Vol 43 # 2 June 2011 - Kma.org.kw

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Laparoscopic Appendectomy in the Third Trimester of Pregnancy: Report of Two Cases ...
June 2011
Fig. 1: Port sites for patients in the third trimester. A 10 mm camera
port (C), was inserted 3 to 4 cm above the superior margin of the
uterus. A 10 mm working port (W1) was inserted below the xiphoid
process. A 5 mm sub costal working port (W2) was inserted at the
right anterior axillary line.
30 degree scope below the xiphoid process. Another
5 mm subcostal working port was inserted at the
right anterior axillary line (Fig. 1). The CO 2
pressure
was maintained between 8 – 12 mmHg, trying to
maintain the minimum level required to obtain a
correct working space. Care was taken to minimize
manipulation of the gravid uterus.
The mesentery of the appendix was secured with
endoclips. Once the base was reached, two pre-tied
chromic catgut loops were applied and the appendix
was cut between both loops with scissors. The organ
was delivered through the subxiphoid port. The right
lower quadrant was irrigated with saline. Hemostasis
was secured and the base of the appendix was
inspected one last time to recheck the security of the
applied endoclips.
The ports were removed under direct vision, the
pneumoperitoneum was evacuated and the rectus
sheath of the optical port was closed using 2/0 PDS.
Skin was closed using subcuticular absorbable suture.
An ultrasound examination was repeated before
the patient’s discharge which confirmed fetal vitality.
She was discharged home on the second postoperative
day.
Pathological examination of the specimen was
consistent with torsion of appendices epiploica with
a histologically normal appendix. The patient did not
require tocolytics and delivered vaginally at term.
Case 2
A 29-year-old woman was admitted to our
hospital with generalized abdominal pain of one day
duration which later localized to the right flank area.
Gestational age was estimated to be 28 weeks. There
were no symptoms associated with the abdominal
pain and there was no vaginal bleeding. The patient
was afebrile and her vitals were stable. Her physical
examination showed a gravid uterus along with
right lumbar tenderness and guarding. The clinical
diagnosis was acute appendicitis.
Laboratory evaluation showed a normal white
blood cell count and her ultrasound was equivocal.
A laparoscopic appendectomy similar to the one
described above was performed without incident.
Findings were that of an acutely inflamed retrocecal
appendix with mild intraperitoneal fluid reaction.
An ultrasound examination was repeated before
the patient’s discharge which confirmed fetal vitality.
She was discharged home on the third postoperative
day. Pathological examination of the specimen was
consistent with an acutely inflamed appendix. The
patient did not require tocolytics and delivered
vaginally at term.
DISCUSSION
Acute appendicitis is the most common nonobstetric
cause of acute abdomen during pregnancy.
The prevalence is evenly distributed throughout all
trimesters [5] . The diagnosis of acute appendicitis in
pregnant woman is more difficult than it is in other
clinical settings, as the physiological and anatomic
changes in pregnancy can obscure the condition [6,7] .
Delayed treatment of acute appendicitis increases
the rate of maternal complication or fetal loss [6-8] .
Therefore, early and aggressive treatment of clinically
suspected appendicitis in pregnancy is justified. The
laparoscopic approach has become more widely
accepted as safe and effective and has become the
standard of care at some institutions in all trimesters
of pregnancy [9] .
Limited data exists on third trimester laparoscopic
appendectomy and some authors recommend
the second trimester as the safest for performing
laparoscopy [10] . The major advantages of the
laparoscopic approach to appendectomy in the third
trimester are better visualization resulting in limited
uterine manipulation and minimal morbidity for a
negative exploration.
Rollins et al reported that as many as 41% of the
appendices removed during pregnancy for clinically
suspected appendicitis, using the conventional open
approach, were found to be normal [7] . Reduced intraoperative
uterine manipulation may lead to decreased
postoperative uterine irritability, premature labour,