From the Guidelines
Laparoscopic appendectomy is the preferred surgical approach for managing appendicitis in pregnant patients, as it is associated with shorter length of hospital stay and lower incidence of surgical site infection, according to the 2020 update of the WSES Jerusalem guidelines 1.
Key Considerations
- The use of laparoscopy during pregnancy is technically safe and feasible, with no increased risk of fetal loss or preterm delivery 1.
- Preoperative care should include measures to minimize risks to both mother and fetus, such as intravenous antibiotics and fetal monitoring.
- Imaging for diagnosis should prioritize ultrasound first, followed by MRI without contrast if ultrasound is inconclusive, with CT reserved as a last option to minimize radiation exposure.
Surgical Techniques
- Simple ligation is recommended over stump inversion, either in open or laparoscopic surgery, as it is associated with shorter operative times, less postoperative ileus, and quicker recovery 1.
- The use of endoloops/suture ligation or polymeric clips is recommended for stump closure, whereas endostaplers may be used when dealing with complicated cases depending on the intra-operative judgment of the surgeon and resources available 1.
Postoperative Care
- Postoperative care should include adequate pain management, early ambulation, and continued pregnancy monitoring.
- The use of wound ring protectors is recommended in open appendectomy to decrease the risk of surgical site infection 1.
- Primary skin closure with a unique absorbable intradermal suture is recommended for open appendectomy wounds 1.
Complications
- Delayed diagnosis increases risks of perforation, which significantly raises maternal morbidity and fetal mortality rates.
- The use of drains after appendectomy for perforated appendicitis and abscess/peritonitis should be discouraged, as it is associated with longer length of hospitalization and increased 30-day morbidity and mortality rates 1.
From the Research
Diagnosis of Appendicitis in Pregnancy
- The clinical presentation of acute appendicitis is altered during gestation, and diagnosis becomes increasingly difficult when close to term 2
- Abdominal pain, nausea, and vomiting are important symptoms, while peritoneal signs occur in the right lower quadrant early in pregnancy, but the upper quadrant or entire right side are more common locations as the appendix is displaced upward by the enlarging uterus 2
- Gestational physiologic changes obscure the accurate diagnosis of acute appendicitis 3
Management of Appendicitis in Pregnancy
- Prompt diagnosis is the cornerstone of a good outcome, and early surgical intervention is indicated if acute appendicitis is suspected 2, 4
- Pregnancy is not a reason to delay surgery 2
- The type of surgery depends on the surgeon's preference and experience 4
- Appendectomy via open laparotomy or laparoscopy is the standard treatment for acute appendicitis 5
Complications and Outcomes
- Perforation can lead to sepsis and occurs in 17% to 32% of patients with acute appendicitis 5
- Prolonged duration of symptoms before surgical intervention raises the risk of perforation 5
- Adverse sequelae of acute appendicitis are obviated by prompt operative exploration and prevention of appendiceal perforation 3
- There were no significant differences between patients with positive and negative laparotomies regarding frequency of presenting symptoms and signs or laboratory results 3