SCIENTIFIC PAPER

Laparoscopic Appendicectomy in all Trimesters

of Pregnancy
Norman Oneil Machado, MBBS, MS, FRCSEd, Christopher S. Grant, FRCS

ABSTRACT INTRODUCTION
Background: The laparoscopic approach for appen- Appendicectomy is the most common nonobstetric oper-
dicectomy in pregnancy was not considered the preferred ation during pregnancy.1,2 Pregnancy was a relative con-
procedure until recently. The aim of this study was to traindication to laparoscopy until recently because of the
examine our experience with laparoscopic appendicec- belief that the procedure would decrease uterine and fetal
tomy in pregnancy and review the scientific evidence blood flow and result in abortion or possibly influence
available in the medical literature. fetal development. Several reports of successful laparo-
scopic procedures in pregnancy have indicated the safety
Method: The clinical data of all patients who underwent
of laparoscopy in pregnancy.3–30 However, a recent re-
laparoscopic appendicectomy during pregnancy at our
view of laparoscopic appendicectomy in pregnancy re-
hospital between 1999 and 2007 were collected and ret-
ported a significantly higher fetal loss rate compared with
rospectively analyzed. A Medline literature search re-
open appendicectomy and has raised some concerns.31
stricted to English language articles on laparoscopic ap-
Our experience is presented here, and the available liter-
pendicectomy in pregnancy was carried out.
ature is reviewed, regarding the present status of laparo-
Result: Twenty patients underwent laparoscopic appen- scopic appendicectomy in pregnancy.
dicectomy during pregnancy. Of these, 8 were in the first
trimester, 9 in the second trimester, and 3 in the third METHODS
trimester. Fifteen patients had histologically confirmed
appendicitis. The mean operating time was 45 minutes, The data for all patients undergoing laparoscopic appen-
and the average postoperative stay in the hospital was 1.5 dicectomy during pregnancy in our hospital from January
days. All patients except one had a full-term normal de- 1999 to January 2007 were analyzed. The data studied
livery. Literature search: An additional 637 patients from included presentation, estimated weeks of gestation at
the English literature were reviewed and summarized. presentation, procedures, intraoperative findings, compli-
cations, and the outcome of laparoscopic appendicec-
Conclusion: Our results demonstrate that laparoscopic tomy. The birth records were also reviewed for outcome,
appendicectomy can be safely performed during all tri- including gestational age at delivery, birth weight, and
mesters of pregnancy. The literature search suggests that Apgar score.
although laparoscopic appendicectomy in pregnancy is
associated with a low rate of intraoperative complications Operative Technique
in all trimesters it may be associated with a significantly
higher rate of fetal loss compared with open appendicec- The procedure was carried out with the patient under
tomy. general anesthesia with end tidal carbon dioxide monitor-
ing that was maintained within the physiological range (30
Key Words: Laparoscopic appendectomy, Pregnancy, mm Hg to 40 mm Hg). A Foley catheter was inserted in all
Abortion. patients and removed at the end of the surgery. Patients
were tilted to the left to displace the uterus from the IVC.
In the initial 3 cases, pneumoperitoneum was carried out
using a Veress needle. In all the later cases, pneumoperi-
Senior Consultant, Department of Surgery, Sultan Qaboos University Hospital
Muscat/Sultanate of Oman (Dr Machado)., Professor & Chairman, Department of
toneum was carried out using an open (Hasson) tech-
Surgery, Sultan Qaboos University Hospital, Muscat/Sultanate of Oman (Dr Grant). nique. The pneumoperitoneum pressure was maintained
Address reprint requests to: Dr. Norman Machado, Senior Consultant, Department between 10mm Hg to 12mm Hg. Fetal heart rate was
of Surgery, Sultan Qaboos University Hospital, PO Box 38, Postal Code 123, recorded immediately before and after surgery.
Muscat/Sultanate of Oman. E-mail: norman@omantel.net.om
© 2009 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by The procedure was always performed using 3 ports, and
the Society of Laparoendoscopic Surgeons, Inc. their placement was modified in accordance with gesta-

384 JSLS (2009)13:384 –390

tional age. The first port (10 mm) was placed 2 cm ceph- gery within 12 hours of admission, 5 within 24 hours, 4
alad to the gravid uterus in the upper midline between the within 48 hours, and one after 72 hours. A preoperative
umbilicus and xiphoid process. The second port (5 mm) obstetric assessment was carried out in all the patients.
was placed laterally in the right lower quadrant, and the After an informed consent, laparoscopic appendicectomy
third port (10 mm) was placed in the right upper quadrant was performed.
in a more cranial location. The appendix was ligated with
endoloops and extracted after the entire appendix was The details of our patients including the operative findings
placed within the 10-mm port to reduce the possibility of and outcome are outlined in Table 1. The intraoperative
contamination of the port site. Patients were administered findings included inflamed appendix in 12 patients,
antibiotics (cefuroxime and metronidazole), and the du- phlegmonous appendix in 2, appendicular mass in 1, and
ration of antibiotic therapy was 24 hours for acute appen- normal appendix in 5 patients. Fifteen patients had histo-
dicitis and 2 days to 3 days for phlegmonous appendicitis. logically proven appendicitis. Among the 5 patients with a
Oral intake was started on the first postoperative day, and normal appendix, the abnormal findings included omen-
tocolysis in the form of indomethacin 100 mg suppository tal adhesions to the right fallopian tube and cecum (2
was given to 4 patients because of uterine contractility on patients) and an appendicular fecalith and torsion of the
the advice of the obstetrician. ovary in one patient each. The average duration of surgery
was 45 minutes (range, 25 to 90). The hospital stay ranged
Literature Review from 3 days to 8 days (mean, 3.5). A delay in surgery of
A review of the literature was carried out by searching the more than 24 hours after admission was noted in 5 pa-
Medline database selecting only studies published in En- tients. These included those who were primarily admitted
glish that described well-documented cases of laparo- under an obstetrician’s care or had atypical presentation.
scopic appendicectomy in patients with intrauterine preg- The mean postoperative stay in the hospital was 1.5 days
nancy and those in whom the surgical and obstetric (range, 1 to 5). In 2 patients, the postoperative stay was
outcome were clearly linked to the operative approach. longer than 3 days; these include the patient with appen-
Studies with incomplete or confusing data were rejected. dicular mass and the one with hydronephrosis. The pa-
tient with hydronephrosis developed Klebsiella pneumo-
RESULTS nia that was effectively treated with antibiotics and
supportive treatment. This patient was discharged on the
During the period under review, 16 803 deliveries were fifth postoperative day after the fever subsided. The other
conducted by the obstetrical service. Twenty-six appen- patient with appendicular mass had postoperative ileus
dicectomies were performed during pregnancy, an inci- for 2 days and was mildly febrile. These symptoms im-
dence of 0.15%. In 6 cases, an open procedure was cho- proved by the third postoperative day, and the patient was
sen before surgery because of advanced gestational age or discharged a day later. None of these patients developed
patient preference. The data of the remaining 20 patients wound complications, including wound infection in the
who underwent laparoscopic appendicectomy are sum- immediate postoperative period and port-site hernia fol-
marized in Table 1. lowing subsequent follow-up. No other postoperative
Fourteen patients had acute pain located at McBurney’s complications were seen. All patients except one had a
point. In 2 cases, the pain was located in the right flank, full-term normal delivery. The exception was a patient
and 4 had central abdominal pain. The temperature with a past history of recurrent abortion who aborted 3
ranged from 37°C to 38.5°C (mean temperature, 37.5°C), weeks following appendicectomy. No perinatal deaths
and WBC count ranged from 7.1x109/L to 18x109/L (mean, occurred. The birth weights of the infants ranged from
15.7x109/L). Ultrasound of the abdomen was carried out 3050 g to 3400 g (mean, 3200), and the mean Apgar score
in 10 patients in whom the diagnosis was uncertain. The at 5 minutes was 9 (range, 8 to 10). Normal milestones
findings included pericecal fluid collection in 5, thickened were observed in all infants at 1-year follow-up.
edematous appendix in 2, and hydronephrosis in one
patient. Four patients were initially admitted under an The English literature search yielded 28 main reports with
obstetrician’s care and then transferred to the surgical a total of 637 patients who underwent laparoscopic ap-
service once a diagnosis of acute appendicitis was enter- pendicectomy during pregnancy3–31 and matched our in-
tained. The remaining patients were admitted primarily clusion criteria and are included in the review. The data
under the surgical service. Ten patients underwent sur- are summarized in Table 2.

JSLS (2009)13:384 –390 385

Laparoscopic Appendicectomy in all Trimesters of Pregnancy, Machado NO et al.

Table 1.
Operative Details and Outcome in Patients Undergoing Laparoscopic Appendectomy in This Series
Patient Age Gestation Abdominal Entry Operative Finding Operative Outcome of Hospital
No. (years) (weeks) (Veress Needle/ Time Pregnancy Stay
Hasson Technique) (min) Delivery (days)
(weeks)

1 26 20 V Acute appendicitis 48 38 3
2 30 13 H Appendicular mass 55 39 7
3 19 22 V Fecalith normal 30 39 4
appendix
4 26 16 V Acute appendicitis 60 40 3
5 27 9 H Acute appendicitis 50 Abortion 3
6 19 25 H Normal appendix 35 38 8
right hydronephrosis
7 23 26 H Acute appendicitis 42 39 3
8 31 12 H Omental adhesions to 40 38 3
right salpinx normal
appendix
9 38 10 H Mucocele of 35 39 3
appendix
10 22 13 H Acute appendicitis 50 38 3
11 24 11 H Acute appendicitis 40 39 3
12 20 15 H Omental adhesions to 45 40 3
caecum / right
salpinx normal
appendix
13 24 12 H Acute appendicitis 40 38 3
14 21 24 H Acute appendicitis 60 40 3
15 26 28 H Acute appendicitis 55 39 3
16 19 13 H Acute appendicitis 40 40 3
17 24 23 H Torsion of right ovary 55 39 4
normal appendix
18 28 10 H Phlegmonous 65 40 4
appendicitis
19 25 24 H Acute appendicitis 55 40 4
20 19 14 H Acute appendicitis 45 38 3

DISCUSSION trimester (69%) compared with the first and second tri-
mester.33 Twenty-five per cent of all pregnant women
Acute appendicitis is the most common cause of nonob- who have acute appendicitis will progress to perfora-
stetric acute abdomen during pregnancy, with a reported tion.34 A 66% perforation incidence has been reported
incidence of 0.05% to 0.1%.1,2,21 Even though the inci- where surgery is delayed by more than 24 hours com-
dence of acute appendicitis in pregnancy has been con- pared with 0% incidence when surgical management is
sidered identical to that in the nonpregnant population, a initiated prior to 24 hours after presentation.35
recent case control study suggested a lower incidence in
pregnant women, with the third trimester being particu- The difficulty in making a clinical diagnosis particularly
larly protective.32 However, it has been noted that perfo- close to term combined with the previously quoted high
ration of the appendix occurs twice as often in the third incidences of fetal and maternal mortality for appendiceal

386 JSLS (2009)13:384 –390

 Table 2.
Laparoscopic Appendectomy During Pregnancy Literature Review
Study n Trimester V / H* MP* MOT* (min) Tocolysis Introp Postop Preterm Fetal
(1; 2; 3) (mmHg) Complications Complications Delivery Loss

Present study 20 8; 9; 3 3/17 10–12 45 4 — — — 1

12
Andreoli 5 0; 5; 0 NI 12 40 — — — — —
Affleck3 19 6; 9; 4 NI NI 54.5 4 — NI 3 —
14
Amos 3 0; 3; 0 -/3 12 NI — NI NI 1
Barnes20 2 0; 0; 2 -/2 12 60 1 NI — —
22
Buser 1 0; 1; 0 NI NI NI NI — — — —
Carver9 17 5; 12; 0 NI NI NI — — — — 2
Curet 21 4 0; 4; 0 -/6 10–15 82 — — — — —
dePerrot11 6 2; 2; 2 1/5 12 51.6 3 — — 1 2
23
Friedman 1 0; 1; 0 1/- NI NI — 1 1 1 1
Geisler24 2 0; 2; 0 2/- 15 NI — — — — —
Gurbuz13 5 2; 0; 3 -/5 12 64 — — — — —
Halkic6 11 0; 11; 0 0/11 10–12 45 — — — — —
25
Hee 7 NI NI NI NI NI — — — —
Lemaire18 4 1; 3; 0 4/- 12 33.7 1 — — — —
Lyass10 11 5; 4; 2 0/1 12 46 11 — — — —
McGory31 454 NI; NI; NI — — — — — — 1 31
Moreno-Sanz4 6 4; 2; — 0/6 12 46 0 — — 1 —
Palanivelu7 7 0; 7; 0 6/1 NI NI NI 0 0 0 0
16
Posta 1 0; 1; 0 -/1 12 70 — — — — —
Radwan26 1 1 NI 10–12 — — — — — —
27
Rizzo 4 0; 4; 0 -/4 10 25–90 — — — 2 —
Rollins5 28 6; 13; 9 17/11 15 46.3 6 — NI 6 —
19
Schreiber 6 2; 4; 0 6/- NI NI 1 — — NI —
Schwartzberg15 1 1; 0; 0 -/1 15 NI — — — — —
Spirtos28 13 NI — — — 1 —
Thomas29 2 2; 0; 0 -/2 NI NI NI — — 1 —
30
Tracey 3 1; 2; — — — — — — — — —
Wu8 11 4; 6; 1 0/11 NI 50.5 3 — 1 — 1
*V ⫽ Veress needle; H ⫽ Hasson technique; MP ⫽ mean pneumoperitoneum pressure; MOT ⫽ mean operative time; NI ⫽ not
indicated.

perforation has led to a traditionally low threshold for Use of laparoscopic procedures has rapidly gained accep-
surgical intervention. This has resulted in a higher nega- tance in the treatment of patients with appendicitis. In a
tive appendicectomy rate, ranging from 23% to 55% in study of 3133 pregnant patients who underwent appen-
pregnant women compared with 18% in nonpregnant dicectomy,31 the laparoscopic approach was used in 14%
women (P⬍0.05).4,25,29,31,32,36 However, of concern was of pregnant women compared with 23% of nonpregnant
the finding in the systematic review by Walsh et al36 who women. This change in approach stems from the fact that
noted that fetal loss rates in the group with no evidence of laparoscopic appendicectomy, in addition to its general
appendicitis were as high as for those with simple appen- advantage of a smaller incision, less postoperative pain,
dicitis. and earlier return to normal activity, offers other potential

JSLS (2009)13:384 –390 387

Laparoscopic Appendicectomy in all Trimesters of Pregnancy, Machado NO et al.

advantages for pregnant women.3– 6,10 Laparoscopy can nant patients in accordance with SAGES recommenda-
result in less manipulation of the uterus while obtaining tions.38 The remaining trocars can be positioned accord-
optimum exposure of the surgical field and could reduce ing to the preferences of the surgical team but always
delays in diagnosis and treatment. It affords easier visual- displaced cephalad to avoid the uterine fundus. It is rec-
ization and treatment of ectopically located appendix or ommended that the patient be placed on her left side after
helps in detecting other unexpected sources of pain as in the second term of pregnancy to prevent uterine compres-
4 of our patients.10,11 Lower rates of dehiscence or herni- sion of the vena cava and to facilitate access to the ap-
ation during labor are another potential benefit. Rapid pendix.4,37 This can be achieved by tilting the operating
return to full activity could reduce the frequency of ma- table to the left; it is unnecessary to place the patient in a
ternal thrombosis and embolic events, which can be a strict lateral decubitus position.4 In a recent review,36 the
major source of maternal mortality in some patients.4,11,21 mode of laparoscopic entry was documented in 116 cases;
the open (Hasson) technique was used in 68% of cases
The major concerns, however, have been the potential compared with the use of the Veress needle in 32% cases.
effects of pneumoperitoneum on fetal physiology and the
possibility of injury to the uterus during the operation. The Tocolytic agents are used in patients either prophylacti-
effects of laparoscopic appendicectomy due to increased cally or following the development of postoperative uter-
intraabdominal pressure and fetal acidosis during CO2 ine contractions. However, a recent review revealed no
pneumoperitoneum have been looked into in clinical or statistical difference in the rate of preterm delivery among
experimental studies, and no substantial adverse effects the prophylactic tocolysis group (0/15) and the nontoco-
for the fetus have been found when the maximal pneu- lysis group (3/79; P⫽0.59).36 Hence, the use of prophy-
moperitoneum pressure was limited to 10mm Hg to 12mm lactic tocolytic agents is not indicated but can be appro-
Hg for a duration of ⬍60 minutes.21,37 Although studies priate if there are obstetric criteria as evidenced by uterine
have demonstrated that laparoscopy can be performed contractions and risk of premature birth.4,36,37 This has
safely during any trimester with good fetal and maternal been the practice in our unit.
outcomes, the long-term effects on the child after delivery The need for continuous fetal monitoring by ultrasonog-
have not been well studied. However, one recent study27 raphy scans has been reported previously.17,38 Despite
evaluating 11 children from 1 year to 8 years whose being SAGES recommendations, this measure has been
mothers underwent surgery during pregnancy found no abandoned because it is difficult to carry out and has a
growth or developmental delay in these children. low efficacy.4 Most of the recent recommendations con-
Guidelines for laparoscopic procedures during pregnancy sider it essential to have uterine and fetal monitoring
have previously been published by the Society of Ameri- before and after operations rather than intraoperatively,
can Gastrointestinal and Endoscopic Surgeons38 and mod- and some would repeat this just before the discharge of
ifications have been proposed by Moreno-Sanz et al.4 A their patients.3–5,11
pneumoperitoneum pressure of ⬍12 mm Hg is recom- Operative times were reported in 110 cases (mean 51⫾13
mended, because previous animal studies have demon- min)(median, 46). The mean operative times were 45, 51,
strated fetal hypercapnia and acidosis secondary to CO2 and 59 minutes for procedures in the first, second, and
pneumoperitoneum in pregnant ewes.39 However, sub- third trimesters, respectively.36 This has been quicker than
stantial adverse effects to the fetus with pneumoperito- the recently reported median operating time for laparo-
neum limited to 10 mm Hg to 12 mm Hg have not been scopic appendicectomy (LA) in a nonpregnant population
demonstrated.21,39 (median 60 min) and may reflect the fact that the laparo-
scopic procedure in pregnancy is usually performed by
Some controversy exists about the best approach to access
experienced surgeons.36,40 This is supported by the low
the abdomen and to create the pneumoperitoneum. Com-
(1%) rate of conversion to laparotomy that is better than
plications have been described for all techniques, but
most published rates of nonpregnant patients.36 The mean
accidental puncture of the uterus with a Veress needle is
stay was 5⫾3.8 days. Information on the use of intraop-
the most serious.21,23 Open access to the abdomen was the
erative antibiotics was sparse, with antibiotic administra-
most common approach reported in the literature re-
tion routinely in 29/36 cases.36
viewed,6,8,9,11,13,15,17,20,27,29 but the Veress needle was only
routinely used in 3 studies.18,19,24 The correct use of the Advanced pregnancy was initially considered a relative
Hasson technique is completely safe and reproducible contraindication by authors who suggested the gestational
and is recommended as the standard technique in preg- age limit for successful completion for laparoscopic sur-

388 JSLS (2009)13:384 –390

gery during pregnancy should be 26 weeks to 28 who underwent appendectomy via a laparoscopic approach
weeks.14,17 However, there are several reports of success- despite a higher rate of nonappendicitis in this group.31
ful laparoscopic appendicectomy carried out in patients Hence, it appears that negative appendectomy is not entirely
beyond the estimated gestational age of 26 weeks.3,5,20 a benign intervention in a pregnant woman, and the risk of
Review of the literature reveals gestational age being re- misdiagnosis needs to be carefully balanced against the risks
corded in 155 cases. Of these, 52, 77, and 26 women of perforation from a delay in diagnosis.
underwent LA in the first, second, and third trimesters of
pregnancy, respectively. The mean (standard deviation) CONCLUSION
gestational age at the time of LA was 17.9 weeks
(SD⫾5.7). Among the patients in the third trimester, 8 Laparoscopic appendicectomy is technically feasible in all
were in advanced pregnancy with the gestational age trimesters of pregnancy and is associated with the same
above 30 weeks.3,5,20 Even though successful LA has been benefits of laparoscopic surgery experienced in nonpreg-
carried out in advanced pregnancy, some feel that the size nant patients, provided the specific recommendations for
of the gravid uterus in the third trimester may interfere these types of patients are strictly followed. Although the
with adequate visualization and instrumentation,20 and laparoscopic approach to appendectomy in pregnancy is
these procedures that are technically demanding should associated with a low rate of intraoperative complications
be carried out by experienced laparoscopic surgeons. in all trimesters, the rate of fetal loss following LA is almost
However, there was no significant difference reported in 6%, which is significantly higher than that following open
the rates of intraoperative complications, fetal loss, or appendectomy. Rates of preterm delivery appear to be
preterm delivery between the first and among the 26 equal or slightly better in the LA group. The data available
patients in third trimesters.36,37 at present on LA in pregnancy are derived from case
reports and retrospective case series rather than random-
The overall rate of preterm delivery following LA in preg- ized controlled trials. However, given the surgical exper-
nancy was 2.1% (13/624), which is significantly lower than tise needed to confidently perform laparoscopic proce-
that reported following open appendectomy (OA) (8.1%, dures in pregnant women, a large randomized trial to
346/4193; P⬍0.0001).36 No fetal deaths were recorded address the optimal surgical approach to appendicitis in
among the cases of preterm delivery following LA although pregnancy, though desirable, seems less likely.
other neonatal outcomes are not reported. Data are insuffi-
cient to examine the effect of appendectomy on subsequent
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