Laparoscopic appendicectomy in pregnancy: is it safe?

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It is always difficult when you are asked to assess a patient where your domain of clinical knowledge and expertise intersects with another sphere of clinical practice. Particularly if that intersection is infrequent. As a general surgeon, I can think of a number of such intersections. The coming together is often on the basis of assessment of acute abdominal pain. An example would be assessing abdominal pain in a quadriplegic patient. The neurological injury may make abdominal examination quite difficult to interpret. Another might be assessing abdominal pain in a patient with an acute psychosis. Both history and physical examination might be clearly unreliable and difficult to assess.
Why do we find this so stressful?
The reason is that we are unable to fall upon what Rhona Flin describes as an ‘inventory of experience’.1 Unfortunately, the cupboard is relatively bare and it is that inventory of experience that will often define us as being expert. That intuitive feeling you have with often a limited set of information that allows you to come to a valid decision. A kind of ‘supercharged’ pattern recognition. To compensate we often over investigate and perhaps even over operate in these circumstances.
We feel both stressed and inadequate.
I can think of no greater example of this than when being asked to assess a young pregnant woman with abdominal pain. Often this is on the basis of possible acute appendicitis. The difficulty is amplified because you are reluctant to fall back on your default approach of imaging, particularly in the earlier stage of pregnancy; the first trimester and the early part of the second. Sure, magnetic resonance imaging is probably safe, but it is not always available. Ultrasound is more accessible but in this setting can be difficult. Even if X‐ray and computed tomography imaging is feasible, interpretation may be difficult. There is the added stress of treating both mother and baby. If you operate, in the back of your mind you have a significant concern about the effects of anaesthesia and the physical insult that surgery might have on the unborn. This might push you into a conservative mode but then you know that the effect of uncontrolled maternal abdominal sepsis can be devastating in the pregnant woman with high foetal loss.2
In the setting of probable acute appendicitis, particularly in the earlier stages of pregnancy, it seems logical to perform a laparoscopic appendicectomy (LA). After all, it is minimally invasive. Surely it must be less of an insult to mother and baby.
This may be a grave error! The evidence may be to the contrary.
A systematic review and meta‐analysis was performed by Wilasrusmee et al. in 2012.3 This meta‐analysis included over 3400 pregnant women who had an appendicectomy. Some 600 had an LA, the rest having an open appendicectomy (OA). The foetal loss in the LA group was significantly higher with a relative risk of 1.91 as compared to OA.
This paper did generate significant criticism. There was no real consideration given to the stage of pregnancy or the age of the mother. There was also a significant impact from a single study of McGory that contributed 3133 patients where age of mother and stage of pregnancy was not reported.4 A 2008 systematic review by Walsh et al. showed 5.6% risk of foetal loss with LA as compared to OA at 3.1%.5 This was a significant difference. The stage of pregnancy was partly discussed but McGory's data were also included.
In this issue, this question is addressed with a very well‐constructed retrospective study by Winter et al.

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