Laparoscopic Appendectomy in the 35th Week of Pregnancy

Abstract

Introduction:

Laparoscopic appendectomy is generally considered safe in pregnancy, but controversy exists in the surgical management of late third trimester acute appendicitis because of concerns over adequate visualization and potential harm to the large gravid uterus. ^{1 –3} We present a video with a running time of 2 minutes 12 seconds of a 25-year-old woman at 35 weeks estimated gestational age who presented with abdominal pain and was found to have acute appendicitis.

Operative Technique:

The patient was placed in the supine position with the left arm tucked. General endotracheal anesthesia was performed. A Foley catheter was placed and the patient was securely strapped to the operating room table. The abdomen was prepped and draped in sterile fashion. The surgeon and assistant stood on the patient's left side. The patient was tilted to the left to displace the uterus from the inferior vena cava. A 1-cm right subcostal incision at the level of the anterior axillary line was used for open cut-down entry into the peritoneal cavity, away from the gravid uterus. The anterior rectus sheath was identified and incised, and the underlying muscle was split. The peritoneal cavity was entered under direct vision by lifting the posterior rectus fascia and parietal peritoneum with tonsils. The Hasson trocar was placed, and the abdomen was insufflated to 12 mmHg of pressure without any adverse hemodynamic consequences. Two 5-mm trocars were inserted: one epigastric and one in the right subcostal mid-clavicular line. Optics were through the 5-mm mid-clavicular trocar, utilizing the 5-mm, 30-degree laparoscope. The surgeon's right and left hands utilized the 10-mm and 5-mm epigastric trocars, respectively. The table was then airplaned even further to the left. The appendix was identified and was clearly inflamed. The ultrasonic scalpel (Sonosurg; Olympus) was used to partially mobilize the cecum to better expose the appendix. The mesoappendix was divided with the ultrasonic scalpel and dissected to the base of the cecum. The appendix was transected flush with the cecum with an Endo-GIA 45-3.5 mm stapler buttressed with Duet (Covidien). The appendix was extracted via the Hasson trocar site with the 10-mm Endo-catch bag. An abdominal examination was unremarkable except for the gravid uterus. The Hasson trocar site was closed with 0 vicryl using the suture passer device, and the 5-mm ports were removed under direct observation. Intra-operative fetal monitoring by obstetrics was normal. The total operating time was 35 minutes. She was discharged on postoperative day 2 without complications. She delivered a healthy baby at 39 weeks estimated gestational age.

Conclusion:

With minor adjustments in technique, laparoscopic appendectomy can be performed safely during the late third trimester.

No competing financial interests exist.

Runtime of video: 2 mins 12 secs