Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review

Pregnant patients undergoing cholecystectomy: nationwide assessment of clinical characteristics and outcomes

BACKGROUND

Gallstone disease in pregnancy is one of the most common indications for nonobstetrical surgery during pregnancy. National-level data on contemporary surgical practice and outcomes are limited.

OBJECTIVE

This study aimed to assess the clinical characteristics and outcomes of patients undergoing cholecystectomy during pregnancy.

STUDY DESIGN

This cross-sectional study examined the Healthcare Cost and Utilization Project's 2 nationwide databases in the United States: the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample. The study population included 18,630 patients who had cholecystectomy during pregnancy from January 2016 to December 2020. The exposure was gestational age, grouped sequentially into the following 5 groups: first trimester (<14 weeks), early second trimester (14-20 weeks), late second trimester (21-27 weeks), early third trimester (28-36 weeks), and late third trimester (≥37 weeks). The main outcomes were clinical demographics, medical comorbidities, surgical information, and pregnancy characteristics and outcomes, assessed by gestational age.

RESULTS

Cholecystectomy was most common in the early second trimester (32.1%), followed by the first trimester (25.2%), late second trimester (23.1%), early third trimester (12.4%), and late third trimester (7.2%). Patients in the first-trimester group were more likely to be aged ≥35 years, to smoke, and to have acute cholecystitis, severe hyperemesis gravidarum including metabolic disturbance, pregestational diabetes, multifetal gestation, and sepsis/shock (P<.001). Patients in the early-third-trimester group were more likely to be obese and have gestational diabetes, Charlson Comorbidity Index of ≥1, premature rupture of membranes, and intrauterine growth restriction, whereas those in the late-third-trimester group were more likely to have gallstone pancreatitis, biliary colic, chorioamnionitis, gestational hypertension, preeclampsia, and severe maternal morbidity including sepsis (P<.001). At the cohort level, a laparoscopic approach was used in most cholecystectomy procedures (97.5%), and bile duct injury was uncommon (<0.1%). Delivery during the admission occurred in 0.3%, 0%, 0.6%, 17.8%, and 60.6% in the 5 gestational age groups, respectively (P<.001). Among the cases that had delivery in the early- and late-third-trimester groups, the delivery event preceded cholecystectomy in 61.4% and 86.2%, respectively, whereas both delivery and cholecystectomy occurred on the same day in 34.3% and 13.8%, respectively.

CONCLUSION

This nationwide analysis suggests that clinical and pregnancy characteristics and outcomes of patients undergoing cholecystectomy differ by pregnancy stage with a bimodal distribution. Although patients in the first and third trimesters have distinct medical conditions, more clinically significant pregnancy and maternal outcomes were found in both groups compared with patients in the second trimester.

Treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy after in vitro fertilization and embryo transfer

OBJECTIVE

To compare the treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy (HP) after in vitro fertilization-embryo transfer (IVF-ET).

METHODS

The retrospective case-control study enrolled 109 patients diagnosed with HP after IVF-ET treatment in our hospital from January 2009 to March 2020. All patients received surgical treatment by either laparoscopy or laparotomy. Data for general characteristics, diagnostic features, surgical parameters, as well as perinatal and neonatal outcomes were collected.

RESULTS

Sixty-two patients received laparoscopy and 47 received laparotomy. Significantly lower percentage of large hemoperitoneum (P = 0.001), shorter surgery duration (P < 0.001), less intraoperative blood loss (P = 0.001), higher rates of general anesthesia (P < 0.001), and lower cesarean section rates for singletons (P = 0.003) were found in the laparoscopy group. The perinatal and neonatal outcomes were comparable between the two groups. When interstitial pregnancy was considered alone, the surgical blood loss was significantly reduced in the laparoscopy group (P = 0.021), but there was no significant difference in hemoperitoneum, surgery duration, or perinatal and neonatal outcomes in singletons.

CONCLUSION

Both laparoscopy and laparotomy are effective surgical treatments for HP after IVF-ET. Laparoscopy is minimally invasive but laparotomy can be an alternative in emergency situations.

Parturient with Acute Abdomen

Management of a parturient with an acute abdomen presents unique challenges. We aim to review the common obstetric and nonobstetric causes for acute abdomen in pregnancy, approach to diagnosis, the role of imaging, and management including the scope and timing of operative intervention.

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.

Postoperative complications after non-obstetric surgery among pregnant patients in the National Surgical Quality Improvement Program, 2005-2012

BACKGROUND

To examine whether pregnant patients have higher risk of major 30-day postoperative complications compared with their non-pregnant counterparts after non-obstetric surgery.

METHODS

A secondary analysis of the prospective National Surgical Quality Improvement Program (NSQIP) from 2005 to 2012 of pregnant patients 18-51 years old, without surgery in the preceding 30 days, and who underwent a non-obstetrical operation. The primary outcome was composite 30-day major postoperative complications. We used modified Poisson regression.

RESULTS

Among 354,251 assessed patients, 3655 (1%) were pregnant. The overall incidence of 30-day major postoperative complication was 6%, and did not vary by pregnancy status. Pregnant patients were not at higher risk of 30-day major postoperative complications compared to non-pregnant patients following non-obstetric surgery. This held for most procedures, except pregnant patients were at a higher risk of complications with colorectal and hernia surgeries. Secondarily, pregnant patients were at higher risk of transfusion.

CONCLUSIONS

Pregnant patients are generally not at higher risk of major postoperative complications following non-obstetric surgery. This information can be used when counseling pregnant patients about the risks versus benefits of non-obstetric surgery.

Primary Hyperparathyroidism During Pregnancy Treated With Parathyroidectomy: A Systematic Review

OBJECTIVES/HYPOTHESIS

The primary objective of this study was to assess the safety of parathyroidectomy during pregnancy as treatment for hyperparathyroidism (HPTH) in comparison to nonsurgical management plans. Secondary outcomes involved analyzing the safety of surgery in the third trimester and the benefit of operating on asymptomatic pregnant patients.

STUDY DESIGN

Systematic review.

METHODS

PRISMA-guided systematic review of all cases of primary hyperparathyroidism during pregnancy published in peer-reviewed English journals on PubMed/MEDLINE, EMBASE, and SCOPUS from 1980 to 2020.

RESULTS

A total of 75 manuscripts were included in this review describing 382 cases of gestational hyperparathyroidism. The median maternal age was 31 years. Overall, 108 cases (28.3%) underwent parathyroidectomy during pregnancy while 274 cases (71.7%) were treated nonsurgically. The majority of surgeries took place during the second trimester (67.6%). Complications and/or deaths were less likely to occur after surgery in the second trimester (4.48%) as compared to surgery in the third trimester (21.1%). Nine surgically treated cases resulted in infant complications and/or death; however, none of these nine cases had any surgical complications. Despite these complications, the overall infant complication rate for patients who underwent surgical treatment remained lower than that of patients treated with conservative therapy (9.1% vs. 38.9%).

CONCLUSIONS

This review suggests that for all pregnant patients with diagnosed HPTH, parathyroidectomy should be considered regardless of symptomatology. Our data suggest that parathyroidectomy is associated with fewer risks than more conservative treatments and results in better fetal outcomes. Surgery during the third trimester is feasible and surgery should be considered in both symptomatic and asymptomatic patients. Laryngoscope, 131:1915-1921, 2021.

Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery

OBJECTIVE

To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery.

TARGET POPULATION

All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars.

OUTCOMES

Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery.

EVIDENCE

We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A).

INTENDED AUDIENCE

Surgeons performing laparoscopic gynaecological surgery.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Ovarian Cancer and Pregnancy-A Current Problem in Perinatal Medicine: A Comprehensive Review

The frequency of concomitant adnexal tumors in pregnancy is reported to be at 0.15-5.7%, while ovarian cancer complicates 1 in 15,000 to 1 in 32,000 pregnancies, being the second most common gynecologic cancer diagnosed during pregnancy. The aim of this review is to discuss the problem of ovarian cancer complicating pregnancy and the current recommendations for diagnostics and treatment, with an emphasis on the risk to the fetus. A detailed analysis of the literature found in the PubMed and MEDLINE databases using the keywords "ovarian cancer", "ovarian malignancy", "adnexal masses", "ovarian tumor" and "pregnancy" was performed. There were no studies on a large series of pregnant women treated for ovarian malignancies and the management has not been well established. The diagnostics and therapeutic procedures need to be individualized with respect to the histopathology of the tumor, its progression, the gestational age at the time of diagnosis and the mother's decisions regarding pregnancy preservation. The multidisciplinary cooperation of specialists in perinatal medicine, gynecological oncology, chemotherapy, neonatology and psychology seems crucial in order to obtain the best possible maternal and neonatal outcomes.

Extraovarian dysgerminoma in a pregnant woman: an extremely rare finding

Extraovarian germ cell tumors are very rare and their occurrence during pregnancy is exceptional. In this case report an abdominal mass was shown by ultrasonography, during a routine monitoring of a 26-year-old pregnant woman. The patient was left under radiological control in the following months in order to bring the pregnancy to term. A few months after the delivery, the patient underwent surgery and a diagnosis of extraovarian (abdominal) dysgerminoma was made. To the best of our knowledge, there are only 3 other case reports describing an extra-gonadal dysgerminoma occurring during pregnancy. The aim of this study was to report an extremely rare tumor, whose management can be challenging first because this neoplasm has some differences from its ovarian and testicular counterparts. Furthermore, the occurrence during pregnancy makes the multidisciplinary approach mandatory since 3 distinct but not independent entities are involved (tumor, mother and fetus).

Considering delay of cholecystectomy in the third trimester of pregnancy

INTRODUCTION

Current guidelines support laparoscopic cholecystectomy as the treatment of choice for pregnant women with symptomatic gallbladder disease, regardless of the trimester. Early intervention has remained the standard of care, but recent evidence has challenged this practice in pregnant women. We sought to compare surgical and maternal-fetal outcomes of antepartum versus postpartum cholecystectomy in New York State.

METHODS

Between 2005 and 2014, the New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for patients who underwent cholecystectomy within 3 months before (antepartum cholecystectomy, APCCY: n = 82) and after (postpartum cholecystectomy, PPCCY: n = 5040) childbirth to approximate third-trimester operations. All patients who underwent cholecystectomy during pregnancy (n = 971) were extracted to evaluate inter-trimester differences. Subgroup analysis compared APCCY patients who were not hospitalized within 1 year before APCCY (n = 80) and PPCCY patients who were hospitalized within 1 year before childbirth (n = 29) for symptomatic biliary disease. Multivariable generalized linear regression models were used to characterize the association between timing of cholecystectomy and several primary outcomes: length of stay (LOS), 30-day non-pregnancy, non-delivery readmission (NPND), bile duct injury (BDI), composite maternal outcome (antepartum hemorrhage, preterm delivery, cesarean section), any complications, and fetal demise.

RESULTS

Third-trimester APCCY women had longer LOS (Ratio: 1.44, 95% CI [1.26-1.66], p < 0.0001) and greater incidence of preterm delivery (OR 2.54, 95% CI [1.37-4.43], p = 0.0019). Cholecystectomy timing was not independently associated with differences in composite maternal outcome (p = 0.1480), BDI (p = 0.2578), 30-day NPND readmission (p = 0.7579), any complications (p = 0.2506), and fetal demise (2.44% versus 0.44%, p = 0.0545). Subgroup analysis revealed no differences in any of the seven outcomes.

CONCLUSIONS

New York Statewide data suggest that although laparoscopic cholecystectomy is safe in pregnancy, delay of cholecystectomy should be discussed in the third trimester due to an increased risk for preterm delivery.

Gynecologic cancer in pregnancy

Cancer complicates 1 in 1000 pregnancies. Multidisciplinary consensus comprised of Gynecologic Oncology, Pathology, Neonatology, Radiology, Anesthesiology, Maternal Fetal Medicine, and Social Work should be convened. Pregnancy provides an opportunity for cervical cancer screening, with deliberate delays in treatment permissible for early stage carcinoma. Vaginal delivery is contraindicated in the presence of gross lesion(s) and radical hysterectomy with lymphadenectomy at cesarean delivery is recommended. Women with locally advanced and metastatic/recurrent disease should commence treatment at diagnosis with chemoradiation and systemic therapy, respectively; neoadjuvant chemotherapy to permit gestational advancement may be considered in select cases. Most adnexal masses are benign and resolve by the second trimester. Persistent, asymptomatic, benign-appearing masses can be managed conservatively; surgery, if indicated, is best deferred to 15-20 weeks, with laparoscopy preferable over laparotomy whenever possible. Benign and malignant germ cell tumors and borderline tumors are occasionally encountered, with unilateral adnexectomy and preservation of the uterus and contralateral ovary being the rule. Epithelial ovarian cancer is exceedingly rare. Ultrasonography and magnetic resonance imaging lack ionizing radiation and can be employed to evaluate disease extent. Tumor markers, including CA-125, AFP, LDH, inhibin-B, and even CEA and ßhCG may be informative. If required, chemotherapy can be administered following organogenesis during the second and third trimesters. Because platinum and other anti-neoplastic agents cross the placenta, chemotherapy should be withheld after 34 weeks to avoid neonatal myelosuppression. Bevacizumab, immune checkpoint inhibitors, and PARP inhibitors should be avoided throughout pregnancy. Although antenatal glucocorticoids to facilitate fetal pulmonary maturation and amniotic fluid index assessment can be considered, there is no demonstrable benefit of tocolytics, antepartum fetal heart rate monitoring, and/or amniocentesis. Endometrial, vulvar, and vaginal cancer in pregnancy are curiosities, although leiomyosarcoma and the dreaded twin fetus/hydatidiform mole have been reported. For gynecologic malignancies, pregnancy does not impart aggressive clinical behavior and/or worse prognosis.

Gynecologic cancers in pregnancy: guidelines based on a third international consensus meeting

We aimed to provide comprehensive protocols and promote effective management of pregnant women with gynecological cancers. New insights and more experience have been gained since the previous guidelines were published in 2014. Members of the International Network on Cancer, Infertility and Pregnancy (INCIP), in collaboration with other international experts, reviewed existing literature on their respective areas of expertise. Summaries were subsequently merged into a manuscript that served as a basis for discussion during the consensus meeting. Treatment of gynecological cancers during pregnancy is attainable if management is achieved by collaboration of a multidisciplinary team of health care providers. This allows further optimization of maternal treatment, while considering fetal development and providing psychological support and long-term follow-up of the infants. Nonionizing imaging procedures are preferred diagnostic procedures, but limited ionizing imaging methods can be allowed if indispensable for treatment plans. In contrast to other cancers, standard surgery for gynecological cancers often needs to be adapted according to cancer type and gestational age. Most standard regimens of chemotherapy can be administered after 14 weeks gestational age but are not recommended beyond 35 weeks. C-section is recommended for most cervical and vulvar cancers, whereas vaginal delivery is allowed in most ovarian cancers. Breast-feeding should be avoided with ongoing chemotherapeutic, endocrine or targeted treatment. More studies that focus on the long-term toxic effects of gynecologic cancer treatments are needed to provide a full understanding of their fetal impact. In particular, data on targeted therapies that are becoming standard of care in certain gynecological malignancies is still limited. Furthermore, more studies aimed at the definition of the exact prognosis of patients after antenatal cancer treatment are warranted. Participation in existing registries (www.cancerinpregnancy.org) and the creation of national tumor boards with multidisciplinary teams of care providers (supplementary Box S1, available at Annals of Oncology online) is encouraged.

Endoscopic intervention and cholecystectomy in pregnant women with acute biliary pancreatitis decrease early readmissions

BACKGROUND AND AIMS

Acute biliary pancreatitis (ABP) is associated with increased rates of morbidity in pregnancy. Because there is a paucity of population-based studies evaluating ABP in pregnancy, we sought to investigate clinical outcomes in hospitalized pregnant women on a national level.

METHODS

By using the Nationwide Readmission Database (2011-2014), we identified all women (age ≥18 years) with an index admission for ABP in the United States. Multivariate and propensity-score matched analyses were performed to evaluate the impact of pregnancy on the clinical outcomes of early readmission and severe acute pancreatitis (SAP) in ABP.

RESULTS

There were 7787 hospitalizations for ABP in pregnant women during the study period. The rate of 30-day readmission was 16.26%; 57% of these early readmissions were due to adverse events of ABP. Compared with nonpregnant women with ABP, ERCP (21.1% vs 25.2%; P < .001) and cholecystectomy (52.8% vs 55.2%; P = .02) were performed less frequently during pregnancy. Propensity-score matched analysis revealed an increased risk of 30-day readmissions in pregnancy (odds ratio [OR], 1.96; 95% confidence interval [CI], 1.67-2.30), whereas there was no difference in the risk of SAP (OR, 1.09; 95% CI, 0.76-1.57). Multivariate analysis demonstrated that weekend admission (OR, 1.40; 95% CI, 1.10-1.79) and >1 week of hospitalization (OR, 1.75; 95% CI, 1.24-2.48) increased the risk of 30-day readmission, whereas ERCP (OR, 0.40; 95% CI, 0.27-0.57) and cholecystectomy (OR, 0.13; 95% CI, 0.10-0.18) reduced the odds of early readmission in pregnancy.

CONCLUSIONS

Pregnant women with ABP less frequently undergo timely endoscopic biliary decompression and cholecystectomy. These modifiable factors can potentially lower early readmissions in pregnant women.

Cholecystectomy During the Third Trimester of Pregnancy: Proceed or Delay?

BACKGROUND

Current guidelines suggest that cholecystectomy during the third trimester of pregnancy is safe for both the woman and the fetus. However, no population-based study has examined this issue. The aim of this analysis was to compare the results of cholecystectomy during the third trimester of pregnancy with outcomes in women operated on in the early postpartum period in a large population.

METHODS

The California Office of Statewide Health Planning and Development database was queried from 2005 to 2014. Women undergoing cholecystectomy during the third trimester of pregnancy (n = 403) were compared with those having this procedure in the 3 months post partum (n = 17,490). Patient demographics as well as maternal delivery and cholecystectomy-related outcomes were compared by standard statistics as well as after adjustments for age, race, comorbidities, insurance status, and hospital setting.

RESULTS

Women who underwent cholecystectomy during the third trimester were older (27 vs 25 years; p < 0.001), but did not differ in race or insurance status. Cholecystectomy during pregnancy was more likely to require hospitalization (85% vs 63%; p < 0.001) and more likely to be performed open (13% vs 2%; p < 0.001). Composite maternal outcomes (odds ratio 1.88; p < 0.001), including preterm delivery (odds ratio 2.05; p < 0.001) as well as length of hospital stay (+0.83 days; p < 0.001) and readmissions (odds ratio 2.05; p = 0.002), were all significantly increased when cholecystectomy was performed during pregnancy.

CONCLUSIONS

Maternal delivery and procedure-related outcomes were worse when cholecystectomy was performed during the third trimester of pregnancy. Preterm delivery, which is associated with multiple adverse infant outcomes, was increased in third-trimester women. Whenever possible, cholecystectomy should be delayed until the postpartum period.

Hydrosalpinx with acute abdominal pain during the third trimester of pregnancy: A case report

Background

Acute abdomen in pregnancy is a unique clinical challenge. We report a rare case of hydrosalpinx presenting as acute abdomen in the third trimester of pregnancy in the absence of infection and hormonal treatment.

Case

A 38-year-old Caucasian woman (gravida 4, para 3), at an estimated 29 weeks of a spontaneous singleton pregnancy, presented to the emergency department with severe abdominal pain in the right lower quadrant, which had been present for three days. Magnetic resonance imaging (MRI) demonstrated a right-sided hydrosalpinx. It was successfully treated with conservative treatment and the patient delivered vaginally at term without complication.

Conclusion

Hydrosalpinx should be considered as one of the differential diagnoses for acute abdomen during pregnancy. A multidisciplinary approach is recommended, with a careful work-up, due to the risks to both fetus and mother.

Adnexal Torsion during Pregnancy: Outcomes after Surgical Intervention-A Retrospective Case-Control Study

STUDY OBJECTIVE

To investigate the pregnancy and neonatal outcomes of surgical treatment for adnexal torsion (AT) during pregnancy.

DESIGN

A retrospective case-control study (Canadian Task Force classification II-2).

SETTING

A tertiary care academic medical center.

MEASUREMENTS AND MAIN RESULTS

The study group included all parturients who underwent surgery for suspected AT during pregnancy from January 2005 to January 2017. The control group included parturients with an uneventful pregnancy matched by maternal age, parity, multiple gestation, and pregnancy complications. The primary outcome was gestational age at delivery. Secondary outcomes were perinatal outcomes and intraoperative and immediate postoperative complications. Among 85 study group patients with suspected AT, 78 (91.7%) underwent laparoscopy and 7 (8.3%) laparotomy. Torsion was diagnosed in 84 patients (98.8%). The gestational age at delivery was similar between the study and control groups (38.7 ± 1.5 vs 38.6 ± 1.6 weeks, respectively; p = .908) as was preterm labor (5.8% in both groups, p = 1.00). There was no significant difference between the study and control groups in pregnancy and neonatal outcomes, including Apgar scores, mean cord blood pH (7.25 ± 0.1 and 7.26 ± 0.08, respectively), and birth weight (3040 ± 473 g and 3115 ± 584 g, respectively). In the study group, the mean gestational age at surgery was 11.2 ± 6 weeks (range, 4-34 weeks). The average operative time was 40.2 ± 22 minutes. In the postoperative follow-up, 3 (3.5%) patients had a first trimester miscarriage. A previous cesarean delivery was a risk factor for ovarian torsion during pregnancy (p = .012).

CONCLUSION

Adnexal detorsion with or without additional surgical procedures during pregnancy did not affect the gestational age at delivery and did not appear to increase fetal or maternal complication rates.

Demystifying endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy

BACKGROUND

For many years, ERCP was avoided in pregnancy given the concerns regarding the adverse effects that, with special focus on radiation, could occur in the developing fetus. However, the postponement or rejection of ERCP in pregnant women, may lead to a higher risk for mother and fetus, especially when the indication is unequivocal, namely cholangitis, biliary pancreatitis and symptomatic choledocholithiasis.

SUMMARY AND KEY MESSAGES

This review aims to summarize the scarce literature on the subject in order to plan ERCP in pregnancy with the highest safety. The use of techniques that reduce radiation and increase the protection of pregnant women allow radiation levels far below the safety limits. We also discuss the various alternatives of ERCP without radiation. EUS can eliminate the need for ERCP with doubtful choledocholithiasis and plan the best approach in those with previous evidence. The possibility of performing "ERCP" with a linear echoendoscope uniquely under ultrasound control has been described. Conversely, the two-step strategy (initial sphincterotomy with stent placement without fluoroscopy and after delivery, ERCP with lithiasis extraction) proved to be safe obviating fluoroscopy. In conclusion, ERCP can be performed in pregnancy safely and effectively with minimal radiation or even no-radiation at all.

Laparoscopy in the second and third trimesters of pregnancy for abdominal surgical emergencies

OBJECTIVE

To assess complications and outcomes of pregnancies following laparoscopic abdominal surgery during the second and third trimesters of pregnancy.

MATERIAL AND METHODS

Retrospective single-center study of 23 cases of laparoscopic surgery in the second or third trimesters of pregnancy between January 2005 and May 2016.

RESULTS

The laparoscopies were performed between 15 and 33 weeks of gestation, a mean of 23 weeks+2 days, with 6 cases in the 3rd trimester. The operations were: 11 cholecystectomies, 6 appendectomies, 1 intestinal occlusion (volvulus on a gastric band), 3 adnexal torsions, 1 ovarian cyst and 1 paratubal cyst with torsion. No secondary laparotomy was required. The postoperative courses were favorable in most cases. However, 3 appendectomies were complicated, one by chorioamnionitis and miscarriage at 20½ weeks of gestation and 2 by right iliac fossa abscesses requiring percutaneous radiological drainage, one of these women delivered a healthy term baby and the other had chorioamnionitis and preterm delivery at 34 weeks, followed by neonatal death.

CONCLUSION

Laparoscopy can be safely performed for surgical indications in the second and third trimesters of pregnancy. In case of abdominal symptoms, a timely diagnosis is required to decide whether or not to operate and imaging should not be withheld particularly in case of suspected appendicitis which has a high risk of complications.

Treatment of gynecological cancers diagnosed during pregnancy

Because of a notable increase in age at delivery, the incidence of malignancy diagnosed during pregnancy has substantially increased. This review aims to summarize the literature and expert knowledge on gynecologic cancers diagnosed in pregnancy regarding epidemiology, examination and staging procedures, description of treatment modalities and management of gynecological malignancies with special interest in cervical and ovarian cancer. Thorough attention is paid to the surgery and chemotherapy administration for early-stage cervical cancer diagnosed during pregnancy.

Ovarian cancer in pregnancy

Although the occurrence of ovarian masses in pregnancy is relatively common, the majority of them is functional and resolve spontaneously; nevertheless, ovarian cancer is the fifth most common malignancy diagnosed in pregnancy. If malignancy is suspected, treatment should be decided on the basis of gestational age, stage of the disease and patient preferences. In early stage, ovarian cancer surgery may be planned preferably after 16 weeks of pregnancy, and chemotherapy can be administered from the second trimester if indicated as in non-pregnant patients. In advanced-stage disease, when complete cytoreduction is not achievable, neoadjuvant chemotherapy could be administered even in pregnancy. Chemotherapy should be a combination of carboplatin and paclitaxel in epithelial ovarian cancer patients and a combination of cisplatin, vinblastin and bleomycin in non-epithelial ovarian cancer. The outcome of patients with ovarian cancer diagnosed in pregnancy is similar to non-pregnant patients, and stage of the disease is the most important prognostic factor.

WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.

Laparoscopic surgery in pregnancy

Each year, roughly 2% of pregnant women will undergo non-obstetrical abdominal surgery. Appendicitis, symptomatic cholelithiasis and adnexal masses are some of the common diagnoses encountered. Pregnancy poses challenges in the diagnosis and surgical management of these conditions for several reasons. Since the 1990’s, laparoscopic surgery has gained popularity and in the past few years has become the standard of care for pregnant women with surgical pathologies. The advantages of laparoscopic surgery include shorter hospital stay, lower rates of wound infection, and decreased time to bowel function. This brief review discusses key points in laparoscopic surgery during pregnancy and highlights studies comparing laparoscopic and open approaches in common surgical conditions during pregnancy.

Emergency laparoscopy: Role and implementation

Laparoscopic surgery has emerged over the past two decades as the surgical approach of choice in the treatment of many digestive disorders. Laparoscopy has its place in the management of abdominal surgical emergencies since it provides the same benefits: less postoperative pain and shorter length of hospital stay when compared to laparotomy. However, its role in the management of abdominal emergencies has not yet been fully clarified. In this review, we focus on what has been validated concerning the role of emergency laparoscopy in the management of abdominal diseases.

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.

Diagnosis and laparoscopic management of a rare endometriosis-related peritoneal mass with rapid growth in early pregnancy

Herein is described the diagnosis, clinical management and laparoscopic removal of a rapid growing retro-uterine mass in a pregnant woman. After laparoscopic removal of the pelvic mass, diagnosis of peritoneal endometriotic cyst was made on histology. The patient was asymptomatic and no history of endometriosis was reported. The laparoscopic management of the peritoneal mass was safe and effective and to our knowledge this is the first case report describing a decidualized endometriotic lesion in the absence of a pre-pregnancy endometriosis diagnosis.

Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy

PURPOSE

The aim of our study was to assess the clinical and obstetric outcomes of laparoscopic surgeries performed during advanced pregnancy compared to those performed in early pregnancy.

METHODS

We retrospectively reviewed all cases of patients who underwent laparoscopic surgery during pregnancy in our institution between 1996 and 2013.

RESULTS

We reviewed cases of 117 pregnant women who underwent laparoscopic surgery during the study period. There were no conversions to laparotomy. 71 surgeries were performed in the first trimester (group 1, mean gestational age 7.7 ± 1.9 weeks) and 46 were performed in the second and third trimesters (group 2, mean gestational age 18.1 ± 4.3 weeks). More patients in group 1 underwent surgery for suspected adnexal torsion (p < 0.001), while more patients in group 2 underwent surgery for presumptive cholecystitis (p = 0.014) and persistent ovarian mass (p = 0.011). The interval between admission and surgery differed significantly between the groups and was longer in group 2 compared to group 1 (18.2 ± 24.0 vs. 6.8 ± 10.6 h, p = 0.001). No difference was found between the two groups regarding surgical complications, histopathological findings and pregnancy outcomes.

CONCLUSION

In our experience, laparoscopic surgery in advanced pregnancy was found to be feasible and safe as in early pregnancy, without any adverse effects on pregnancy outcome.

Laparoscopic cholecystectomy in pregnancy: An Australian retrospective cohort study

INTRODUCTION

Biliary tract disease is a common non-obstetric surgical presentation during pregnancy. Although small international series demonstrate favourable outcomes following laparoscopic cholecystectomy (LC) during pregnancy, there is a paucity of Australian data to complement these findings.

METHOD

Between 1st January 2003 and 30th June 2013, all patients undergoing planned LC during pregnancy at Western Health were retrospectively identified.

RESULTS

Twenty-two patients underwent planned LC with 3 (13%) cases converted to open surgery. The median maternal age was 31 years (27.8-36) with an estimated median gestational age (EGA) of 19.5 weeks (16.5-23.5). Eighteen (82%) cases were performed during the second trimester. Nine (40%) patients had 2 or more hospital admissions for similar presentations. Twelve (54%) were performed as index cases. Operative indications included 12 (54%) with recurrent biliary colic, five (22%) with acute cholecystitis and 3 (14%) with gallstone pancreatitis. Median operating time for completed LCs was 65 min (60-95). Intra-operative cholangiogram was performed in seven (32%) cases, 5 (71%) of which employed protective uterine lead shielding. There was no fetal loss or uterine injury. Median hospital stay was 3 days (2-7) for completed LCs. Major morbidity occurred in 2 (10%) completed LCs that required a return to theatre. Five (23%) births were lost to follow up. The median time to delivery post-surgery was 13 weeks (11-15). Two (12%) preterm deliveries occurred, with subsequent neonatal complications.

CONCLUSION

Antenatal laparoscopic cholecystectomy demonstrated comparably safe outcomes. Increasing its utilization to manage symptomatic cholelithiasis during pregnancy may be considered.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Non-operative management of symptomatic cholelithiasis in pregnancy is associated with frequent hospitalizations

Symptomatic cholelithiasis (SC) is common in pregnancy. Guidelines recommend laparoscopic cholecystectomy (LC) for SC in pregnancy. Our aim was to evaluate current practice patterns and outcomes for patients undergoing initial non-operative management for uncomplicated SC during pregnancy. We performed a retrospective analysis and telephone survey of all patients presenting in a 42-month period to a tertiary care center for uncomplicated SC during pregnancy. Women with complicated gallstone disease, including cholecystitis, pancreatitis, choledocholithiasis, and cholangitis were excluded. We identified 53 patients with uncomplicated SC during pregnancy. LC was performed in 4 (7.5%) antepartum and in 28 (51.7%) postpartum. The majority of LCs (21, 75%) were performed within 3 months postpartum. Of those with postpartum LC, 22 (78.6%) had recurrent postpartum symptoms prior to LC, and 14 (50%) had repeat hospitalizations prior to undergoing surgery. Given the safety of antepartum LC and the frequency of recurrent symptoms and hospitalizations, early surgical intervention during pregnancy may be the optimal strategy to reduce antepartum and early postpartum admissions for uncomplicated SC.

Laparoscopic Surgery in Luminal Gastrointestinal Emergencies-a Review of Current Status

Laparoscopy has already established itself as the preferred surgical approach in a variety of elective surgical conditions. Along with its usual advantages of less tissue trauma and faster recovery, its diagnostic as well as therapeutic role is making it an attractive option in emergency surgery. In this paper, we have reviewed the current status of laparoscopic surgery in luminal gastrointestinal emergencies. Relevant papers were selected using Medline database from 2007 to the present. These were reviewed, and outcomes were stated under the headings of appendicitis, perforated peptic ulcer, colorectal emergencies and small bowel obstruction. The laparoscopic intervention was found to be of clear benefit in most of the patients with appendicitis. Its role, however, is not absolutely clear in managing perforated peptic ulcers. Laparoscopic lavage and drainage have been recommended in diverticular perforation with limited contamination. Small case series and studies have shown benefits of laparoscopic surgery in iatrogenic colonic perforations, colonic obstruction, emergency colectomy and small bowel obstruction. Laparoscopic surgery can be recommended in appendicitis and low-risk cases of perforated peptic ulcers. Its definitive role in other conditions needs more evidence. The surgeon's experience and careful patient selection are very important to improve the outcome.

Heterotopic triplet pregnancy after in vitro fertilization with favorable outcome of the intrauterine twin pregnancy subsequent to surgical treatment of the tubal pregnancy

Heterotopic triplet pregnancy is an exceptionally rare medical condition. The broad use of assisted reproductive technologies has contributed to the increase of ectopic and subsequently heterotopic pregnancy rate, masking a life-threatening condition for the gravid and the intrauterine pregnancy. We describe a case of a woman with heterotopic triplets at 9⁺⁴ gestational week following transfer of three embryos obtained by in vitro fertilization techniques. The ectopic tubal pregnancy was ruptured and salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed to the delivery by cesarean section of two healthy twins at 36⁺² gestational age. Heterotopic triplets with tubal ectopic are a special diagnostic and therapeutic challenge for the obstetrician. High index of suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy.

Prevalence and complications of gallstone disease among pregnant women in a Nigerian hospital

OBJECTIVE

To determine the prevalence of gallstone disease and its complications among pregnant women in a semi-urban Nigerian setting.

METHODS

Consecutive consenting pregnant women presenting at the prenatal clinic of a Nigerian tertiary hospital were recruited over an 18-month period. During routine obstetric ultrasound, the presence of gallstones and/or associated sequelae was investigated. Patients' sociodemographic data and hemoglobin genotype were documented.

RESULTS

Overall, 1283 pregnant women (14-43 years of age) were included in the study. Thirty-seven (2.9%) had sonographic evidence of gallstones, 26 (2%) had biliary sludge, and 2 (0.2%) had gallbladder polyps. Twenty-one (56.8%) of the 37 women with gallstones were 30 years of age or younger. Only 1 (1.2%) of 85 selected women in the first trimester of pregnancy with no gallstones who were followed throughout pregnancy developed gallstones in the third trimester. Overall, 3 (0.2%) women had clinical and radiologic evidence of acute calculous cholecystitis, 2 of whom underwent laparoscopic cholecystectomy after delivery.

CONCLUSION

The present study demonstrated a low prevalence of gallstone disease and its acute complications among pregnant Nigerian women in a semi-urban setting.

Appendectomy during pregnancy--is pregnancy outcome depending by operation technique?

OBJECTIVE

To compare perioperative and pregnancy outcome between women undergoing laparoscopic appendectomy and those undergoing open appendectomy during pregnancy for presumed acute appendicitis.

METHODS

A retrospective cohort study of all women undergoing appendectomy during pregnancy in a tertiary referral medical center from 2000 to 2009. Outcome was compared between those undergoing laparoscopic appendectomy and those undergoing open appendectomy.

RESULTS

Overall, 83,510 deliveries occurred during the study period, 85 (0.10%) were eligible for the study group. Of these, 26 (31%) had a laparoscopic appendectomy and 59 (69%) had an open appendectomy. No significant difference was found in the general, delivery and neonatal outcome characteristics between the two groups. There was a significant difference in the mean gestational age at surgery between laparoscopic appendectomy and the open appendectomy groups (14.6 versus 19.3 weeks respectively, p = 0.009). Post-operative complications (fever >38.0 °C or the presence of uterine contractions) rate was higher in the open appendectomy compared to the laparoscopic appendectomy group (25.5% versus 3.8%, respectively, p = 0.009).

CONCLUSION

Laparoscopic appendectomy appears to be a safe procedure for presumed acute appendicitis during pregnancy with less post-operative complications as compared to open appendectomy.

Gasless laparoscopic surgery during pregnancy: evaluation of its role and usefulness

The minimally invasive laparoscopic approach in the surgical treatment of diseases during pregnancy has become progressively more accepted and applied. In an attempt to overcome the potential adverse effects of pneumoperitoneum on the fetus, gasless laparoscopic surgery (GLS) has been developed. This article reviews the evidence available for the role and effectiveness of GLS in pregnancy. A computerized literature search was conducted on Medline, Science Citation Index, Current Contents, Embase, and PubMed databases for English language publications from the first report of GLS in pregnancy in 1995 to June 2012. Eleven case reports or retrospective series were identified. A total of 44 pregnant women underwent GLS for various surgical indications. In all cases, the procedures were carried out without complication, and the women were discharged from hospital with a continuing pregnancy. GLS in pregnancy has comparable outcomes to conventional CO2 laparoscopy, but it is associated with some advantages. Hypercarbia and increased intraperitoneal pressure due to CO2 insufflation are avoided. The use of high-pressure continuous suction may prevent the problems that are potentially associated with intra-abdominal smoke generated by electrosurgery, which can increase the risk of fetal exposure to elevated levels of toxic gases. Because this procedure may be performed under regional anesthesia, avoiding general anesthesia, there is a minimal transplacental passage of anesthetic drugs to the fetus. The surgeon must be expert in advanced laparoscopic procedures.

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.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

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