission were considered to have acute appendicitis during pregnancy. These patients were divided into three groups according to the type of treatment: LA, OA, and non-operative treatment. Outcome measures that were compared between the groups included maternal complications such as preterm labor, abortion, and the need of cesarean section. Besides, the differences of medical expenditure and length of hospital stay between the groups were also analyzed.

RESULTS

From 2005 to 2010, a total of 859 pregnant women who had acute appendicitis were identified. They had increased risks for preterm labor, abortion, and increased requirement of cesarean section compared to the control group (i.e., those without acute appendicitis). Among the three groups, the non-operated group has the highest risk of preterm labor. Patients who underwent LA did not have any increased risk of maternal complications compared to the OA group. Furthermore, LA patients had shorter hospital stay than OA.

CONCLUSION

Compared to non-operative treatment, appendectomy is the preferred treatment for pregnant patients who have acute appendicitis. LA can be performed safely in pregnant patients without bringing additional maternal complications compared to OA.

Clinical outcomes compared between laparoscopic and open appendectomy in pregnant women

BACKGROUND

Despite the initial absolute or relative contraindication of laparoscopic surgery during pregnancy, in the last decade, laparoscopic appendectomy (LA) has been performed in pregnant women. But few studies compare the outcomes of LA compared with open appendectomy (OA). We investigated clinical outcomes to evaluate the safety and efficacy of LA compared with OA in pregnant women.

METHODS

We recruited consecutive pregnant patients with a diagnosis of acute appendicitis who were undergoing LA or OA between May 2007 and August 2011 into the study.

RESULTS

Sixty-one patients (22 LA and 39 OA) enrolled in our study. There were no significant differences in duration of surgery, postoperative complication rate and obstetric and fetal outcomes, including incidence of preterm labour, delivery type, gestation age at delivery, birth weight and APGAR scores between the 2 groups. However, the LA group had shorter time to first flatus (2.4 ± 0.4 d v. 4.0 ± 1.7 d, p = 0.034), earlier time to oral intake (2.3 ± 1.6 d v. 4.1 ± 1.9 d, p = 0.023) and shorter postoperative hospital stay (4.2 ± 2.9 d v. 6.9 ± 3.7 d, p = 0.043) than the OA group.

CONCLUSION

Laparoscopic appendectomy is a clinically safe and effective procedure in all trimesters of pregnancy and should be considered as a standard treatment alternative to OA. Further evaluation including prospective randomized clinical trials comparing LA with OA are needed to confirm our results.

Cost-effectiveness of preoperative imaging for appendicitis after indeterminate ultrasonography in the second or third trimester of pregnancy

OBJECTIVE

To assess the cost-effectiveness of diagnostic laparoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) after indeterminate ultrasonography in pregnant women with suspected appendicitis.

METHODS

A decision-analytic model was developed to simulate appendicitis during pregnancy taking into consideration the health outcomes for both the pregnant women and developing fetuses. Strategies included diagnostic laparoscopy, CT, and MRI. Outcomes included positive appendectomy, negative appendectomy, maternal perioperative complications, preterm delivery, fetal loss, childhood cancer, lifetime costs, discounted life expectancy, and incremental cost-effectiveness ratios.

RESULTS

Magnetic resonance imaging is the most cost-effective strategy, costing $6,767 per quality-adjusted life-year gained relative to CT, well below the generally accepted $50,000 per quality-adjusted life-year threshold. In a setting where MRI is unavailable, CT is cost-effective even when considering the increased risk of radiation-associated childhood cancer ($560 per quality-adjusted life-year gained relative to diagnostic laparoscopy). Unless the negative appendectomy rate is less than 1%, imaging of any type is more cost-effective than proceeding directly to diagnostic laparoscopy.

CONCLUSIONS

Depending on imaging costs and resource availability, both CT and MRI are potentially cost-effective. The risk of radiation-associated childhood cancer from CT has little effect on population-level outcomes or cost-effectiveness but is a concern for individual patients. For pregnant women with suspected appendicitis, an extremely high level of clinical diagnostic certainty must be reached before proceeding to operation without preoperative imaging.

APPENDICITIS IN PREGNANCY

Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnancy, complicating 1/500 to 1/2000 deliveries. Due to the anatomical and physiological changes associated with pregnancy, appendicitis may present a diagnostic dilemma, leading to management delays and thus increasing the risk of appendiceal perforation. Many of the common presenting symptoms of appendicitis are common features of normal pregnancy including lower abdominal pain, nausea, vomiting and leukocytosis. Furthermore, the enlarging gravid uterus may displace the appendix to varying degrees thus altering the classic symptom pattern of appendicitis. The often nonspecific presentation in pregnancy may necessitate the utilization of diagnostic imaging to aid in accurate diagnosis. However, the perforated appendix is the most common surgical cause of fetal loss and the time required for any diagnostic aid must be weighed against the increasing risk of perforation caused by delay in surgical intervention.

Safety and Clinical Efficacy of Laparoscopic Appendectomy for Pregnant Women with Acute Appendicitis

Introduction: The aim of this study was to investigate the clinical efficacy and safety of laparoscopic appendectomy (LA) during pregnancy by comparing the operative and obstetric outcomes of patients who during pregnancy underwent LA performed by an expert gynaecologic laparoscopist (LA group) with those patients who underwent an open appendectomy (OA) by a general surgeon (OA group). Materials and Methods: In this retrospective study, we evaluated all patients consecutively who had undergone appendectomy for acute appendicitis during pregnancy from January 2000 to December 2010. Twenty-eight patients underwent OA and 15 were treated by LA. We reviewed the clinical charts and analysed the data for each patient’s age, parity, body mass index, gestational age at appendectomy, type of appendectomy, operating time, haemoglobin change, hospital stay, histopathological results, postoperative analgesics, complications, and obstetric outcomes. Results: There were no significant differences between the OA and LA groups in terms of clinical characteristics, hospital stay, haemoglobin change, return of bowel activity, complication rates, gestational age at delivery, and birth weight. However, there were significantly shorter operating time and less usage of postoperative analgesics in LA group. Conclusion: LA performed by an expert gynaecologist can be a safe and effective method for treating acute appendicitis during the first and second trimester of pregnancy. Key words: Laparoscopic appendectomy, Appendicitis, Pregnant women

Suspicion of acute appendicitis in the third trimester of pregnancy: pros and cons of a laparoscopic procedure

This review suggests that diagnostic laparoscopy during the third trimester of pregnancy is a logical strategy to minimize maternal and fetal risk when acute appendicitis is suspected.

The presentation of acute appendicitis during pregnancy may cause diagnostic and therapeutic difficulty. Delay in diagnosis may lead to increased maternal and fetal risk. Therefore, an aggressive surgical approach is mandatory, even though this may result in an increased number of appendectomies for normal appendices. Diagnostic laparoscopy, followed by laparoscopic appendectomy in case of inflammation, seems a logical strategy. We present the case of a 36-week pregnant woman who presented with suspicion of acute appendicitis. The pro and cons of a laparoscopic approach in the third trimester of pregnancy are discussed as is its safety by reviewing the literature.

Management of a persistent adnexal mass in pregnancy: what is the ideal surgical approach?

STUDY OBJECTIVE

To compare short-term and pregnancy-related outcomes of laparoscopy with laparotomy for management of a persistent second-trimester adnexal mass.

DESIGN

Retrospective cohort study of pregnant women at 14 weeks or more of gestation undergoing laparoscopy or laparotomy for management of an adnexal mass (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Women of reproductive age with a persistent adnexal mass at 14 weeks or more of gestation.

INTERVENTION

Removal of adnexal mass via laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

Between 1990 and 2008, 101 pregnant women underwent treatment of a persistent adnexal mass at 14 weeks or more of gestation at our institution. Fifty women underwent laparoscopy, and 51 underwent laparotomy. Similar demographic and adnexal mass characteristics were identified between the 2 surgical groups. Eight patients in the laparotomy group experienced postoperative complications, compared with none in the laparoscopy group (p < .02). Mean surgical estimated blood loss and length of hospital stay were significantly less in the laparoscopy group compared with the laparotomy group: 17.5 mL vs 100 mL (p < .001) and 0.7 days vs 2.78 days (p < .001), respectively. There were no observed differences in pregnancy-related outcomes between the 2 groups.

CONCLUSION

Minimally invasive surgery is a reasonable approach to management of a second-trimester adnexal mass in gravid women. Laparoscopy enables a shorter hospital stay, decreased blood loss, and fewer postoperative complications without seeming to have a negative effect on pregnancy-related outcomes. While these findings are reassuring, larger studies are encouraged to continue to evaluate this issue.

Appendectomy in pregnancy: evaluation of the risks of a negative appendectomy

BACKGROUND

In pregnant women, a high negative appendectomy (NA) rate often is reported; however, the outcome of pregnancy after a NA is not well studied.

METHODS

Among 1,696 consecutive patients (728 men and 968 women) who underwent an appendectomy at our institution (1996-2005), 87 pregnant women were identified. Postoperative surgical and obstetric outcomes were analyzed based on the final pathologic report of the appendix (normal appendix, inflamed, or perforated).

RESULTS

The NA rate was significantly higher in pregnant women compared with nonpregnant women (36% vs 14%; P < .05). The fetal demise rate was similar between the NA group and the inflamed group (3% vs 2%; P = NS), and highest (14%) in the perforated group, although this difference did not reach statistical significance (P = .3). Wound infections were most frequent in the perforated group (P < .05).

CONCLUSIONS

NA during pregnancy is not free of risk to the fetus. We recommend careful assessment to avoid unnecessary exploration when appendicitis is suspected in pregnant women.

Laparoscopic cholecystectomy in the third trimester of pregnancy: report of 3 cases

AIM

Symptomatic cholelithiasis and acute appendicitis are the most common surgical conditions requiring nonobstetric abdominal surgery during pregnancy. Cholelithiasis is diagnosed in 0.07% of pregnancy and in about 40% of these patients surgery may be required. Pregnancy was once considered an absolute contraindication for laparoscopic surgery, but pregnant patients undergoing laparoscopic surgery have been reported increasingly in the past decade. However, most case reports and case series are confined to patients in the first and second trimester. We report here 3 patients who underwent laparoscopic cholecystectomy in the third trimester and review the relevant literature.

METHODS

Pregnant women in the third trimester who underwent laparoscopic cholecystectomy were reviewed between the years 2000 and 2004 at our hospital.

RESULTS

Three pregnant patients in the third trimester at a gestational age of 28 weeks, and 2 at 26 weeks underwent laparoscopic cholecystectomy. Initial port was placed in all patients by Hasson open technique, few centimeters cephalad to fundal height. The insufflation pressure was maintained between 12 to 14 mm Hg. The duration of surgery ranged from 64 to 80 minutes (mean: 72 min). Obstetric assessment was carried out preoperatively and fetal well-being was monitored postoperatively. Tocolytic agents were used in 2 patients. There were no intraoperative or postoperative complications. All patients were discharged on the second postoperative day. All the 3 patients delivered healthy babies normally at full term (range: 39 to 40 wk).

CONCLUSION

Laparoscopic cholecystectomy can be carried out safely in the third trimester of pregnancy with minimal risk to the fetus and the mother.

Robotic resection of pheochromocytoma in the second trimester of pregnancy

In this study, a Da Vinci robotic system was successfully used to perform resection of pheochromocytoma during the second trimester of pregnancy.

Pheochromocytoma is a rare neuroendocrine tumor diagnosed in 1:50 000 pregnancies. Normal physiologic changes associated with pregnancy often make early recognition difficult and diagnosis delayed. Treatment consists of medical followed by surgical intervention. This case of a 34-year-old African American female diagnosed with an adrenal pheochromocytoma during her second trimester of pregnancy is the first reported case of successful robotic resection. The robot provided advantages, such as enhanced visualization and freedom of dissection, within this confined space. These added benefits over traditional laparoscopy provide a means for performing difficult procedures within a decreased space possibly allowing for interventions in later or larger pregnancies.

Appendicitis and cholecystitis in pregnancy

Acute abdominal pain in pregnancy may be attributable to a broad range of nonobstetrical causes. The evaluation of an acute abdomen during pregnancy must include in the differential diagnosis appendicitis and cholecystitis, which are 2 of the most common reasons for nonobstetric surgical intervention in pregnancy. Both conditions may be associated with significant maternal and fetal morbidity and/or mortality. This study will provide a contemporary synopsis regarding the diagnosis and management of appendicitis and cholecystitis during pregnancy.

Diagnosis of appendicitis in pregnancy

BACKGROUND

The diagnosis of appendicitis in pregnant patients is challenging.

METHODS

The records of pregnant patients with suspected appendicitis were reviewed.

RESULTS

Forty-seven patients with suspected appendicitis were identified. Twenty-four patients did not undergo surgery. Twenty-three patients had ultrasound (US), none of which visualized the appendix. Seventeen patients were followed up clinically and improved. Six patients had a negative computed tomography (CT) and none required surgery. Twenty-three patients underwent surgery for presumed appendicitis. Three patients had no imaging. Twelve patients had US only; US was positive in 5 patients and all had appendicitis. Seven patients who underwent surgery had a nondiagnostic US. One patient had appendicitis. Seven patients had a positive CT and appendicitis at surgery. One patient had a positive US and magnetic resonance imaging, and had appendicitis. A total of 43 patients had US, of which 86% were nondiagnostic. Six US were read as positive and all patients had appendicitis. Thirteen patients had CT with no false-positive or false-negative results.

CONCLUSIONS

US, when read as positive, requires no further confirmatory test other than surgery. If US is nondiagnostic, further imaging may avoid a negative appendectomy.

Laparoscopy: a safe approach to appendicitis during pregnancy

BACKGROUND

The aim of this study was to evaluate laparoscopic versus open surgery for suspected appendicitis during pregnancy.

METHODS

A hospital-based retrospective review of 65 consecutive pregnant patients who underwent surgery for suspected appendicitis from 1999 to 2008 was performed. Significance was determined by Pearson's chi(2) test, Fisher's exact test, Mann-Whitney test, and Kruskal-Wallis test.

RESULTS

Of the 65 patients, 48 cases were laparoscopic and 17 open. Use of the laparoscopic versus open approach was significantly increased in the first (100% vs. 0%, p < 0.001) and second trimesters (73% vs. 27%, p < 0.001). The open approach was used more frequently in third-trimester patients (71% vs. 29%, p = NS). Significance was demonstrated in mean length of hospital stay in the laparoscopic versus open group (3.4 vs. 4.2 days, p = 0.001). No maternal mortalities occurred. Follow-up of fetal outcome was achieved in 89% of patients. No difference was demonstrated in fetal loss (1 in laparoscopic group), APGAR score, birth weight, and preterm delivery rate by operative approach. Adverse outcome was associated with maternal temperature greater than 38 degrees C, leukocytosis greater than 16 x 10(9)/l, or more than 48 h between onset of symptoms and emergency room presentation.

CONCLUSIONS

This article is the largest hospital-based series evaluating the laparoscopic versus open approach for pregnant patients with presumed acute appendicitis. While methodological limitations preclude a definitive recommendation, laparoscopy appears to be a safe, feasible, and efficacious approach for pregnant patients with presumed acute appendicitis. We conclude that it is likely not the surgical approach but the underlying diagnosis combined with maternal factors that determine the risk for pregnancy complications. A benefit of laparoscopy is the diagnostic ability to identify other intra-abdominal pathology which may mimic appendicitis and harbor pregnancy risks.

Safety of laparoscopic appendectomy during pregnancy

BACKGROUND

Use of laparoscopic appendectomy (LA) remains controversial during pregnancy because data regarding procedure safety are limited. The outcome of LA in pregnant women was evaluated and compared to results of open surgery.

METHODS

Between January 1997 and December 2007, 42 pregnant women (mean age 24 years [range: 19-40 years]; range of gestation: 5-25 weeks) underwent appendectomy for suspected acute appendicitis: 23 laparoscopic (LA) and 19 open appendectomies (OA). Retrospective review of medical charts included preoperative information, surgery results, and outcome of the pregnancy.

RESULTS

There was no difference between groups in surgery delay following arrival at the hospital. All procedures, except one case of Meckel's diverticulitis, were completed laparoscopically without need for conversion. Acute appendicitis was found in 19 cases and Meckel's diverticulitis in one case during LA (87%) and in 18 cases (95%) during OA. Complicated appendicitis was found in 7 (30%) pregnant women in the LA group and 1 (5%) in the OA group. Five women with normal preoperative abdominal ultrasonography had acute appendicitis (2 in the OA group and 3 in the LA group). The laparoscopic procedure was performed more often by senior surgeons (70% of cases), and OA was more commonly done by residents (47% of cases). There were no intraoperative or postoperative complications recorded. The length of postoperative hospital stay was slightly prolonged after LA-2.4 days versus 1.4 day after OA. There was one fetal loss in each group, 1 and 2 months after the operation.

CONCLUSIONS

Laparoscopic appendectomy is safe and effective during pregnancy and is associated with good maternal and fetal outcome.

Laparoscopic appendectomy in pregnant patients: a review of 45 cases

BACKGROUND AND OBJECTIVES

Laparoscopic surgery in pregnancy remains debated, especially in cases of suspected appendicitis. Cases of suspected appendicitis treated by the laparoscopic approach in a single institution over a 10-year period were reviewed (1997-2007). The objectives were to evaluate the immediate complications of the procedure and the outcome of pregnancies including foetal loss and preterm delivery.

RESULTS

Retrospective analysis of 45 consecutive cases of suspected appendicitis during pregnancy was carried out. Forty-two patients (93%) had a preoperative ultrasound, of which 13 (33%) confirmed an acute appendicitis. Out of 45 cases, 15 (33%) had the surgical procedure during the first trimester, 22 (49%) in the second and 8 (18%) in the third. Two (4%) patients had major complications (intra-abdominal abscess and uterine perforation) and two others (4%) had minor complications (cystitis and ileus). No patients underwent delivery in the month following surgery and there was no foetal loss in the follow-up. Three (8.1%) patients delivered prior to 35 weeks' gestation and 18.1% delivered before term (<37 weeks). As previously reported, a high rate of normal appendix (33%) was found at surgery. No significant differences were found in rates of preterm delivery, adverse outcome or operative time between trimesters of pregnancy at the time of surgery. Mean operative time was 49 +/- 19 min.

DISCUSSION

This large series from a single institution shows a low rate of preterm delivery and absence of foetal loss after laparoscopic appendectomy. Regardless of trimester, the low rate of complication makes it a valuable option for pregnant patients with suspicion of acute appendicitis. The rate of normal appendectomies remaining high, efforts have to be made towards new diagnostic modalities to lower the negative appendectomy rate in this specific population.

Laparoscopic versus open appendicectomy in pregnancy: a systematic review

BACKGROUND

Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnant women. The benefits of a laparoscopic over an open approach to appendicectomy are well established in the non-pregnant population. Data on the optimal surgical approach to acute appendicitis in pregnant women are conflicting.

METHODS

A systematic review of reported cases of laparoscopic appendicectomy (LA) in pregnancy over the period 1990 to 2007. Twenty-eight articles documenting 637 cases of LA in pregnancy were included. Data on pregnancy outcome, patient characteristics, operative technique and peri-operative complications were analysed.

RESULTS

The rate of fetal loss following LA in pregnancy approaches 6% and is significantly higher than that following open appendicectomy. Fetal loss was highest in cases of complicated appendicitis. Incidence of preterm delivery appears lower in the LA group although this complication is likely to be under-reported in a significant proportion of cases. Trimester at the time of LA does not appear to influence complication rates. The negative appendicectomy rate in this series was 27%, which is higher than in the non-pregnant population. Complication rates following LA with negative appendicitis are as high as with simple appendicitis. Rates of entry-related complications were 2.8% in the Veress needle group and 0% in the Hasson open entry group. The overall rate of conversion to laparotomy was 1%. No difference was found in the preterm delivery rate between women who received prophylactic tocolysis and those who were not tocolysed.

CONCLUSIONS

Laparoscopic appendicectomy in pregnancy is associated with a low rate of intra-operative complications in all trimesters. However, LA in pregnancy is associated with a significantly higher rate of fetal loss compared to open appendicectomy. Rates of preterm delivery appear similar or slightly better following a laparoscopic approach. Open appendicectomy would appear to be the safer option for pregnant women for whom surgical intervention is indicated.