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

Laparoscopic Surgery During Pregnancy: A Meta-Review and Quality Analysis Using the Assessment of Multiple Systematic Reviews (AMSTAR) 2 Instrument

Accumulation of experience with minimally invasive surgery over the last three decades has rendered laparoscopic surgery the mainstay of management for surgical pathology during pregnancy. In the present meta-review, we compiled the available evidence on the safety of laparoscopic and robotic-assisted surgeries during pregnancy, based on relevant systematic reviews (SR) and meta-analyses (MA). A systematic review was performed for articles published until February 2024 in English using PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online) and Google Scholar based on predefined selection and exclusion criteria. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and included SRs and MAs examining women of childbearing age (population) who had undergone laparoscopic surgery or robotic-assisted laparoscopic surgery during pregnancy (intervention). The presence of comparison to open surgery was desirable but not mandatory (comparator). The included studies should necessarily report on fetal loss (outcome), and optionally on other metrics of fetal, maternal, or operative performance. We considered SRs/MAs analyzing randomized trials, observational studies, case reports, and case series (study design). The methodological quality of SRs/MAs not exclusively including case reports and case series was assessed with the Assessment of Multiple Systematic Reviews (AMSTAR) 2 instrument. A total of 1229 articles were screened, of which 78 were potentially eligible. Of these, 33 articles met our inclusion criteria, 18 containing SRs only and 15 SRs with MA. The examined disciplines were laparoscopic appendectomy (10 studies, 30.3%), laparoscopic cerclage for cervical insufficiency (eight studies, 24.2%), adnexal-ovarian laparoscopic surgery (five studies, 15.2%), laparoscopic cholecystectomy and biliary tree exploration (three studies, 9.1%), laparoscopic myomectomy (two studies, 6.1%), and one study each for laparoscopic surgery regarding pancreatic indications, adrenal indications, and bariatric complications (3.0%). The odds ratio/relative risk for fetal loss rate ranged from 0-1.9, with variable statistical significance depending on the discipline. Twenty-three out of the 33 studies were submitted to quality evaluation with the AMSTAR 2 instrument, with three being of "low quality" (13.0%) and the remaining 20 of "critically low quality" (87.0%). In conclusion, the widespread acceptance of laparoscopic surgery for treating surgical pathology during pregnancy is substantiated by heterogeneous and low-quality evidence. Literature mainly revolves around laparoscopic appendectomy, whereas other disciplines that may commonly arise during pregnancy, such as cholecystectomy and the acute abdomen following bariatric surgery, are underrepresented in the literature. Factors such as anatomical alterations that may affect surgical access, surgeon's expertise, and the biological course of the underlying pathology should be taken into consideration when selecting the appropriate mode of operating during pregnancy.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part II

Introduction

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

Aim

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

Material and methods

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. The recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

Results and conclusions

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The second part of the guidelines covers sections 6 to12 and the following challenges for surgical practice: acute appendicitis, acute mesenteric ischemia, abdominal injuries, bowel obstruction, diverticulitis, laparoscopy in pregnancy and postoperative complications requiring a reoperation.

Safety of laparoscopic surgery during pregnancy: a Korean nationwide population-based study

BACKGROUND

The optimal surgical approach to perform during pregnancy is still controversial. This study evaluated pregnancy and operative outcomes in women undergoing an appendectomy or cholecystectomy during pregnancy, and compared them between the laparoscopic and open approach using nationwide population-based data.

METHODS

Between 2009 and 2019, a total of 2941 pregnant women with procedure codes for an appendectomy or cholecystectomy were extracted from the Korean National Health Insurance claims data (laparoscopy: 1504; open: 1437). Surgical outcomes [length of stay (LOS), anesthesia time, 30-day readmission rates, transfusion rates, second laparotomy, and 30-day mortality rates] and pregnancy outcomes (live birth rate, overall and spontaneous abortion rates, threatened abortion rate, type of delivery, preterm labor, stillbirth, fetal screening abnormalities, and intrauterine growth retardation) were compared between the open and laparoscopic groups.

RESULTS

The laparoscopic group had a significantly shorter LOS than the open group, and transfusions were less frequent in the laparoscopic group. Mortality, 30-day readmission rates, and second laparotomy were not statistically significant between the two groups. There were no significant differences in fetal loss and live birth rates between the two groups in all gestational ages. Preterm labor within 30 days of surgery was more frequent in the laparoscopy group than in the open surgery group, especially for those in their first and third trimesters. Open procedures were associated with an increased rate of cesarean sections.

CONCLUSIONS

Laparoscopic surgery was found to be feasible and safe without adverse postoperative outcomes. Careful observation of postoperative preterm labor is necessary, especially for women who undergo laparoscopic surgery in their first and third trimesters.

Laparoscopy vs. Laparotomy for the Management of Abdominal Trauma: A Systematic Review and Meta-Analysis

Background

There is still no consensus regarding the role of laparoscopy in trauma cases. The purpose of this paper is to assess the value of diagnostic and therapeutic laparoscopy for patients with blunt or penetrating abdominal trauma by performing a systematic review and meta-analysis.

Methods

PubMed, Embase, and the Cochrane library were systemically searched for the randomized controlled trials (RCTs) and non-RCT comparative studies on effectiveness and safety of laparoscopy vs. laparotomy for the two authors independently performed the search, data extraction, and quality assessment.

Results

A total of 5,517 patients were enrolled in 23 eligible studies that were published in English. Meta-analysis results suggest that there is no significant difference in the incidence of missed injury and mortality between abdominal trauma patients receiving laparoscopy and those receiving laparotomy. Concerning postoperative complications, compared with patients in the open surgery group, those in the laparoscopy group are at a similar risk of intra-abdominal abscesses, thromboembolism, and ileus, while there is a decreased incidence of wound infection and pneumonia. Besides, patients in the laparoscopy group experience shorter hospitalization times and procedure times. For most outcomes, the sensitivity analysis yielded similar results to the primary analysis.

Conclusion

Laparoscopic surgery is a practical alternative to laparotomy for appropriate patients. The decision to perform laparoscopy should be based on the experience of the surgeon and the resources available.

Laparoscopic appendectomy vs open appendectomy during pregnancy: a systematic re-view

BACKGROUND

Acute appendicitis and cholecystitis during pregnancy are the most common non-obstetrical surgical emergencies and can create severe clinical issues. Surgical treatment tends to be the method physicians recommend due to its tolerability and safety. During pregnancy, surgical intervention should minimize fetal risk without compromising the mother's health, although a favorable outcome for pregnant women is heavily dependent on accurate, early diagnosis and prompt intervention. Furthermore, the physicians should remain informed on the differences in current techniques to optimize the outcome of the operation.

METHODS

This article performs a systematic review of the literature to examine whether laparoscopic treatment of acute appendicitis in pregnancy is a better option when compared to open surgery. We searched all major medical databases, identified the most relevant published studies on the subject, and performed a statistical analysis to answer that question.

RESULTS

We identified 15 studies for inclusion, and their data were extracted. The resulting pool referred to 2,837 pregnant patients. Of those included patients, 1,103 underwent laparoscopic surgery and 1,656 had open surgery. All surgeries occurred in the second trimester. For laparoscopic surgery, the fetal demises rate was 2.44 % (27 deaths), and the preterm deliveries rate was 9.79 % (108 deliveries) as opposed to open surgery with a fetal demise rate of 2.64 % (48 deaths), and preterm deliveries rate at 10.7 % (178 deliveries).

CONCLUSIONS

Our meta-analysis and data suggest that laparoscopic appendectomy is a safer option for treatment. There is a reduced risk of fetal demise and preterm delivery for pregnant women. HIPPOKRATIA 2022, 26 (1):1-6.