Laparoscopic Versus Open Appendectomy during Pregnancy: Is Fetal Outcome Really Different?

Elshamy E; El-Sattar LA; Shaheen A

Research Article

Austin J Obstet Gynecol. 2022; 9(2): 1203.

Laparoscopic Versus Open Appendectomy during Pregnancy: Is Fetal Outcome Really Different?

Elshamy E^1,2*, El-Sattar LA^3,4 and Shaheen A¹

¹Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Egypt

²Department of Obstetrics and Gynecology, Rabia Hospital, Riyadh, Saudi Arabia

³Department of General Surgery, Faculty of Medicine, Al-Azhar University, Egypt

⁴Department of General Surgery, Rabia Hospital, Riyadh, Saudi Arabia

*Corresponding author: Elsayed Elshamy, Department of Obstetrics and Gynecology, Rabia Hospital, Riyadh, Saudi Arabia

Received: August 05, 2022; Accepted: September 01, 2022; Published: September 08, 2022

Abstract

Purpose: To assess maternal and fetal outcome of pregnant women with acute appendicitis underwent open versus laparoscopic appendectomy with emphasis on the pregnancy loss rate.

Methods: This was a retrospective review of 116 pregnant women with acute appendicitis between 2011 and 2021 in single center, who were allocated either into open appendectomy (n=68) or laparoscopic appendectomy (n=48). Maternal and fetal outcome was recorded, tabulated and statistically analyzed.

Results: There was no significant difference between both groups in terms of the rates of abortion [p>0.05, OR (CI 95%) 1.47 (0.42-5.18)], intrauterine fetal demise [p>0.05, OR (CI 95%) 0.94(0.2-4.39)], preterm delivery [p>0.05, OR (CI 95%) 1.9(0.56-6.45)], placental abruption [p>0.05, OR (CI 95%) 2.23(0.43- 11.53)], mode of delivery (p>0.05) and neonatal admission to NICU (p>0.05). There was no significant difference between both groups regarding perioperative data in terms of duration of symptoms before attending the hospital, final diagnosis, postoperative fever, re-operation, thromboembolism, surgical site infection and histopathology results (p>0.05). Laparoscopic appendectomy was associated with shorter operative time (p<0.05), shorter time for return of bowel motility (p<0.001) and shorter hospital stay (p<0.05).

Conclusion: Laparoscopic appendectomy is safe, feasible and minimallyinvasive surgery during pregnancy and not associated with increased pregnancy loss when performed under strict criteria. Larger trials are warranted to confirm or refute these findings.

Keywords: Acute appendicitis during pregnancy; Laparoscopy; Appendectomy; Maternal outcome; Fetal outcome

Introduction

Acute appendicitis is the commonest non-obstetric surgical emergency occurring during pregnancy with reported rate of 25%, and variable incidence of one in every 500 to 2000 pregnancies (0.04 % and 0.2 %) [1-4].

The reported rate of appendiceal perforation during pregnancy can be as high as 43%, compared with only 19% in the general population. Complicated appendicitis is associated with poor obstetric outcome, such as fetal loss; thus, patients with acute appendicitis during pregnancy should immediately undergo appendectomy [4,5].

Although laparoscopy is associated with less pain, shorter hospital stay and fewer wound infections than the open approach, Open Appendectomy (OA) is still recommended for pregnant patients over Laparoscopic Appendectomy (LA), which might be associated with higher rates of fetal loss [6-8].

A recent systematic review and meta-analysis reported, it is not reasonable to conclude that LA in pregnant women might be associated with a greater risk of fetal loss as the difference between LA and OA with respect to preterm delivery was not significant [9].

The aim of this study was to assess maternal and fetal outcome of pregnant women with acute appendicitis underwent open versus laparoscopic appendectomy with emphasis on the pregnancy loss rate.

Materials and Methods

This retrospective analysis was conducted at the department of General Surgery in collaboration with the Obstetrics and Gynecology department at Rabia Hospital, Riyadh, Saudi Arabia.

Medical records of pregnant women diagnosed with acute appendicitis during the period between the beginnings of August 2011 and August 2021were reviewed.

Diagnosis was accomplished after complete history taking, full clinical examination, laboratory testing and ultrasound examination were enrolled. Clinical criteria for diagnosis included acute abdominal pain started as diffuse then settled in the right iliac fossa, associated with one or more of the followings; anorexia, nausea, vomiting, constipation, fever (≥ 38° C), tenderness in the right iliac fossa and rebound tenderness [10]. Complete blood count with Total Leucocytic Count (TLC) above 16,000/mm³ [11]. Further imaging modalities as C.T. scan and MRI were not preformed secondary to their higher cost and non-availability.

Ultrasound criteria included the identification of a noncompressible, blind-ended tubular structure localized at the lower right quadrant of the abdomen, with a maximal diameter exceeding 6 mm, round configuration in the transverse section (Target sign), increased echogenicity of the peri-appendiceal fat with fluid collection and hypervascularization of the appendix on color Doppler study [12,13].

Complicated appendicitis was diagnosed in patients with appendicular mass or abscess, appendicular perforation or with signs of peritonitis.

Patients presented with fetal demise, abnormal vaginal bleeding, having history of bleeding tendency; were excluded from the analysis.

Included patients were designated either to laparoscopic or open approach based on the patient preference as most of the included patients were not covered by health insurance with laparoscopic route at our hospital was more costly (about double expenses) compared to laparotomy. The study included 116 patients who were divided into two groups:

Group 1 (open appendectomy group): included 68 pregnant patients with acute appendicitis.

Group 2 (Laparoscopic appendectomy): included 48 pregnant patients with acute appendicitis.

Open appendectomy was performed either via Mc Burney or Midline incision under regional or general anesthesia based on the clinical circumstances.

Laparoscopic appendectomy was performed under general anesthesia with the Hasson open technique was used to gain initial abdominal access and CO₂ pneumoperitoneum was achieved at the maximal intra-abdominal pressure between 10–12 mm Hg throughout the operation.

All patients received antibiotic coverage and tocolytic therapy in the form of Indomethacin 100 mg rectal suppositories every 12 hours started half an hour before surgery and maintained for 2-5 days according to patients’ need for analgesia.

Histopathology was performed to determine the type of pathology (normal appendix, focal appendicitis, suppurative appendicitis or gangrenous appendicitis).

Following surgery, routine antenatal care visits data till the end of puerperium and Obstetric (maternal and fetal) outcome was recorded.

Outcome Measures

Maternal outcome: operative details (including type of anesthesia, operative time, need for drain) and postoperative outcome as fever, time to first flatus, wound infection, re-exploration, thromboembolism and length of hospital stay), abortion (pregnancy loss prior to 20 weeks’ gestation), preterm delivery (defined as delivery before completed 37 weeks) and mode of delivery.

Fetal-neonatal outcome: intrauterine fetal demise, prematurity and admission to Neonatal Intensive Care Unit (NICU) and neonatal death (defined as death during the first 28 days after birth).

Statistical Analysis

Statistical analysis was performed using Statistical Package for the Social Sciences Version 16 (IBM Corp., Armonk, NY, USA).

Quantitative data were expressed as means and standard deviations. Chi-squared test and t-test were used to compare the two groups as indicated. P value > 0.05 was non-significant, p≤ 0.05 was significant and p≤ 0.001 was considered highly significant.

Results

There was no significant difference between both groups regarding maternal demographic data in terms of age, parity, body mass index, history of previous cesarean delivery and gestational age in relation to pregnancy trimester (p>0.05) as depicted in (Table 1).

Table 1: Maternal demographic data.








  

    

    Open appendectomy (n=68) 

    Laparoscopic appendectomy (n=48) 

    Student t-test 

    P-value 

  

  

    Age (years) 

    24.21±6.11 

    23.96±6.74 

    0.21 

    >0.05 

  

  

    Parity 

    2.82±0.92 

    2.42±1.26 

    1.98 

    >0.05 

  

  

    Body mass index (Kg/m²) 

    25.11±4.86 

    25.58±4.22 

    0.54 

    >0.05 

  

  

    Previous cesarean deliveries 

    12 

    8 

    0.01* 

    >0.05 

  

  

    Gestational age 

    

    

    

    

  

  

    -First trimester 

    28

    18

    0.04*

    >0.05

  

  

    -Second trimester 

    32

    26

    0.32*

    >0.05

  

  

    -Third trimester 

    8

    4

    0.08*

    >0.05

  

  

    *Chi    square test.






Table 1: Maternal demographic data.

There was no significant difference between both groups regarding perioperative data in terms of duration of symptoms before attending the hospital, final diagnosis, postoperative fever, re-operation, thromboembolism, surgical site infection and histopathology results (p>0.05). Laparoscopic appendectomy was associated with shorter operative time (p<0.05), shorter time for return of bowel motility (p<0.001) and shorter hospital stay (p<0.05) as revealed in (Table 2).

Table 2: Perioperative data.








  

    

    Open appendectomy (n=68) 

    Laparoscopic appendectomy (n=48) 

    Chi square test 

    P-value 

  

  

    Duration of symptoms: 

    

    

    

    

  

  

    -Less than 24 hours.

    54 

    40 

    0.08 

    >0.05 

  

  

    -More than 24 hours.

    14

    8

  

  

    Final diagnosis: 

    

    

    

    

  

  

    -Uncomplicated appendicitis.

    40

    32

    0.44 

    >0.05 

  

  

    -Complicated appendicitis.

    28

    16

  

  

    Operation time (minutes)

    42.86±18.44 

    35.32±15.62 

    2.31* 

    <0.05 

  

  

    Time to first flatus (hours)

    46.28±10.56 

    32.16±8.28 

    7.73* 

    <0.001 

  

  

    Reoperation 

    0 

    0 

    - 

    - 

  

  

    Fever 

    14 

    5 

    1.45 

    >0.05 

  

  

    Thromboembolism 

    2 

    1 

    0.09 

    >0.05 

  

  

    Length of hospital stay (days) 

    3.24±1.88 

    2.32±1.62 

    2.75* 

    <0.05 

  

  

    Surgical site infection 

    8 

    2 

    1.21 

    >0.05 

  

  

    Histopathology: 

    

    

    

    

  

  

    -Normal appendix.

    0

    1

    0.03

    >0.05

  

  

    -Focal appendicitis

    28

    16

    0.44

    >0.05

  

  

    -Suppurative appendicitis.

    34

    30

    1.31

    >0.05

  

  

    -Gangrenous appendicitis

    6

    1

    1.22

    >0.05

  

  

    *Student    t-test.






Table 2: Perioperative data.

Regarding obstetric outcome, there was no significant difference between both groups in terms of the rates of abortion [p>0.05, OR (CI 95%) 1.47 (0.42-5.18)], intrauterine fetal demise [p>0.05, OR (CI 95%) 0.94(0.2-4.39)], preterm delivery [p>0.05, OR (CI 95%) 1.9(0.56-6.45)], placental abruption [p>0.05, OR (CI 95%) 2.23(0.43- 11.53)], mode of delivery (p>0.05) and neonatal admission to NICU (p>0.05) as shown in (Table 3).

Table 3: Obstetric outcome.








  

    

    Open appendectomy (n=68) 

    Laparoscopic appendectomy (n=48) 

    Chi square test 

    P-value 

    OR (CI 95%) 

  

  

    Abortion (before 20 weeks’) 

    8 

    4 

    0.08 

    >0.05 

    1.47 (0.42-5.18) 

  

  

    Fetal demise (after 20 weeks’) 

    4 

    3 

    0.1 

    >0.05 

    0.94(0.2-4.39) 

  

  

    Preterm delivery 

    10 

    4 

    0.56 

    >0.05 

    1.9(0.56-6.45) 

  

  

    Placental abruption 

    6 

    2 

    0.36 

    >0.05 

    2.23(0.43-11.53) 

  

  

    Mode of delivery: 

    

    

    

    

    

  

  

    -Vaginal delivery.

    40

    26

    0.1 

    >0.05 

    1.21(0.57-2.55) 

  

  

    -Cesarean section.

    20

    18

  

  

    NICU admission 

    8 

    2 

    1.21 

    >0.05 

    3.07(0.62-15.13) 

  

  

    Neonatal death 

    0 

    0 

    - 

    - 

    - 

  

  

    OR=Odd    ration, CI 95%=Confidence interval at 95%.






Table 3: Obstetric outcome.

Table 4 reveals no significant difference between both groups regarding contributing factors to pregnancy loss in terms of duration of the symptoms before surgery, gestational age and histopathology results (p>0.05).

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Citation: Elshamy E, El-Sattar LA and Shaheen A. Laparoscopic Versus Open Appendectomy during Pregnancy: Is Fetal Outcome Really Different?. Austin J Obstet Gynecol. 2022; 9(2): 1203.

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Laparoscopic Versus Open Appendectomy during Pregnancy: Is Fetal Outcome Really Different?

Abstract

Introduction

Materials and Methods

Outcome Measures

Statistical Analysis

Results

Discussion

Conclusion

Acknowledgements

Disclosure

References