International Journal of Surgery 12 (2014) 1235e1241

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International Journal of Surgery

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Original research

Laparoscopic appendicectomy in pregnancy: A systematic review of

the published evidence
Humphrey G.M. Walker, Ahmad Al Samaraee*, Sarah J. Mills, M. Reza Kalbassi
Department of General Surgery, Wansbeck General Hospital, Ashington NE63 9JJ, UK

h i g h l i g h t s

Surgical intervention for acute appendicitis during pregnancy carries significant risk to both mother and foetus.

The safety of Laparoscopic Appendicectomy in pregnancy has been a matter of debate among clinicians.

There is no current strong evidence as to the preferred modality of appendicectomy during pregnancy.

Low grade evidence indicates that laparoscopic appendicectomy might be associated with higher rates of foetal loss.

a r t i c l e i n f o a b s t r a c t

Article history: Surgical intervention for acute appendicitis during pregnancy carries significant risk to both mother and
Received 3 August 2014 foetus. The safety of Laparoscopic Appendicectomy in pregnancy has been a matter of debate among
Received in revised form clinicians. We have critically reviewed the available published evidence in regards with this debate.
8 August 2014
Conclusion: There is no strong current evidence as to the preferred modality of appendicectomy; open
Accepted 27 August 2014
Available online 9 September 2014
or laparoscopic, during pregnancy from the prospect of foetal or maternal safety. However, low grade
evidence shows that laparoscopic appendicectomy during pregnancy might be associated with higher
rates of foetal loss.
Keywords:
Appendicitis
© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Appendicitis in pregnancy
Laparoscopy in pregnancy and laparoscopic
appendicectomy/appendectomy

1. Introduction throughout pregnancy can obscure the classical abdominal signs of

Non-Obstetric causes of acute abdominal pain that require
surgery during pregnancy are uncommon. However, these could
carry significant risks to both mother and foetus through delay to
diagnosis or the actual surgical intervention combined with general
anaesthesia. It has been estimated that 2e3% of pregnant women
are affected by various surgical causes of abdominal pain each year.
Acute Appendicitis (AA) is perhaps the most common pathology;
with rates reported in the literature varying between 1 in 500 to 1
in 2000 pregnancies. [1e4]
Both AA and normal uncomplicated pregnancy can be associ-
ated with abdominal pain, anorexia, nausea and vomiting,
increased heart rate, and leucocytosis. Moreover, the upwards
anatomical displacement of the appendix by the gravid uterus
* Corresponding author. General Surgery (Colorectal Secretaries), Wansbeck
General Hospital, Ashington NE63 9JJ, UK.
E-mail address: ahmadas@doctors.org.uk (A. Al Samaraee).
AA [5e8].
The role of imaging in confirming the diagnosis of AA during
pregnancy is limited by the risks of radiation and contrast on the
foetus. Ultrasonography is probably the most frequently used im-
aging modality for abdominal pain in pregnancy. However, it is
operator dependent, and the findings of a normal abdominal ul-
trasound do not exclude acute appendicitis [9]. Conversely, ultra-
sonography can help in excluding other causes of acute abdominal
pain in pregnancy like acute cholecystitis and urolithiasis. In
addition, it helps in establishing the foetal viability and the gesta-
tional age [10]. The risks of radiation and contrast that are associ-
ated with the use of Computerized Tomography (CT) scan, has
limited its role in pregnancy. Exceptions include conditions that
could risk the mother's life, such as polytrauma [9]. Non-Contrast
abdominal Magnetic Resonance Imaging (MRI) has been reported
to be useful in the diagnosis of acute appendicitis when ultraso-
nography is inconclusive [11,12]. However, potential risks include
the heat effect of the magnetic field on the foetus, specifically in the
first trimester [8,13].

http://dx.doi.org/10.1016/j.ijsu.2014.08.406
1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
1236 H.G.M. Walker et al. / International Journal of Surgery 12 (2014) 1235e1241

Therefore, the diagnosis of AA in pregnancy is challenging; with
the potential for delayed surgical intervention and the develop-
ment of serious complications [3,14]. It has been demonstrated that
a 24 h delay in surgery after presentation can lead to a 66% increase
in perforation rate, when compared to those operated on in under
24 h [15]. Complicated appendicitis in pregnancy carries significant
risks to both mother and the foetus, with reported foetal loss rate
around 20% in cases with perforated appendicitis and 35.7% with
generalized peritonitis. On the other hand, foetal loss rate is esti-
mated to be less than (5%) in cases of uncomplicated AA [16e20].
Moreover, surgical intervention for AA carries potential risks. All
general anaesthetic drugs cross the placenta and there is no
optimal general anaesthetic technique. It is not known in what way
these drugs affect the human foetus, since it is not ethical to
perform randomized controlled trials in this field. Performing
laparoscopic surgery during pregnancy could lead into increased
intra-abdominal pressure, resulting in decreased maternal cardiac
output and as a result, decreased utero-placental perfusion.
Nevertheless, there is some evidence indicating that there is no
statistical difference between the open or laparoscopic approaches
of surgery on foetus wellbeing. On the whole, it is highly recom-
mended to use the least extensive anaesthetic technique with the
shortest anaesthetic time possible to minimise potential foetal or
maternal complications [21,22].
As a general rule, the clinical suspicion of acute appendicitis
during pregnancy is an indication for an urgent surgical interven-
tion, in order to avoid the development of serious complications for
both of the foetus and mother. Diagnostic imaging could help in
establishing the diagnosis or rule out other causes of acute
abdominal pain in pregnancy; however these are not always
conclusive. The surgical approach to appendicectomy can be open
(OA) or laparoscopic (LA).
The aim of this review is to evaluate whether LA is safe during
pregnancy. The authors have not explored specific surgical tech-
niques used in LA.
2. Methods
Electronic literature search of the databases (Medline, Pubmed,
Ovid and Blackwell Synergy). The keywords used were appendi-
citis, appendicitis in pregnancy, laparoscopy in pregnancy and
laparoscopic appendicectomy/appendectomy. Searches were
screened for relevant studies and full text versions retrieved. The
references to all retrieved texts were searched for further relevant
studies. Studies were critically analysed and evidence was graded
as follows:
Level 1 e multiple randomised controlled trials (RCT) or meta-
analysis.
Level 2 e adequately powered single RCT.
Level 3 e experimental non-randomised data.
Level 4 e experimental design such as cohort study.
Level 5 e single case report, expert opinion
The reviewed evidence has been summarised in Tables 1 and 2.

Table 1
Individual studies.

Author Level of Surgical Patient Average Average Length Surgical complications Foetal Statistically significant Laparoscopic safety
evidence method numbers gestation operation of stay complications findings
(weeks) time (days)
(minutes)

Eom et al. 3 LA 15 15 27.5 4 Nil 6% (n ¼ 1) Significantly (p ¼ 0.001) Safe in 1st/2nd Trimester

(2012) post- shorter operating times for LA,
[23] operative less use of analgesics post-
uterine operatively (p ¼ 0.033)
contraction
OA 28 17 55 5 11% (n ¼ 3) post- 11% (n ¼ 3)
operative fever and 4% PTD
(n ¼ 1) intraperitoneal
abscess
Holzer et al. 5 LA 1 33 N/A N/A Haemorrhage e Nil N/A In 3rd Trimester convert
(2011) converted to OA to open once diagnosis
[24] made
Corneille 3 LA 9 11 N/A N/A 11% (n ¼ 1) conversion 11% (n ¼ 1) No statistical analysis Safe e regardless of
et al. to OA PTD, 11% performed access at risk for peri-
(2010) (n ¼ 1) pre- natal complications
[25] eclampsia/
eclampsia
OA 40 17 N/A N/A 13% (n ¼ 5)
PTD, 8%
(n ¼ 3) foetal
death, 8%
(n ¼ 3) pre-
eclampsia/
eclampsia
Park et al. 4 LA 8 15.5 22.5 3 Nil Nil No statistical analysis Safe
(2010) performed
[26]
Sadot et al. 3 LA 48 18.1 54 3.4 2% wound infection 29% PTD Patients in 1st and 2nd Appears to be safe. Need a
(2010) OA 17 24.3 55 4.2 6% abscess 19% PTD trimester more likely to randomised control trial
[27] undergo LA (p < 0.001);
shorter stays in LA group
(p ¼ 0.001)
Buser 4 LA 9 N/A N/A N/A Nil Nil No statistical analysis Safe, as long as surgeon is
(2009) performed skilled
[1]
4 OA 37 N/A N/A N/A N/A
 H.G.M. Walker et al. / International Journal of Surgery 12 (2014) 1235e1241 1237

Table 1 (continued )

Author Level of Surgical Patient Average Average Length Surgical complications Foetal Statistically significant Laparoscopic safety
evidence method numbers gestation operation of stay complications findings
(weeks) time (days)
(minutes)

Kazim,; 8% (n ¼ 3) wound 13% (n ¼ 5) No statistical analysis

Inam Pal, infection, 3% (n ¼ 1) preterm performed
(2009) intraabdominal contractions,
[5] abscess, 6% (n ¼ 2) 8% (n ¼ 3)
pulmonary embolism PTD, 3%
(n ¼ 1) foetal
death
Lemieux 4 LA 45 18.1 48.3 N/A 2% (n ¼ 1) 19% (n ¼ 7) Statistical analysis looks at Safe
et al. intraabdominal PTD those in different trimesters
(2009) abscess, 2% (n ¼ 1) (no statistically significant
[16] intra-operative findings) and those with a
uterine perforation, 2% normal appendix (shorter
(n ¼ 1) ileus, 7% (n ¼ 1) operating time (p ¼ 0.02) and
conversion to open increased risk of delivery <35
weeks (p ¼ 0.03))
Machado 4 LA 20 17 45 3.5 5% (n ¼ 1) 5% (n ¼ 1) No statistical analysis Higher risk of foetal loss
et al. postoperative fever intrauterine performed
(2009) death
[28] (patient had
history of
intrauterine
death)
Kirshtein 3 LA 23 12 29.9 2.4 4% (n ¼ 1) converted 4% (n ¼ 1) No significant findings for any When performed by
et al. to open as an inflamed spontaneous of the pregnancy outcomes experienced surgeons is
(2009) Meckel's needed abortion, 27% including loss, weight and as acceptable as the
[29] resection (n ¼ 6) APGAR. LA had longer stay conventional open
premature (p ¼ 0.023) and longer approach. Associated
contractions duration of IV antibiotics with good maternal and
OA 19 16.2 28.9 1.4 Nil 5% (n ¼ 1) (p ¼ 0.037). foetal outcome.
spontaneous
abortion, 16%
(n ¼ 3)
premature
contractions
McGory 3 LA 454 N/A N/A N/A 7% (n ¼ 31) Higher risk of negative Higher rate of negative
et al. foetal loss, appendicectomy in pregnant appendicectomy and
(2007) <1% (n ¼ 1) women (p < 0.05). Increased higher rate of foetal loss
[17] PTD risk of foetal loss with LA laparoscopically. Need
OA 2679 N/A N/A N/A 3% (n ¼ 88) (Odds Ratio ¼ 2.31) more accurate diagnosis.
foetal loss, 8%
(n ¼ 216) PTD
Moreno 4 LA 6 13.7 47.5 N/A Nil 17% (n ¼ 1) No statistical analysis Safe if recommendations
eSanz PROM performed for patient type followed
et al.
(2007)
[30]
Upadhyay 3 LA 4 31 N/A N/A N/A 25% (n ¼ 1) No statistical analysis Feasible in 3rd Trimester
et al. PTD performed
(2007) OA 2 34 N/A N/A N/A Nil
[31]
Halkic et al. 4 LA 11 26 45 2.5 Nil Nil No statistical analysis Safe
(2006) performed
[18]
Palanivelu 4 LA 7 All 2nd N/A 3 Nil 29% (n ¼ 2) No statistical analysis No mortality/morbidity
et al. Trimester required performed for mother or foetus in
(2006) Cesarean study's patients
[32] Sections
Blumenfeld 3 LA 32 16.8 61 2 6% (n ¼ 2) required 10% Pre-term LA at significantly earlier Safe when technically
et al. reoperation for labour gestational age (p ¼ 0.005), feasible.
(2005) bleeding and had longer procedures
[33] transfusion (p ¼ 0.24) and shorted
OA 28 22.2 49 3 48% Pre-term hospital stay (p ¼ 0.004)
labour
Carver et al. 3 LA 17 14 N/A 2.6 N/A 12% (n ¼ 2) No significant differences for No advantages to
(2005) foetal loss any variable, but authors state laparoscopy and added
[34] OA 11 14 N/A 2.4 N/A two foetal losses as risk of foetal loss. OA safer
“concerning”. in first two trimesters
pending further studies.
Wu et al. 4 LA 11 4e30 50.5 4.2 9% (n ¼ 1) wound 9% (n ¼ 1) No statistical analysis Safe in all trimesters
(2005) infection foetal loss, performed
[35] 27% (n ¼ 3)
(continued on next page)
1238 H.G.M. Walker et al. / International Journal of Surgery 12 (2014) 1235e1241

Table 1 (continued )

Author Level of Surgical Patient Average Average Length Surgical complications Foetal Statistically significant Laparoscopic safety
evidence method numbers gestation operation of stay complications findings
(weeks) time (days)
(minutes)

need for
tocolysis
Barnes et al. 5 LA 2 30 60 2 Nil 50% (n ¼ 1) No statistical analysis LA should be procedure of
(2004) needed performed choice in all trimesters
[36] tocolytics e with modified techniques
baby
delivered at
term
Rollins et al. 4 LA 28 20.7 N/A N/A N/A N/A PTD mothers had lower intra- Modified guidelines in
(2004) operative BP (p ¼ 0.04) and use at study hospital have
[19] higher foetus had higher heart not significantly
rates (p ¼ 0.04), in PTD group increased morbidity or
mothers had lower ETCO2 mortality
(p ¼ 0.052)
Lyass et al. 2 LA 11 16 60 3.6 Nil 9% (n ¼ 1) Significantly shorter stay Safe in all trimesters:
(2001) uterine (p ¼ 0.05) need more large scale
[37] contractions studies
(treated with
tocolytics)
OA 11 24 40 5.2 Nil 9% (n ¼ 1)
uterine
contractions
(treated with
tocolytics)
de Perrot 4 LA 6 16.7 52 N/A 33% (n ¼ 2) Safe
et al. foetal death:
(2000) both patients
[38] had uterine
infections
Affleck et al. 3 LA 18 N/A N/A N/A N/A 16% (n ¼ 3) No significant differences for
(1999) PTD any variable
[39] OA 22 N/A N/A N/A N/A 12% PTD
Thomas; 5 LA 2 6 N/A N/A N/A 50% (n ¼ 1) No statistical analysis Can be performed safely
Brisson PROM 33 performed during pregnancy as long
(1998) weeks. as laparoscopist
[40] Healthy experienced
Infant
Gurbuz; 3 LA 5 26 64 1.2 Nil Nil No statistical analysis Safe if experienced
Peetz, OA 4 17 58 1.8 Nil Nil performed surgeon, well planned,
(1997) changed technique. Does
[41] not result in foetal loss

Abbreviations: N/A e data not provided; LA e laparoscopic appendicectomy; OA e open appendicectomy; PTD e pre-term delivery; PTL e pre-term labour, FL e foetal loss;
PROM e premature rupture of membranes; ETCO2 e end tidal CO2; BP e blood pressure.

Table 2
Systematic reviews and meta-analyses.

Author Numbers Surgical complications Foetal complications Conclusions

Wilasrusmee 599 LA, In LA group hospital stay
et al. (2012) 2816 OA significantly shorted;
[2] operation times longer
but not significantly.
Little difference in wound
infection risk.
Alkis et al.
(2010) [3]
Walsh et al. 637 LA, Mean operating time for
(2008) [42] 4193 OA LA is 51 min, and a mean
stay of 5 days. 0.5% complication
rate on Veress method of entry
(n ¼ 1; pneumonia).
Conversion rate to laparotomy was 1%
(n ¼ 3). 0.5% wound infection rate (n ¼ 1)
Only one study (McGory) had significantly
higher foetal loss in LA group. All demonstrated
foetal loss. 44% higher risk of PTL in LA (not significant). of foetal loss.
No significant differences between APGAR scores and
BW.
Significant increase of foetal loss in LA group
(5.6% risk of foetal loss in LA and 3.1% in
OA group; p ¼ 0.001). Significant increase in
PTD in OA group (2.1% vs. 8.1%; p < 0.0001)
Low grade evidence suggests
that LA might increase chances
Before 20 weeks gestation LA safe,
after 20 weeks this should be based
on operator choice. If peritonitis present LA
contraindicated due to higher complication
rate.
Given high foetal loss rate women should
undergo OA despite LA being associated
with low rates of intra-operative
complications and lower rates of PTD.

Abbreviations: N/A e data not provided; LA e laparoscopic appendicectomy; OA e open appendicectomy; PTD e pre-term delivery; PTL e pre-term Labour, FL e foetal loss;
PROM e premature rupture of membranes; ETCO2 e end tidal CO2; BP e blood pressure.
 H.G.M. Walker et al. / International Journal of Surgery 12 (2014) 1235e1241
3. Literature review and analysis
3.1. Length of operation
The aim of the surgeon and the anaesthetist is to minimise
operative time and use the least extensive technique and safest
anaesthetic drugs; in order to decrease the potential risks to both
mother and foetus. The reviewed literature reported a wide range
of operative time (whether open or laparoscopic); ranging between
22.5 and 64 min.
In one small retrospective study, Eom et al. reported that the
average time needed to perform LA in pregnancy was significantly
shorter than OA (27 min vs. 55 min, p ¼ 0.001). In this study, all the
LA cases were of a gestational age of less than 28 weeks, and an
expert laparoscopic gynaecologist performed all procedures. It may
be significant that the laparoscopist used a Harmonic Scalpel for
dissecting the meso-appendix, and Endoscopic Vascular Stapler to
divide the appendix at its base. This approach could explain the
shorter time needed to perform the procedures [23].
Sadot et al. also looked retrospectively into the operative time
needed to perform appendicectomy during pregnancy. A total of 65
pregnant patients were included in the study covering a period of
nearly ten years. LA was performed in 48 patients; the majority of
them (73%) were in their second trimester. The study showed that
the group who had LA needed a slightly shorter operating time
when compared to the OA group. However, this was statistically
insignificant (p ¼ 0.34) [27].
On the other hand, other published evidence reported a longer
operative time with LA during pregnancy. Still, the findings of these
studies were not statistically significant [29,33,37,41].
A systematic review by Walsh et al. stated that the operative
time for LA for pregnant women is less than that for the general
population undergoing a LA. This was put down to the fact that the
surgeons conducting a LA during pregnancy are likely to be more
experienced. They support their conclusion by the low rate (1%) of
conversion to OA, when compared to published rates on non-
pregnant patients [42].
The reasons for the variability in the operating time in the
reviewed literature is not very clear, but it could be related to many
factors like the surgeons' experience, gestational age, maternal
factors and the local factors like the severity of acute appendicitis.
3.2. Maternal complications
Reported maternal complications associated with LA included
various rates of wound infections, haemorrhage, abscess formation,
ileus, and venous thromboembolic events. It is not possible to
statistically compare those complications to the ones associated
with OA either due to the lack of statistical analysis or the type of
the published studies. The rate of conversion to OA ranged from 0 to
11%. However, conversion from LA to OA was only reported in a
single case; which represented a conversion rate of 11% in the
related study [25]. Therefore, no statistical conclusions can be made
about conversion rates. Uterine perforation was reported in a single
case [16]. None of the reviewed papers reported maternal mortality
associated with LA. A large meta analyses in the general population
(non-pregnant patients) has shown that LA has fewer complica-
tions than those undergoing an OA [43,44].
3.3. Foetal complications
This is one of the more controversial areas when it comes to the
authors' conclusions about the safety of LA in pregnancy. Many
reviewed studies were small retrospective reviews that lacked any
statistical analysis. In both the LA and OA group there were high
1239
incidences of Pre-Term Delivery (PTD) and some instances of foetal
loss. These can be seen in Table 1.
Corneille et al. reported a PTD incidence of 11% and 13% in the LA
and OA groups respectively; with a foetal loss rate of 25% (3/12
cases) in the OA group and none in the LA group. The authors
considered that the high rate of foetal loss in the OA group was due
to pre-existing maternal comorbidities and the severity of appen-
dicitis, since all 3 cases had perforated appendicitis [25]. Another
two retrospective studies also reported a high rate of PTD in the OA
group. However the difference was not statistically significant
[23,33].
Conversely, other authors reported higher levels of PTD in the LA
group [27,39], and a higher rate of pre-term contractions in the LA
group [29].
Sadot et al. findings highlighted some interesting statistically
significant correlations. Patients with leucocyte count greater than
(16  109/l) were likely to have advanced appendicitis (p < 0.05),
while those presented with a temperature of greater than (38  C)
had a higher rate of one-month pre-term delivery following sur-
gical intervention for appendicitis (p < 0.05). In addition, patient
interval of greater than 48 h (i.e. the time interval from the onset of
symptoms until hospital presentation) was associated with more
advanced appendicitis, longer hospital stays and preterm delivery.
However, these figures were for all appendicectomies regardless of
the approach used [27]. In Sadot's study, the laparoscopic approach
was used until the 32 nd week of gestation (48 cases), with a foetal
loss rate of 2%. The PTD rates were 29% in the LA group and 19% in
the OA group (p ¼ 0.52) [27]. Affleck et al. did not reproduce these
findings, since no correlation was found between the patient's
characteristics, observations, biochemistry or management pa-
rameters with the final outcome [39].
McGory et al. retrospectively analysed seven years data of over
(3000) pregnant women who had appendicectomy in the state of
California [17]. The authors found that LA is associated with a sta-
tistically significant higher rate of foetal loss when compared to OA
(7% vs. 3% respectively, p < 0.05). They also reported that LA was
associated with lower rates of early delivery when compared to OA
(1% vs. 8% respectively, p < 0.05). Also, pregnant women in this
study seemed to have a higher chance of having negative appen-
dicectomy when compared to non-pregnant women (23% vs. 18%
respectively, p < 0.05). McGory's methodology and results were
criticised by other authors. The criticism was based on issues with
the code used for patients' identification and selection bias
[2,23,27].
Wilasrusmee et al. meta-analysis showed that laparoscopic
appendicectomy in pregnant women might be associated with a
greater risk of foetal loss. However, this was based on low grade
evidence [2].
Rollins et al.'s retrospective review reported some interesting
intra-operative features during laparoscopic surgery in pregnancy,
which could increase the risk of PTD. He found that the maternal
intra-operative blood pressure was significantly lower in the PTD
group (87 mm Hg PTD vs.96 mm Hg term, p ¼ 0.04). Also, the post-
operative foetal heart rate was significantly higher in the PTD group
(153 bpm PTD vs. 142 bpm Term, p ¼ 0.04). Finally the maternal End
e Tidal (ET) CO2 was lower in the PTD group (34 mm Hg PTD vs.
39 mm Hg Term, p ¼ 0.052). The authors recommend the use of
intra-operative foetal heart rate monitoring and maternal ETCO2
monitoring to maximize maternal and foetal safety throughout the
operation [19].
3.4. Trimester
Different articles propose different opinions on whether per-
forming LA is safe in any trimester. The major concerns are related
1240 H.G.M. Walker et al. / International Journal of Surgery 12 (2014) 1235e1241
to injury to the gravid uterus, and increased abdominal pressure
with CO2 insufflation that could compromise the utero-placental
circulation. The SAGES guidelines recommend insufflation pres-
sures of 10e15 mm Hg and that the port position should be adapted
for fundal height [45]. One prospective study demonstrated that
there was no change in the anatomical location of the appendix
during pregnancy [46]. However, this was a single centre study,
with a relatively small number of patients included.
Sadot et al. found a significantly higher rate of PTD in the 3rd
Trimester when compared to the 1st and 2nd trimesters [27]. This
conclusion was supported by Eom et al. who found that LA is safe in
the first two trimesters only [23].
Other authors reported that LA is safe any trimester [16,19,31,37].
Wu et al. reinforces this, but recommended that the port placement
should be modified in the 3rd Trimester [35]. Alkis et al. in a large
review article advised that after 20 weeks of gestation, the decision
of performing LA instead of OA should be surgeon dependent as
long as no contra-indications to LA are present [3]. Other studies
reported longer operating times associated with LA and higher
conversion rates to OA in the 3rd Trimester [16,28].
4. Discussion and conclusion
Surgical intervention for acute appendicitis during pregnancy
carries significant risk to both mother and foetus. The main worries
are inducing miscarriage in the first trimester and premature la-
bour in the third trimester. Early diagnosis and surgical interven-
tion are essential to prevent serious complications. Clinicians
recommend minimising anaesthetic and surgical times during ap-
pendicectomy in pregnant women to reduce those risks. Therefore,
the keys for success lie in early diagnosis, skilled surgeons and
anaesthetists.
In the era of laparoscopic surgery the choice of LA in pregnancy
is an alternative to the traditional OA. However, the safety of LA in
pregnancy has been a matter of debate among clinicians. We have
critically reviewed the available published evidence in regards with
this debate.
The authors conclude that there is no current strong evidence as
to the preferred modality of surgery during pregnancy from the
prospect of foetal/maternal safety. However, low grade evidence
from one meta-analysis study shows that laparoscopic appendi-
cectomy might be associated with higher rates of foetal loss.
Moreover, the reviewed literature reported a wide range of oper-
ative time (whether open or laparoscopic). This conclusion is
mainly based on level 3 and 4 published evidence that is generally
small sample sized retrospective studies; most of which had no
significant statistical findings. It is worth mentioning that the ma-
jority of the studied LA cases were performed at gestational age of
less than 24 weeks. It seems that there is common tendency among
surgeons to avoid LA in the third trimester though this is not based
on strong evidence. Performing a randomised trial of OA versus LA
is unlikely to be possible due to the difficulties associated with trials
in the context of emergency surgery.
Ethical approval
N/A.
Funding
None.
Author contribution
Dr H G M Walker: Literature search, writing, data analysis.
Mr Ahmad Al Samaraee: Literature search, writing, design.
Ms Sarah J Mills: (Consultant Surgeon): comments/corrections
and final approval before submission for publications.
Mr M R Kalbassi (Consultant Surgeon): comments/corrections
and final approval before submission for publications.
Conflict of interest
None.
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