Laparoscopic appendectomy in pregnancy – case report, literature overview Majernik J., Bis D., Hanousek P., Ninger V. – Surgical Department Hospital Chrudim, Czech Republic Simsa J, – Surgical Department , Thomayer´s University Hospital Prague, Czech Republic Summary: Introduction: The authors present a case of 25 year old pregnant patient diagnosed with acute appendicitis, indicated in consultation with gynecologists to laparoscopic appendectomy. No complications occurred during postoperative recovery and the patient was discharged the fifth postoperative day. Vital fetus, with normal development. This case review points to insufficiently discussed topic of laparoscopic appendectomy in pregnant patient as a safe alternative to open surgery. Appendicitis is one of the most common causes for surgery during pregnancy. Appendicitis in pregnancy represents a challenge for surgeon, both in terms of diagnosis as well as treatment and choice of operation access. Appendicitis is one of the most common causes for surgery during pregnancy. Appendicitis in pregnancy represents a challenge for surgeon, both in terms of diagnosis as well as treatment and choice of operation access. Although open appendectomy in pregnancy is considered as standard care, several authors support laparoscopic (5,8) approach as a method of choice. Laparoscopic approach in pregnancy (7) can be used in case of cholecystectomy, adnexal surgery, appendectomy, etc. In our case report, we will only deal with appendicitis in pregnancy. Key words: laparoscopy – appendectomy – appendicitis – pregnancy Case report: The 25 years old patient at 11 th week of pregnancy, was received because of half day lasting stitching pain in right lower abdomen with no propagation and no other problems. According to physical examination, palpable tenderness in the right lower abdomen with indicated peritoneal irritation, laboratory leukocytosis 22.4, without CRP elevation in admition. Sonographically difficult terrain, without any clear evidence of free liquid in the abdominal cavity, undifferentiated appendix. Initial gynecological examination confirmed 11 +0 pregnancy and normal gynecological findings. The patient was indicated in consultation with gynecologist to laparoscopic appendectomy with ulcerative phlegmonous appendicitis findings. Compression elastic legs bandages and preventive dose of low-molecular heparin were used in prevention of thromboembolic disease due to protrombogene state of pregnant patient. Kapnoperitoneum was introduced by Veres needle above the navel, using intra-abdominal pressure of 10 Torr during the operation to prevent fetal acidosis of the fetus. Position the patient during the entire operation was slightly Trendelenburg avoiding pregnant uterus (Fig. 2) to push on the lower vena cava and iliac veins, and thus no increased risk of vein thrombosis in legs. There are several possible treatments of appendix stump. After passing the clip on the peripheral part of the appendix and PDS Endo-loops at the appendix base we have an option to use tobacco laparoscopic suture or leave the stump without plunging preferably including elektrokoagulation of the stump or using harmonic skalpel (Fig. 3) to destroy bacteria and to stick the appendix stump (Fig. 4). in our case the harmonic scalpel was used. Laparoscopic appendectomy was completed with the extraction of the appendix in a plastic extraction bag to prevent infection in the abdominal wall port. Irrigation of the abdominal cavity using bactericidal saline containing betadine and introduction of Redon drainage into Douglas space, due to the fading of seropurulent effusion. (Fig. 5) 1a According to operating findings, patient treated with antibiotics (cephalosporins). after consulting gynecologist. In the postoperative period, a decrease of leukocytosis occurs. Furthermore, the patient has no subjective complaints, wounds are healing by per primam, soft abdomen palpactive painless. Gynecological examination was performed 2 nd postoperative day with vital fetus finding with normal fetal development (Fig. 1a, 1b). Patient released to ambulant care the 5th postoperative day. After 3 weeks planned inspection performed in ambulance – patient 1b subjectively without any complications, the wound healed by per primam, vital fetus. 2 3 4 4 5 Discussion: Acute appendicitis is one of the most common causes requiring urgent surgical intervention in pregnancy. Diagnosis of appendicitis is complicated by physiological and anatomical changes(9), which appears during pregnancy. Diagnostic difficulties results from the fact that some symptoms of appendicitis are identical with physiologic pregnancy. This is essentials concerning leukocytosis, a tendency to develop hypotension and tachycardia, nausea and vomiting, which are normal in pregnancy. Also characteristic pain in the right lower quadrant and McBurney‘s point, this might be over all less helpful in the diagnosis, because the growing uterus may push caecum and appendix cranially in the abdominal cavity. Ultrasound is considered as a safe imaging method in pregnancy, but has its diagnostic limitations. Complications of appendicitis, including perforation are increased by trimester and the appendix perforation consequences are increasing fetal morbidity and mortality. The frequency of interruption by perforated apendix ranges from 20% to 35% (1, 6). Early diagnosis, indication for surgical intervention and selected surgical approach are therefore important. The most discussed issue in case of laparoscopy is the kapnoperitoneum and effect on the fetus. Literature: 1. 2. 3. 4. Chinusamy P. Laparoscopic Appendectomy in Pregnancy: a Case series, JSLS (Jurnal of the Society of Laparoscopic Surgeons) 2006;10:321–325. Stephen J, Laparoscopic Appendectomy and Cholecystectomy during Pregnancy, JSLS (Jurnal of the Society of Laparoscopic Surgeons) 1998;2:41–46. Lemieux P, Laparoscopic Appendectomy in pregnant patients, Springers Science, 2008, Hakim N, Laparoscopic management of appendicitis and symptomatic cholecystitis during pregnancy, Langenbecks archives of surgery, 2006 vol. 391. The effect of pneumoperitoneum is still not fully clear. We know that CO2 can be absorbed through the peritoneum and can lead to fetal acidosis. The result of studies (1, 7) showed that pneumoperitoneum has minimal influence on the fetus in case the intra-abdominal pressure up to 10 mm Hg was used. The second trimester is the safest and best period for laparoscopy, the main advantage appeal when the position of the apendix change compared to the classical approach. Laparoscopy is also possible in the third trimester of pregnancy, using alternative deployment of ports. The Hasson technique can be used with advantage to introduce kapnoperitoneum. conclusion: Laparoscopic appendectomy in pregnant patients is comparatively safe method as open appendectomy. Laparoscopy offers advantages such as reducing the amount of opioids representing a risk to the fetus, better surgical visualization and exploration of the entire abdominal cavity, less postoperative pain, faster postoperative recovery and lower risk of hernia in the scar. Several studies (1, 2, 3, 4, 5, 6) shows that laparoscopy is a safe procedure in pregnant patients without increased risk of fetal morbidity and mortality compared to open surgery. 5. Guidelines for Diagnosis, Treatment, and Use of Laparoscopy for Surgical Problems during Pregnancy, Practice/Clinical Guidelines published on: 01/2011. by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 6. Curet MJ, Alen D, et al., Laparoscopy during pregnancy, Arch Surg. 1996: 546–550 7. Lachman E, Schienfeld A, Voss E, et al. Pregnancy and laparoscopic surgery, Journal American Assoc Gynecol Laparosc 1999;6:347–351. 8. Ludvik P, Strašpilka J, Laparoskopická apendektomie u těhotných – kazuistiky, Rozhl Chir 2001; 80:521-522 9. Lubušký M, Lubušká L, Procházka M. Komplikovaný průběh apendicitidy v graviditě, Gynekolog 2004;13:164–165.