Should the laparoscopic approach be the norm for appendicectomy in the third trimester of pregnancy?

Abstract

Our case describes a pregnant woman with acute appendicitis who presented in the third trimester and underwent a laparoscopic appendicectomy. She made a rapid postoperative recovery and the pregnancy was otherwise uncomplicated, ending with a spontaneous vaginal birth at 41 weeks. The diagnosis of acute appendicitis can be unclear in pregnancy. Difficulty in establishing diagnosis due to atypical presentation often leads to delay in surgery, resulting in significant maternal and fetal morbidity and mortality. Surgical intervention should be prompt in cases of suspected appendicitis and the laparoscopic approach is advocated in the first two trimesters. In the third trimester (after 28 weeks), laparotomy is often performed due to the size of the uterus and the theoretical risk of inadvertent perforation with trocar placement. More recently, several authors have described successful outcomes following laparoscopic appendicectomy after 28 weeks and with increasing reassuring data, we suggest that this minimally invasive approach should be considered in managing appendicitis in the third trimester.

Background

Acute appendicitis is the most common general surgical problem during pregnancy, with an incidence ranging from 1:500 to 1:2000 pregnancies.¹ Acute appendicitis in the non-pregnant population classically presents with right iliac fossa pain, anorexia, vomiting and a change in bowel habit.² Establishing a diagnosis is more challenging in pregnant women as these symptoms can also occur in normal uncomplicated gestations.² Furthermore, the enlarging pregnant uterus can displace the inflamed appendix,² thus altering the intensity and location of the pain.³

Inflammatory markers which aid the diagnosis of acute appendicitis are of little practical help as physiological leucocytosis can be present in a normal pregnancy,³ while the role of imaging is limited.² Both ultrasonography and non-contrast MRI, while useful in non-pregnant patients, can be non-specific, and the difficulty in obtaining an urgent scan slot may further delay intervention.² Holzer et al have noted that a 24 hours delay in surgery following presentation can lead to a 66% increase in perforation rate.³

Surgical intervention should be prompt once a clinical diagnosis is reached and traditionally, this could be either via the open or laparoscopic approaches.³ In the first two trimesters, as the pregnant uterus only extends to the level of the umbilicus, laparoscopic appendicectomy is recommended: this also enables adequate visualisation of abdominal and pelvic organs should a normal appendix be found at laparoscopy.³ The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has published guidelines relating to specific strategies to use in laparoscopic appendicectomy in pregnancy.² These guidelines, however, are less clear in the third trimester, because of the technical difficulties in performing the laparoscopy as well as associated maternal and fetal risks.¹

With the increasing experience in laparoscopic surgery and the publication of several case series, laparoscopic appendicectomy is deemed a safe option in any trimester.¹ The advantages of a smaller incision, less postoperative pain and quicker recovery are well documented.⁴ Laparoscopy also subjects the uterus to less manipulation, thus reducing the risk of uterine irritability (5), while obtaining a sufficient field of vision for the surgeon.⁵

In this article, we report the case of a woman who was 31 weeks pregnant when she presented with acute appendicitis and had a successful laparoscopic appendicectomy.

Case presentation

A 39-year-old primiparous woman at 31 weeks gestation presented with acute onset generalised abdominal pain and vomiting over the duration of a few hours. She had no urinary or bowel symptoms. She had a medical history of uterine fibroids and denied any contact or travel history.

She was apyrexial on admission and fetal cardiotocography was reassuring with no signs of uterine activity. On examination, the abdomen was soft and there was no evidence of peritonism. The pain settled with analgesia and the patient was discharged, but presented again 8 hours later with a fever of 38.1°C and localised right iliac fossa pain. On readmission, she was tachycardic, with tenderness and localised guarding in the right iliac fossa.

Her infection biomarkers were elevated and these values are listed in table 1.

Table 1.

Haematological and biochemical investigations showing raised infective markers

Parameter	Results	Normal values
Haemoglobin (g/dL)	103	120–160
Platelets (x109/L)	369	150–400
White blood cell count (x109/L)	30	4–11
Neutrophils (%)	26.2	2–7.5
CRP (mg/dL)	29.3	<1

Surgical review confirmed a high clinical suspicion of acute appendicitis (no imaging was performed). She was commenced on broad spectrum intravenous antibiotics and prepared for emergency surgery to be performed within 2 hours.

A joint decision was made by the surgical and gynaecology team not to give antenatal steroids (for fetal lung maturation) despite the pregnancy being premature as the patient was clinically septic.

A four port laparoscopic appendicectomy was performed, starting with a sub-umbilical 10 mm Hasson entry for the primary port and insufflation. Initially, 10 mm and 5 mm ports were then placed respectively at the left iliac fossa and suprapubically. Inspection of the peritoneal cavity revealed free pus in the right iliac fossa but the appendix did not appear perforated. When an endoscopic loop was secured around the appendix, it ‘cheese-wired’ through the friable base. A fourth 5 mm port has to be inserted in the right iliac fossa to enable laparoscopic suturing of the appendicular stump. Haemostasis was ensured and a thorough lavage of the peritoneal cavity was performed. The specimen was retrieved using an endoscopic bag and no drains were inserted.

Outcome and follow-up

The laparoscopic appendicectomy was successful and figures 1, 2 and 3 depict the different stages of the procedure. The patient made an uneventful recovery and was discharged on day three following the operation. She received venous thromboembolism prophylaxis (subcutaneous tinzaparin and compression stockings) while an inpatient, however this was discontinued post discharge as she did not have any other antenatal risk factors.

Figure 1.

Laparoscopic view of pus in the abdomen.

Figure 2.

Laparoscopic view of inflamed appendix with endoscopic loop encircling the organ.

Figure 3.

Laparoscopic view of stump post appendicectomy.

On discharge, she was seen routinely in Antenatal Clinic by the Consultant Obstetrician. She subsequently moved to a different region and transferred her care to the local maternity unit. The patient has a successful spontaneous normal vaginal delivery of a healthy male infant in good condition at 41+5 weeks.

Discussion

Guidelines from the SAGES indicate that laparoscopic appendicectomy may be performed safely in pregnant patients (level II, grade B) in any trimester.² The laparoscopic approach is held to be the standard of care for gravid patients with suspected appendicitis, but there are varying opinions on the safety aspects of such a procedure in the third trimester.² Earlier studies had initially demonstrated that this approach may be utilised up to 34 weeks gestation, after which the higher conversion rate to open appendicectomy (due to technical difficulty with the enlarged uterus)¹ and longer operating times can potentially lead to more serious intraoperative complications.³ These opinions were primarily based on case series and there is no conclusive evidence to suggest that the laparoscopic approach should be avoided in the third trimester.¹ Since 2007, however, surgeons have gained more confidence and experience in performing successful laparoscopic appendicectomies in patients beyond 28 weeks gestation.⁴ The advantages of a smaller incision, less postoperative pain and quicker recovery are well documented⁴; moreover, in the case of a false positive diagnosis of acute appendicitis, other abdominal and pelvic organs could be visualised through the laparoscope for other causes of pain.⁵ Laparoscopy also subjects the uterus to less manipulation, thus reducing the risk of uterine irritability (5), while obtaining a sufficient field of vision for the surgeon.⁵

Fetal monitoring is recommended both pre and postoperatively.³ The surgical table should be adjusted to enable a 15°–30° left lateral tilt as this avoid aorto-caval compression⁵ and maintains blood supply to the uterus. Insertion of the primary trocar should be adjusted according to the fundal height and the use of the Hasson entry technique is recommended.⁴ The remaining trocars must be positioned under direct vision according to the preferences of the surgeon, to minimise accidental injury to the uterus.⁴

Earlier theoretical concerns about the negative effects of creating a pneumoperitoneum (ie, increased intra-abdominal pressures can compromise utero-placental circulation)⁴ have been largely refuted, with several clinical studies showing no significant adverse fetal effects when the maximum pneumoperitoneum pressure was set between 10 and 12 mm Hg for less than 60 min.⁴ Incidentally, most authors have quoted a mean operating time of 59 min for laparoscopic appendicectomy in the third trimester.⁴

Both intra- and postoperative leg compression devices are recommended³ in view of increased venous thromboembolic risks in pregnancy but tocolysis should not be considered unless there are signs of premature contractions.³

A systematic review and meta-analysis published in 2012 suggested that laparoscopic appendicectomy in pregnancy was associated with a twofold risk of fetal loss compared with the conventional open approach,⁶ but the authors admitted that most of the data included were observational and retrospective, while only one was a truly randomised controlled trial. A systematic review of 637 published cases of laparoscopic appendectomies reported no significant difference in rates of intraoperative complications, fetal demise and premature delivery between the first and the third trimesters.⁷ Hitherto, there have been more than 20 documented cases of reported laparoscopic appendicectomies after 28 weeks in the literature (1), with authors suggesting that this is a feasible and safe, although a more technically challenging, procedure in the third trimester. More conclusive data from randomised controlled trials is required to confirm its safety and efficacy.¹

Learning points.

• Delay in diagnosis of acute appendicitis due to non-classical presentation leads to a delay in surgical intervention resulting in high maternal and fetal morbidity and laparotomy is often performed in the third trimester due to concerns about longer operating times, technical difficulty and risk of uterine perforation with the laparoscopic approach.

• There has been an overwhelming series of case reports (n=24 including our case) of successful laparoscopic appendicectomy after 28 weeks gestation. The advantages include a smaller incision, less postoperative pain and quicker recovery; moreover, in the case of a false positive diagnosis of acute appendicitis, other abdominal and pelvic organs could be visualised through the laparoscope for other causes of pain.

• The Society of American Gastrointestinal and Endoscopic Surgeons has published guidelines relating to specific strategies to use in laparoscopic appendicectomy in pregnancy. However, this guideline is not specific to the third trimester of pregnancy. More evidence and robust studies are required before laparoscopic appendicectomies can be recommended to third trimesters.

• Multiple variable factors should be considered when choosing the optimal surgical approach with regards to appendicectomies. This includes the patient’s body mass index, clinical status as well as the presence of surgical expertise. For example, as demonstrated in this case report, the laparoscopic approach is still favoured despite the intraoperative findings of a perforated appendix.