Laparoscopy: a safe approach to appendicitis during pregnancy

Removal of an intraabdominal levonorgestrel-releasing intrauterine device during pregnancy

A woman with a viable intrauterine 12-week pregnancy and an intraabdominal levonorgestrel-releasing intrauterine device had the device successfully removed under local anesthesia. The pregnancy continued without complication. The decision to remove an intraabdominal levonorgestrel-releasing intrauterine device during pregnancy remains controversial.

Appendicitis: changing perspectives

Neoplasms are an uncommon finding after appendectomy, with malignant tumors occurring in less than 1% of the surgical specimens, and carcinoid being the most frequent malignancy. A negative or inconclusive ultrasound is not adequate to rule out appendicitis and should be followed by CT scan. For pregnant patients, MRI is a reasonable alternative to CT scan. Nonoperative treatment with antibiotics is safe as an initial treatment of uncomplicated appendicitis, with a significant decrease in complications but a high failure rate. Open and laparoscopic appendectomies for appendicitis provide similar results overall, although the laparoscopic technique may be advantageous for obese and elderly patients but may be associated with a higher incidence of intraabdominal abscess. Preoperative diagnostic accuracy is of utmost importance during pregnancy because a negative appendectomy is associated with a significant incidence of fetal loss. The increased morbidity associated with appendectomy delay suggests that prompt surgical intervention remains the safest approach. Routine incidental appendectomy should not be performed except in selected cases. Interval appendectomy is not indicated because of considerable risks of complications and lack of any clinical benefit. Patients older than 40 years with an appendiceal mass or abscess treated nonoperatively should routinely have a colonoscopy as part of their follow-up to rule out cancer or alternative diagnosis.

Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy

BACKGROUND

Laparoscopic appendicectomy has gained wide acceptance as an alternative to open appendicectomy during pregnancy. However, data regarding the safety and optimal surgical approach to appendicitis in pregnancy are still controversial.

METHODS

This was a systematic review and meta-analysis of studies comparing laparoscopic and open appendicectomy in pregnancy identified using PubMed and Scopus search engines from January 1990 to July 2011. Two reviewers independently extracted data on fetal loss, preterm delivery, wound infection, duration of operation, hospital stay, Apgar score and birth weight between laparoscopic and open appendicectomy groups.

RESULTS

Eleven studies with a total of 3415 women (599 in laparoscopic and 2816 in open group) were included in the analysis. Fetal loss was statistically significantly worse in those who underwent laparoscopy compared with open appendicectomy; the pooled relative risk (RR) was 1·91 (95 per cent confidence interval (c.i.) 1·31 to 2·77) without heterogeneity. The pooled RR for preterm labour was 1·44 (0·68 to 3·06), but this risk was not statistically significant. The mean difference in length of hospital stay was - 0·49 (-1·76 to - 0·78) days, but this was not clinically significant. No significant difference was found for wound infection, birth weight, duration of operation or Apgar score.

CONCLUSION

The available low-grade evidence suggests that laparoscopic appendicectomy in pregnant women might be associated with a greater risk of fetal loss.

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.

Laparoscopy in pregnancy and the pediatric patient

Minimally invasive surgery is now standard of care for many procedures in pediatric gynecology. Laparoscopy has been well documented to produce faster recovery,decreased postoperative pain, and because of smaller incisions, a better cosmetic result. These are important when considering an active pediatric patient. Although a laparoscopic approach to endometriosis, adnexal masses, and ovarian torsion are well supported in the literature in the pediatric patient, more data are needed with regard to SILS in younger patients. Laparoscopy seems to be a better approach to oopheropexy in children undergoing radiation, and in resection of certain mullerian anomalies; however, the numbers are low.Similarly in pregnant patients, laparoscopy provides for shorter recovery times,decrease analgesic use and shorter hospital stays. Concerns about poor fetal outcomes in surgery during pregnancy for non gynecologic problems have been brought to light; however, the evidence indicates that these outcomes can be attributed to the nature of the underlying disease and not the surgical approach. With regard to pneumoperitoneum the effect of CO2 insufflation on fetal physiology and long-term outcomes remains unclear, and will continue to be an issue of controversy until larger studies are published.With both the pediatric and pregnant populations, laparoscopic complications can be diminished when performed by skilled surgeons with strict adherence to good technical principles. The advantages of laparoscopy are great, and this approach should be considered in pediatric and pregnant patients.

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

Appendectomy during pregnancy: follow-up of progeny

BACKGROUND

The incidence of appendicitis in pregnant patients is 0.04% to 0.20%, making it the most common nonobstetric surgical procedure in pregnancy. This study examines whether an appendectomy during any stage of pregnancy affects future development of motor, sensory, and social skills of the progeny.

STUDY DESIGN

A prospective survey was administered to women who underwent an appendectomy during pregnancy at Mount Sinai Hospital from 2000 to 2009. The survey, which ranged from 1 to 9 years postpartum, consisted of questions about motor, sensory, and social development of their progeny, based on established pediatric milestones. Data were collected from the medical records of mother and child. Additional follow-up was gathered from outpatient and emergency room records.

RESULTS

Fifty-two pregnant patients underwent an appendectomy during our study period. All pregnancies continued to full term with the exception of one fetal death due to extreme prematurity. Twenty-nine patients completed the follow-up survey, making the yield response rate 55.8%. There were 7 (26.9%), 14 (48.3%), and 8 (27.6%) appendectomies in the first, second, and third trimesters, respectively. Mean follow-up time was 47.2 months (range 13 to 117 months) after delivery. None of the children exhibited any developmental delay by their third year of life. Timing of the surgery (trimester) had no effect on child development.

CONCLUSIONS

Appendectomy during pregnancy is not associated with developmental delays in children, regardless of which trimester the procedure was performed. All children in this study had normal motor, sensory, and social development by 3 years of age.

Gastrointestinal Conditions during Pregnancy

Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.

Laparoscopic approach for metachronous cecal and sigmoid volvulus

This report indicates that laparoscopic techniques may be a safe approach for acute colonic volvulus.

Background:

Metachronous colonic volvulus is a rare event that has never been approached laparoscopically.

Methods:

Here we discuss the case of a 63-year-old female with a metachronous sigmoid and cecal volvulus.

Results:

The patient underwent 2 separate successful laparoscopic resections.

Discussion and Conclusion:

The following is a discussion of the case and the laparoscopic technique, accompanied by a brief review of colonic volvulus. In experienced hands, laparoscopy is a safe approach for acute colonic volvulus.

Appendectomy during the third trimester of pregnancy in a 27-year old patient: case report of a "near miss" complication

The management of acute appendicitis during pregnancy is not fully established, especially regarding the choice between open and laparoscopic surgery during the third trimester. We report herein the case of a major uterine variecele hemorrhage during a laparoscopic appendectomy in a 27-year old pregnant patient at 33 weeks of amenorrhea. After conversion to a Pfannenstiel incision, the baby was delivered, the bleeding stopped and the appendectomy completed. While both mother and child fully recovered, this «near miss» complication underlines the challenges linked to the management of acute appendicitis during pregnancy. Based on a literature review, we propose an algorithm favoring the laparoscopic approach during the first and second trimesters, and the open approach during the third trimester (especially after the 26th week of amenorrhea). In case of unclear pre-operative diagnosis, a laparoscopy should be conducted even during the third trimester with a Mc Burney conversion when the diagnosis of appendicitis is confirmed.