Appendectomy in Pregnancy: Appraisal of the Minimally Invasive Approach

Abstract

Background:

The optimal surgical approach to acute appendicitis in pregnancy remains controversial. Our aim was to compare perioperative and obstetric outcomes associated with laparoscopic and open appendectomy in a large contemporary cohort of pregnant women.

Methods:

Retrospective review of all women who underwent appendectomy during pregnancy in a single hospital during 2000–2014.

Results:

Ninety-two patients met the study criteria. Fifty (54%) underwent laparoscopic appendectomy and 42 (46%) open appendectomy. The laparoscopy group had a lower median gestational age at surgery (16 weeks versus 24 weeks, P < .001), a shorter median hospital stay (5 days versus 3 days, P < .001), and a lower rate of postoperative complications (8% versus 24%, P = .04). There were no significant between-group differences in the rates of gestational age at delivery, Apgar scores, preterm delivery, and fetal loss.

Conclusions:

Laparoscopic appendectomy during pregnancy is safe and associated with better surgical outcomes than open appendectomy, with no difference in obstetric outcomes.

Introduction

Appendectomy is the most common nonobstetric surgical procedure performed during pregnancy, with an estimated incidence of 1:1500 pregnancies.^1,2 Acute appendicitis in pregnancy poses a unique therapeutic challenge to the surgeon. Studies have shown that abdominal surgery during pregnancy, and specifically appendectomy, may be associated with poor obstetric outcomes,^3,4 with fetal loss rates in the range of 3%–30%^5–7 and premature delivery rates in the range of 15%–45%.⁸ There is also an increased risk of spontaneous abortion, premature contractions, and perinatal morbidity and mortality.⁹ The incidence of obstetric complications rises when the appendicitis is advanced or complicated.¹⁰ Furthermore, the optimal surgical approach to acute appendicitis in pregnancy is still controversial, as the safety and benefits of laparoscopic appendectomy have not been established relative to traditional open appendectomy, a proven safe procedure and still the standard of care in many institutions worldwide. Many studies found that laparoscopic procedures carry no additional risk of obstetric complications and, therefore, support laparoscopic appendectomy as the procedure of choice.^4,11–18 However, other, mostly smaller, studies raised concerns that laparoscopic intervention may cause fetal compromise as a result of elevation in intra-abdominal pressure and fetal acidosis due to CO₂ pneumoperitoneum.^19–21 A recent meta-analysis by Wilasrusmee et al.²² suggested that although laparoscopic appendectomy in pregnant women might be associated with a greater risk of fetal loss, the available evidence on the issue is of low grade.

The present study was conducted on the most comprehensive series to date of pregnant women with a presumed diagnosis of appendicitis treated in a single medical center. The aim of the study was to compare the perioperative and obstetric outcomes in the laparoscopic- and open-appendectomy groups.

Methods

Study design and population

The study was approved by the Institutional Independent Ethics Committee (Helsinki Committee). The cohort included all pregnant women who underwent appendectomy for presumed diagnosis of acute appendicitis between 2000 and 2014 at a single, university-affiliated, tertiary medical center. Patients were identified from the administrative hospital computerized archives using the admission and discharge code-combinations of open or laparoscopic appendectomy and pregnancy.

All patients were evaluated at the emergency department (ED) according to the institutional guidelines by a team of emergency medicine physicians, surgeons, and obstetricians. Starting at the time of the presumed diagnosis, patients were made nil per os and given intravenous hydration and antibiotics. The diagnosis was made on a clinical basis. Typically, patients underwent an abdominal ultrasound to support the diagnosis. In cases of inconclusive ultrasound findings, we generally proceeded with cross-sectional imaging studies (preferably MRI due to the lack of ionizing radiation). Before surgery, patients were assessed by an obstetrician to exclude any possible gynecologic-obstetric source for the clinical presentation. Obstetric ultrasonography and fetal monitoring were performed preoperatively in all patients to establish gestational age and confirm fetal vitality. It was repeated immediately after surgery and before hospital discharge. The surgical approach (laparoscopic appendectomy or open appendectomy) was determined by a board certified surgeon.

Clinical data for the study were extracted retrospectively from the patients' electronic medical records and hospital radiology, operative, and pathology computerized archives. Preoperative data included patient age, gestational age at surgery, body temperature on admission, white blood cell count and neutrophil fraction at admission, imaging findings, time from onset of symptoms to emergency room admission (“patient interval”), and time from emergency room admission to time of skin incision (“hospital interval”). Operative data included surgical approach, operative time, and intraoperative complications. Postoperative data included length of hospital stay, postoperative complications, and pathology results. Obstetric data included gestational age at delivery, Apgar scores at 1 and 5 minutes, birth weight, and maternal and fetal complications.

Definitions

Pathology results were categorized as negative appendectomy, acute (simple) appendicitis, and complicated appendicitis (gangrenous or perforated appendicitis or periappendicular abscess). Patient interval was determined according to the self-report of the patient of the time of onset of symptoms; hospital interval, the time interval from ED admission to skin incision, was calculated from the hospital's computerized medical records. White blood cell count was considered abnormal if it measured <3.5 × 10³/mm³ or >11 × 10³/mm³. Fever was defined as temperature above 37.8°C. Postoperative surgical complications were classified according to the Clavien-Dindo grading system²³; major complications were defined as grade 3b or higher. Preterm delivery was defined as birth on or before the last day of the 37th gestational week (259th day), as defined by the American College of Obstetricians and Gynecologists.²⁴ One-month preterm delivery was defined as preterm birth within 1 month of operative intervention for presumed appendicitis. Trimesters of pregnancy were defined as follows: first trimester, 1–14 weeks; second trimester, 15–28 weeks; and third trimester, 29–42 weeks.²⁵

Data analysis

Descriptive and comparative statistical analyses were performed using Statistical Software for the Social Sciences (SPSS), version 22 (IBM Corp., Armonk, NY). Continuous variables were compared between groups with Student's t test or Mann–Whitney test or analysis of variance, as appropriate by type of distribution. Categorical variables were compared with chi-square or Fisher exact test, depending on the number of observations. A P-value of <.05 was considered significant.

Results

Preoperative and operative factors

The study cohort included 92 consecutive patients who underwent appendectomy for a presumed diagnosis of acute appendicitis during pregnancy. Median age was 28 years (interquartile range [IQR] 25–33). The laparoscopic approach was used in 50 patients (54%) and the traditional open approach in 42 (46%). In two cases (2%), laparoscopic surgery was converted to open appendectomy.

There were no significant differences between the laparoscopic- and open-appendectomy groups in preoperative and operative parameters such as patient age, patient interval, hospital interval, white blood cell count, temperature on presentation, and operative time (Table 1). Gestational age was significantly higher in the open-appendectomy group (24 weeks versus 16 weeks, P < .001) (Table 1).

Table 1.

Characteristics of Patients with a Presumed Diagnosis of Acute Appendicitis During Pregnancy, by Surgical Approach

Characteristics	Total (n = 92)	Open appendectomy (n = 42)	Laparoscopic appendectomy (n = 50)	P
Maternal characteristics
Age, years	28 (25–33)	29 (26–33)	28 (24–33)	.4
Gestational age at surgery, weeks	19 (13–27)	24 (16–33)	16 (12–21)	<.001
Patient interval, hours^a	24 (12–24)	24 (12–24)	24 (12–24)	.6
Abnormal white blood cell count^b	72 (79%)	34 (83%)	38 (76%)	.4
Fever^c	12 (14%)	7 (17%)	5 (11%)	.4
Hospital interval, hours^d	13 (8–17)	12 (7–19)	13 (8–17)	.7
Operative time, minutes	60 (45–75)	60 (45–77)	57 (45–71)	.8
Pathology				.2
Negative appendectomy	20 (22%)	11 (27%)	9 (18%)
Simple appendicitis	59 (66%)	23 (56%)	36 (73%)
Complicated appendicitis^e	11 (12%)	7 (17%)	4 (8%)
Preterm delivery	8 (12%)	3 (9%)	5 (20%)	.3
One-month preterm delivery^f	4 (6%)	1 (3%)	3 (12%)	.3
Length of hospital stay, days	3 (2–5)	5 (3–6)	3 (2–4)	<.001
Hospital stay >2 days	62 (68%)	35 (85%)	27 (54%)	.001
Any postoperative complication	14 (15%)	10 (24%)	4 (8%)	.04
Major postoperative complications^g	2 (2%)	1 (2%)	1 (2%)	1
Postoperative wound infection	5 (5%)	5 (12%)	0	.02
Postoperative abscess	0	0	0	NA
Postoperative contractions	9 (10%)	5 (12%)	4 (9%)	.7
Fetal characteristics
Gestational age at delivery, weeks	39 (38–40)	39 (38–40)	38 (37–40)	.06
Weight at delivery, kg	3.2 (2.9–3.5)	3.4 (3.1–3.5)	3.0 (2.7–3.3)	.02
APGAR score at 1 minute	9 (9–9)	9 (9–9)	9 (9–9)	.7
APGAR score at 5 minutes	(10–10)	10 (10–10)	10 (10–10)	.2
Fetal loss	4 (6%)	2 (5%)	2 (8%)	.7

Bold represents statistically significant P values (P < 0.05).

Continuous variables are expressed as median (interquartile range, IQR); categorical variables are expressed as n (%).

Time from onset of symptoms to emergency department admission.

Defined as <3.5 × 10³/mm³ or >11 × 10³/mm³ white blood cells.

Defined as temperature above 37.8°C.

Time from emergency department admission to skin incision.

Pathological gangrenous appendicitis, perforated appendicitis, or periappendicular abscess.

Preterm delivery within 1 month of surgery.

Included a severe postoperative pain in a patient after laparoscopic appendectomy that warranted repeated diagnostic laparoscopy, which was negative, and evisceration in a patient after open appendectomy that warranted repeated surgery.

Of the 92 patients, 26 (28%) were operated during the first trimester of pregnancy, 45 (49%) during the second trimester, and 21 (23%) during the third trimester. The laparoscopic approach was used significantly more often in women in the first and second trimesters (77% and 64% of surgeries, respectively) than in women in the third trimester (5%; P < .001). The laparoscopic approach was utilized until the 30th week of gestation.

Postoperative surgical outcomes

Hospital stay was significantly longer in the open-appendectomy compared to the laparoscopic-appendectomy group (5 days and 3 days, respectively, P < .001). There were no significant between-group differences in negative appendectomy rate (27% and 18%, respectively) and complicated appendicitis rate (17% and 8%, respectively) (P = .2 for both).

Overall, postoperative complications occurred in 15% of the cohort (n = 14), with significantly higher rates in the open-appendectomy group compared to the laparoscopic-appendectomy group (24% and 8%, P = .04). There were five cases of surgical site infection, all in the open-appendectomy group (P = .2) (Table 1). Compared to third-trimester appendectomies, appendectomies performed in the first and second trimesters were associated with a shorter hospital stay (P < .001), lower rate of postoperative complications (P = .001), and lower rate of surgical site infections (P = .007).

Obstetric (fetal/maternal) outcomes

Complete follow-up data through delivery were available for 64 patients (70%); the remainder gave birth at other hospitals. Median gestational age at delivery was 38 weeks in the laparoscopic-appendectomy group (IQR 37–40) and 39 weeks (IQR 38–40) in the open-appendectomy group (P = .06). Overall, the preterm delivery rate was 12.5% and the 1-month preterm delivery rate was 6%; nine patients (14%) had postoperative contractions. There were no significant differences in any of these factors between the appendectomy groups.

Median Apgar score for the whole cohort was 9 at 1 minute and 10 at 5 minutes, with no significant difference between the groups. There were four postoperative fetal losses (6%), two in the open-appendectomy group and two in the laparoscopic-appendectomy group (P = .7). All four pregnancies were considered normal and nonhigh risk, and no other obvious reason was found for the fetal loss. The fetal losses in the open-appendectomy group and laparoscopic-appendectomy group occurred 1–3 days and 2–3 weeks after surgery, respectively. The corresponding gestational age was 9 and 18–21 weeks, respectively.

Discussion

The optimal surgical approach to presumed acute appendicitis in pregnant patients is still controversial. The established potential advantages of laparoscopic appendectomy over traditional open appendectomy in the general population are smaller abdominal incision, which is associated with a lower rate of surgical site infections, faster recovery, and shorter hospital stay.²⁶ However, in pregnant women, there are substantial concerns that laparoscopic appendectomy may compromise obstetric outcomes,^8,22 although the data are inconclusive. In this study, we performed a comprehensive evaluation of a large cohort of pregnant women attending a single tertiary medical center who underwent appendectomy, and the surgical and obstetric outcomes were compared by the type of the surgical approach (open, laparoscopic). Our findings suggest that laparoscopic appendectomy is safe and feasible in the earlier two trimesters of pregnancy and is associated with the same established postoperative advantages relative to traditional open appendectomy as in the nonpregnant population.

Median gestational age was significantly lower in the laparoscopic- than the open-appendectomy group. As the surgical approach was determined by the operating surgeon, this finding can be explained by the surgeon's decision not to perform laparoscopic appendectomy in the later stages of pregnancy when insertion and manipulation of laparoscopic devices may result in an injury to the enlarged uterus. Therefore only one case was performed laparoscopically in the third trimester.

Postoperatively, the laparoscopic-appendectomy group had a significantly shorter hospital stay and lower rate of wound infection. Those results are in concordance with the literature on the general and the pregnant populations²² and favor laparoscopic appendectomy in pregnant patients. However, the shorter hospital stay and lower complication rate may be attributed to the younger gestational age and not solely to the operative approach.

The obstetrical outcomes in our series, including gestational age at delivery, preterm delivery, postoperative contractions, and Apgar scores, were similar in the open- and laparoscopic-appendectomy groups. Similar findings were reported in the literature.²² Moreover, the overall rate of preterm delivery was similar to the rate reported in the general population of pregnant women.²⁵

Fetal loss is one of the most devastating and dreaded complications of surgical intervention during pregnancy for a presumed diagnosis of acute appendicitis. We observed a postoperative fetal loss rate of 6%, with no difference by type of appendectomy performed. It is noteworthy, however, that two of these cases occurred 2–3 weeks after the appendectomy and so they may not have been directly related to the surgery.

McGory et al.,⁸ in a large population-based study of 3133 pregnant patients who underwent appendectomy, reported a 4% fetal loss rate after surgery. A subsequent meta-analysis and systematic review by Wilasrusmee et al.,²² which included a total of 3415 patients, found that the rate of fetal loss was significantly higher in patients who underwent laparoscopic appendectomy than open appendectomy. The pooled relative risk was 1.91. However, this finding was largely dominated by the study of McGory et al.,⁸ which had a significantly larger sample size than the rest of the studies included in the meta-analysis. After this study was excluded from the pooled analysis, there was no association between the laparoscopic appendectomy and the rate of fetal loss. Furthermore, McGory et al.⁸ derived their data from the California State files database and had no access to the medical charts. Therefore, the study lacked important clinical information such as indication for surgery, laboratory findings, and gestational age on surgery, which might have biased the results.

The single-institution retrospective-cohort design used in the present study has inherent limitations, such as selection bias and limited sample size. In addition, the study period was quite long (15 years) and management algorithms evolved during the interim. Results may also be affected by a bias toward open appendectomy in the third trimester of pregnancy. The longer hospital stay in the open-appendectomy group may be a result of the more advanced gestational week rather than by the surgical approach. This is one of several unavoidable confounders that may have influenced the results. Ideally, the question of how to manage appendicitis during pregnancy should be answered in a randomized prospective trial. However, given the low incidence and relatively indolent course of appendicitis in pregnancy, as well as the strongly held preferences of groups that manage these patients, such a trial is unlikely. Another limitation is the incomplete follow-up through the end of pregnancy, as 30% of the patients gave birth in other hospitals. Nevertheless, our study is the largest contemporary hospital-based series to date that describes and evaluates the clinical and obstetric outcomes after laparoscopic versus open appendectomy during pregnancy. Moreover, unlike population-based studies, our data were collected from primary objective sources (e.g., radiology, operative, and pathology reports).

Conclusions

Laparoscopic appendectomy appears to be safe and feasible in the earlier two trimesters of pregnancy and is associated with the same established postoperative advantages relative to traditional open appendectomy as in the nonpregnant population. Thus, we believe that in the first and second trimesters, the role of the laparoscopic approach is similar in pregnant and nonpregnant patients. In the third trimester, due to surgeon's preference, most of the appendectomies were performed in the open technique resulting in a longer hospital stay and higher rate of superficial surgical site infections. We speculate that it is not the surgical approach that is responsible for poorer obstetric outcomes in the setting of suspected acute appendicitis, but rather the underlying diagnosis together with fetal/maternal factors.

Footnotes

Disclosure Statement

No competing financial interests exist.

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