Laparoscopic Appendectomy During Pregnancy

Marc de Perrot, MD, Alexandra Jenny, MD, Michel Morales, MD, Magdalena Kohlik, MD, andPhilippe Morel, MD

Summary: Appendectomy is the most common nonobstetric operation during preg-nancy, but laparoscopy has not been considered to be the preferred procedure untilrecently. The objective of this study was to report the authors’ experience with lapa-roscopic appendectomy during pregnancy and to review the available literature. Sixpatients underwent laparoscopic appendectomy during pregnancy, and 24 additionalcases from the literature were reviewed. Two patients underwent surgery during thefirst trimester of pregnancy, three patients underwent surgery during the second tri-mester, and one patient underwent surgery during the third trimester. The Hasson opentechnique was used in five cases, and the Veress needle was used in one case. Port sitelocations were adapted to the size of the gravid uterus. Three patients had histologi-cally confirmed appendicitis and underwent delivery of a neonate after 36 weeks (n �1) and 37 weeks (n � 2) of gestation. Two patients had uterine infections andunderwent abortions 2 days after surgery and 6 weeks after surgery, respectively. Onepatient had an isolated torsion of the right fallopian tube that was diagnosed usinglaparoscopy. These results show that laparoscopic appendectomy can be safely per-formed during pregnancy. One limitation may be the size of the gravid uterus, whichinterferes with adequate visualization and instrumentation in the third trimester ofpregnancy. Key Words: Appendectomy, laparoscopy, pregnancy.

Pregnancy initially was thought to be an absolute con-traindication to laparoscopic procedures because of therisk of fetal acidosis secondary to carbon dioxide absorp-tion across the peritoneum and the unknown effects ofincreased intra-abdominal pressure (1). However, be-cause of its success in nonpregnant patients, the numberof laparoscopic cholecystectomies performed duringpregnancy has increased steadily in recent years (morethan 200 cases reported), which suggests that laparosco-py could be performed safely in all trimesters of preg-nancy (2,3). Data regarding laparoscopic appendectomyare not common in the literature. Therefore, the objectiveof this study was to report our experience with laparo-

scopic appendectomy during pregnancy and to reviewthe available literature.

MATERIALS AND METHODS

From January 1998 to March 1999, 294 appendecto-mies (61 open appendectomies and 233 appendectomiesby means of laparoscopy) were performed in our insti-tution. During the same period, 3,702 deliveries wereperformed in the Department of Obstetrics. Nine appen-dectomies were performed during pregnancy (six appen-dectomies by means of laparoscopy). In three cases, anopen procedure was chosen before surgery because ofadvanced gestational age.

The characteristics of the six patients who underwentlaparoscopic appendectomy are summarized in Table 1.Four patients had acute abdominal pain located at the“McBurney point.” In two cases (patients 4 and 5), thepain was located in the right flank. Patient temperatureranged from 37.5° C to 39.8° C (mean fever temperature,38.4° C), and leukocytosis ranged from 12.7 × 103 cells–mm3 to 18.0 × 103 cells–mm3 (mean, 15.4 × 103 cells–mm3). Five patients underwent preoperative ultrasoundand, in two cases (patients 1 and 5), the findings showedprobable appendicitis. Five patients underwent surgery

Received October 18, 1999; revision received June 30, 2000; ac-cepted July 10, 2000.

From the Clinic of Digestive Surgery (MDP, AJ, PM), and the De-partment of Gynecology and Obstetrics (MM, MK), University Hos-pital of Geneva, Switzerland.

Address correspondence and reprint requests to Marc de Perrot, MD,Department of Surgery, University Hospital of Geneva, rue Micheli-du-Crest 24, 1211 Geneva 14, Switzerland.

Address electronic correspondence to marcdeperrot@hotmail.com.

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within 12 hours after admission. In one case, surgery wasdelayed until 24 hours after admission.

Operative TechniqueGeneral anesthesia with end-tidal carbon dioxide

monitoring was used routinely. A Foley catheter wasinserted in all patients. Deep vein thrombosis was pre-vented with use of low-molecular-weight heparin started2 to 3 hours after surgery. Sequential compression stock-ings were not used. Patients were tilted to the left todisplace the uterus from the inferior vena cava. The peri-toneal cavity was entered with use of the Hasson opentechnique in five patients. In one case, a Veress needlewas used to insufflate the peritoneal cavity. The needlewas inserted in the midline slightly above the umbilicusto be distant from the uterus. The Veress needle was usedat the beginning of our series, but now we believe thatthe Hasson open technique is safer; therefore, we recom-mend it for our patients. Carbone dioxide pressure wasmaintained at 12 mm Hg or less. Fetal heart rate wasrecorded immediately before surgery and after surgery.

The procedure always was performed with three portsites, and their placement was modified in accordancewith gestational age.

The first port was placed above the gravid uterus in theupper midline between the umbilicus and the xyphoidappendix. The second port was placed laterally in theright upper quadrant. The third port was inserted in thelower midline between the umbilicus and pubic symphy-sis above the uterine fundus during the first trimester,and in the second and third trimesters, the third port wasplaced in the right upper quadrant between the first twoports, but in a more cranial location. The appendix wasligated with use of endoloops and extracted from theperitoneal cavity with use of a plastic bag.

Literature ReviewA literature search was performed with use of

MEDLINE to retrieve information regarding the major-ity of patients who underwent laparoscopic appendec-tomy during pregnancy.

RESULTS

Three patients had histologically proven appendicitis.Two of these patients, who underwent surgery during thesecond trimester and third trimester of gestation, neededtocolysis because of premature labor that occurred within24 hours after surgery and was resolved after 2 days and3 days of treatment, respectively. Delivery occurred after36 (n � 1) and 37 weeks (n � 2) of gestation. Noperinatal death was observed. Birth-weight was 3050 gr,3100 gr, and 3620 gr and Apgar score reached 10 at 5minutes in all infants.

Uterine infection was present in two patients with nor-mal appendices. The diagnoses of uterine infection weresuspected intraoperatively because of an edematousuterus. The patients underwent therapeutic abortion 2days after the laparoscopic procedure and 6 weeks afterthe laparoscopic procedure, respectively. The infectiousprocess was started preoperatively in these cases; there-fore, abortion procedures are best not related to surgery.

Finally, one patient underwent laparoscopic appendec-tomy. The appendix was normal, but an isolated torsionof the right fallopian tube was detected. The necroticportion was removed, and diagnosis was confirmed his-tologically. Tocolysis was instituted prophylactically fortwo days. The postoperative course was uneventful, andthe patient was delivered of a neonate at 38 weeks ofgestation.

No intraoperative cardiovascular instability was re-corded and no clinical deep vein thrombosis was de-tected in the six patients. The outcome of each patient isreported in Table 1.

Experience From the LiteratureThe literature search yielded seven main reports that

showed 24 patients who underwent laparoscopic appen-dectomy during pregnancy (4–9). The data are summa-rized in Table 2. Twenty-one procedures were performedduring the first trimester and second trimester of gesta-tion; however, only three patients underwent laparoscop-ic appendectomy between 26 weeks and 32 weeks ofgestation. Insufflation of the pneumoperitoneum through

TABLE 1. Outcome of patients undergoing laparoscopic appendectomy

PatientWeeks ofgestation

Operativetechnique

Operativetime (min) Surgical findings Tocolysis Outcome Fetus

1 8 weeks Open 45 Appendicitis No Delivery (37 weeks) Alive2 12 weeks Open 60 Flabby uterus No Abortion (18 weeks) Dead3 16 weeks Veress 45 Appendicitis Yes Delivery (36 weeks) Alive4 16 weeks Open 45 Flabby uterus No Abortion (16 weeks) Dead5 28 weeks Open 45 Appendicitis Yes Delivery (37 weeks) Alive6 20 weeks Open 70 Torsion of right fallopian tube Yes Delivery (38 weeks) Alive

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a Veress needle was used in 10 patients. Tocolysis wasnecessary in two patients because of premature labor.Fifteen patients were reported to have normal-term de-livery. Amos et al (5) reported four fetal deaths amongseven laparoscopic procedures (four cholecystectomiesand three appendectomies). These adverse outcomes mayhave been related to underlying maternal disease (pro-longed anorexia in two patients), to a tendency to havemore advanced disease, and to the underlying diseaseprocesses rather than to the laparoscopic procedure (10).

DISCUSSION

Acute appendicitis is the most common nonobstetricabdominal emergency that necessitates surgery duringpregnancy, but is a rare event (11). The diagnosis can bedifficult because the symptoms are nonspecific, and aleukocyte count as high as 16.0 × 103 cells/mm3 can beshown during the third trimester of pregnancy (12). Thepercentage of misdiagnoses ranges from 23% to 46%,and often is higher during the second and third trimestersof gestation (13,14). In our series, a rate of misdiagnosesof 50% was observed and may be explained with a ma-jority of patients who underwent surgery during the sec-ond trimester of pregnancy. The rate of normal appen-dices discovered at surgery occasionally may be lower,but this rate often replaces a higher incidence of perfo-rated or gangrenous appendicitis (14). Because morbidityand mortality of appendicitis in a pregnant patient oftenis because of a delay in diagnosis and treatment, we andothers recommend that patients with suspected appendi-citis undergo surgical exploration, without regard to thetrimester of pregnancy in which it occurs (15).

Use of laparoscopic procedures rapidly has gained ac-ceptance in the treatment of patients with appendicitis,but the unknown effect of carbon dioxide and increasedintra-abdominal pressure on the fetus initially caused acontraindication of this technique during pregnancy (1).However, because of the absence of long-term compli-cations after laparoscopic exploration in pregnant

women (16,17), laparoscopic appendectomy becamemore prevalent in the early 1990s (8).

At least 30 patients, including our patients, underwentlaparoscopic appendectomy during pregnancy so far.Twenty-six of these patients underwent surgery duringthe first trimester and second trimester of pregnancy, butonly four patients underwent laparoscopic appendectomyduring the third trimester.

Although controlled data are not available to evaluate,laparoscopic procedures do not seem to increase the fetalrisk when compared with laparotomy. Mazze and Kallen(13), who reviewed 778 cases of open appendectomyduring pregnancy in Swedish healthcare registries, re-ported an increased risk of preterm delivery. During thefirst postoperative week, infants with low birth weightsand live born infants dying within 168 hours increasedpostappendectomy. In our experience, delivery did notoccur before week 36 of gestation, and birth weight ex-ceeded 3000 g in infants after laparoscopic appendec-tomy. Similarly, as reported in the literature, most pa-tients had normal-term delivery of healthy infants, andno perinatal deaths after laparoscopic appendectomyhave been reported (Table 2).

Amos et al (5) reported four fetal deaths of sevenlaparoscopic procedures performed during pregnancy.However, such adverse events may not have been relatedto the laparoscopic procedure. In our experience, twopatients had intrauterine infections and underwent thera-peutic abortion 2 days after surgery and 6 weeks aftersurgery. The diagnosis of uterine infection was suspectedduring laparoscopy, and the outcome was not influencedby the surgical procedure in these cases.

Laparoscopy has been reported to decrease hospitalstay, to decrease postoperative pain and paralytic ileus,and to accelerate the recovery period (18). No random-ized study has been performed in pregnant patients withsuspected appendicitis, but similar conclusions probablyconcur with these cases. Laparoscopic procedure alsoprovides thorough exploration of the abdomen and pelvisto find a cause of the abdominal pain. This procedure

TABLE 2. Reported cases of laparoscopic appendectomy during pregnancy

Authors (ref.) n

Trimester

TechniqueMean operating

time (min)Tocolysis

(n)Abortion

(n)Term delivery

(n)I II III

Gurbuz et al. (4) 5 2 0 3 Hasson 64 0 0 5Amos et al. (5) 3 – 3 – 0 Hasson NS 0 NS NSCuret et al. (3) 4 – 4 – 0 Hasson 82 0 0 4Lemaire et al. (6) 4 1 3 0 Veress 35 1 0 4Schwartzberg et al. (7) 1 1 0 0 Hasson NS 0 0 1Schreiber (8) 6 2 4 0 Veress NS 1 0 NSPosta (9) 1 0 1 0 Hasson 70 0 0 1

NS, not stated.

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was well-demonstrated in our final patient who had anisolated torsion of the right fallopian tube that wouldhave been missed using a right flank laparotomy. Torsionof the fallopian tube is a very rare condition that usuallyis diagnosed during surgery and necessitates unilateralsalpingectomy (19).

In conclusion, controlled data are not available forevaluation, but laparoscopic appendectomy does notseem to be more hazardous for the fetus or for the pa-tient, when compared with data from the literature re-garding open surgery (13). However, during the thirdtrimester, laparoscopic appendectomy may be limited bythe size of the gravid uterus, which interferes with ad-equate visualization and instrumentation.

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