Page 22 - WJOLS - World Journal of Laparoscopic Surgery

Safety and Efficacy of Laparoscopic Appendectomy in Pregnancy
Table 3: Operative outcomes of laparoscopic and open appendectomy acute appendicitis was found in 77.78% (14 patients) in LA, and was
during pregnancy found in 69.23% (nine patients) in OA. In a study by Chung et al.,

Outcomes LA (18 patients) OA (13 patients) p value acute appendicitis was found in 15 (68.2%) patients in the LA group
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Operative 40 ± 18.4 minutes 45 ± 15.6 minutes 0.284* and 28 (71.8%) in the OA group.
duration In the last decades, the treatment of choice for acute
Time to 1st flatus 1.4 ± 0.5 days 2.7 ± 1.2 days 1* appendicitis during pregnancy was open appendectomy. But
recently, laparoscopic appendectomy could be done in pregnant
Time to oral fluid 2.2 ± 0.4 days 4.1 ± 1.9 days 1* women with good maternal and fetal outcomes. Our study
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Length of 3.2 ± 1.8 days 5.9 ± 2.6 days 0.9* supported the safety of LA; the outcomes of LA and OA were the
hospital stay same. Moreover, some proven advantages of LA, including better
Complications 1 (pelvic abscess) 2 (wound infection) 0.361** intraoperative visualization, decreased surgical trauma, decreased

*t test p value gravid uterine manipulation, shorter postoperative hospital stay,

**Chi-square test p value and faster return to work, maybe even more important in pregnant

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women. In our study, the LA group had an earlier recovery of bowel
Table 4: Obstetric outcomes of laparoscopic and open appendectomy function and shorter hospital stay.
during pregnancy Guidelines for laparoscopic procedures during pregnancy
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Χ p have previously been published by the Society of American
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Outcomes LA (18 patients) OA (13 patients) value Gastrointestinal and Endoscopic Surgeons (SAGES) and
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Preterm labor 1 (5.56%) 0 1 modifications were proposed by Moreno-Sanz et al. A
CS delivery 13 (72.22%) 9 (69.23%) 0.856 pneumoperitoneum pressure of 10–12 mm Hg is recommended
as previous animal studies have demonstrated fetal hypercapnia
Vaginal delivery 5 (27.78%) 4 (30.77%) 0.856
and acidosis secondary to CO pneumoperitoneum in pregnant
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females. In our study, pneumoperitoneum was adjusted to
10–12 mm Hg throughout the duration of the operation.
dIscussIon It has been recommended to position the patient on her left
The most common abdominal surgery during pregnancy for side during surgery to prevent uterine compression of the inferior
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nonobstetric causes is acute appendicitis, and its incidence is vena cava and to facilitate access to the appendix. Morrell and
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similar to that in nonpregnant women; the diagnosis is difficult colleagues have suggested a lateral rotation of the operating table to
because of the physiologic and anatomic changes that occur displace the uterus for better venous return. In our study, all patients
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during pregnancy. The risk for appendicitis does not appear were placed in a supine position with a slight left side tilt (20–30°).
to be increased by pregnancy, but the incidence of perforated One of the most important concerns during LA in pregnancy
appendicitis in pregnant women is much higher than in the general is the potential risk of injury to the gravid uterus during ports
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population. Complicated appendicitis can lead to maternal and insertion. The Veress needle or the Hasson open technique can be
fetal morbidity and even fetal loss, so pregnant women should used to gain initial abdominal access. Even though complications
undergo immediate surgery when appendicitis is suspected, have been described for all methods, spontaneous puncture of
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regardless of the gestation age of the fetus. the uterus with a Veress needle is the most serious. Friedman
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Acute appendicitis can present at any trimester but half of the and colleagues reported results in a young pregnant woman at
cases can be seen at the 2nd trimester, an observation published 21 weeks’ gestation who underwent LA for suspected appendicitis.
by Kapan et al. In our study, more than half of the cases were Injury to the serosa of the gravid uterus with the Veress needle
presented in the 2nd trimester. But in a study by Kazar et al. and resulted in postoperative pneumoamnion with subsequent
Mazze et al., they observed that the most accurate diagnosis for fetal loss. In our study, we insert the camera port supraumbilical
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acute appendicitis was during the first trimester. 3–4 cm above the uterine fundus with open method (HASSON
It was known that the change in the physiology and the anatomy method) according to the SAGES guidelines for laparoscopy during
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during pregnancy made the diagnosis of acute appendicitis more pregnancy.
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difficult in pregnant women. The number of negative laparoscopic Stasis of blood in the lower limbs is common during
and open exploration rates during pregnancy ranges from 0% pregnancy, so pregnant women are at high risk of thromboembolic
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to 50% and 15% to 50%, respectively. In our study, the negative complications. According to the SAGES guidelines, pneumatic
appendectomy rate was 16.13% (five patients) and it was 11.11% compression devices were recommended to be used during
(two patients) in LA and 23.08% (three patients) in OA. In a study by intraoperative and postoperative periods with early postoperative
Jun Chul et al., the overall negative appendectomy rate was 9.8% ambulation to prevent deep vein thrombosis in pregnant
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(9.1% for the LA group and 10.3% for the OA group). patients, and this was applied in the study with no postoperative
In our study, there was no conversion of laparoscopic to open thromboembolic complications.
because the operation is done by a highly experienced laparoscopic The risk of preterm labors with any operative interference
surgeon. Walsh et al. reported 1% as the rate of conversion of during pregnancy was reported to be 10–15%. The same was
laparoscopic to open appendectomy. In this study, none of our observed after laparoscopic or open appendectomies that were
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procedures converted from laparoscopic to open appendectomy. reported by Kazar and Roslyn. The overall rate of preterm labors
Diagnostic imaging studies are often used to clarify a confusing was one patient (3.22%) in LA.
clinical picture. Ultrasonography is widely used as a first-line In conclusion, laparoscopic appendectomy is distinguished
diagnostic test because of its safety for the mother and fetus by safety and efficacy throughout pregnancy and associated
and its relatively high sensitivity and specificity for many intra- with good maternal and fetal outcomes, similar to those of open
abdominal processes. In our study, U/S was done in all patients; appendectomy. In addition to all the advantages of laparoscopy, LA
130 World Journal of Laparoscopic Surgery, Volume 11 Issue 3 (September–December 2018)