Skip to main content

Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients

Abstract

Background

When pregnant patients require surgery, whether to perform an operation open or laparoscopic is often debated. We evaluated the impact of laparoscopy for common general surgical problems in pregnancy to determine safety and trends in operative approach over time.

Methods

Pregnant patients undergoing appendectomy or cholecystectomy were identified using the National Surgical Quality Improvement Program (NSQIP) database. We analyzed demographics, operative characteristics, and outcomes. Univariate comparison and multivariate regression analysis (MVA) were performed adjusting for confounding factors: age, body mass index (BMI), diabetes, and smoking, and an additional MVA was performed for perforated cases.

Results

A total of 1999 pregnant patients between 2005 and 2012 were evaluated. Of 1335 appendectomies, 894 were performed laparoscopically (LA) and 441 open (OA). For 664 cholecystectomies, 606 were laparoscopic (LC) and 58 open (OC). There were no deaths. For LA versus OA, patient characteristics were not different {age: 27.7 vs. 28.2 years, p = 0.19; diabetes: 1.8 vs. 0.9 %, p = 0.24; smoking: 19 vs. 16.1 %, p = 0.2} except for BMI (27.9 vs. 28.4 kg/m2; p = 0.03). LA had shorter operative times (ORT), length of stay (LOS), and fewer postoperative complications compared to OA. In MVA, difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.01), and wound complications (<0.01). MVA was performed for perforated cases alone: LA had equal ORT (p = 0.19) yet shorter LOS (p = <0.001). The majority of LA were performed in the last 4 years versus the first 4 years (61 vs. 39 %, p < 0.001). For LC versus OC, patient characteristics were not different: age (28.3 vs. 28.7 years; p = 0.33), BMI (31.4 vs. 33.2 kg/m2, p = 0.25), diabetes (2.8 vs. 3.5 %, p = 0.68), and smoking (21.1 vs. 25.9 %, p = 0.4). LC had a shorter ORT, LOS, and fewer postoperative complications than OC. In MVA, the difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.0001), and minor complications (<0.01). In MVA for cholecystitis with perforation, no difference was seen for LOS, ORT, or postoperative complications (p > 0.05). The percentage of LC cases appeared to increase over time (89 vs. 93 %, p = 0.06).

Conclusion

While fetal events are unknown, LA and LC in pregnant patients demonstrated shorter ORT, LOS, and reduced complications and were performed more frequently over time. Even in perforated cases, laparoscopy appears safe in pregnant patients.

This is a preview of subscription content, access via your institution.

References

  1. Augustin G, Majerovic M (2007) Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol 131(1):4–12 Epub 2006/09/20

    Article  PubMed  Google Scholar 

  2. Choi JJ, Mustafa R, Lynn ET, Divino CM (2011) Appendectomy during pregnancy: follow-up of progeny. J Am Coll Surg 213(5):627–632 Epub 2011/08/23

    Article  PubMed  Google Scholar 

  3. Wittich AC, DeSantis RA, Lockrow EG (1999) Appendectomy during pregnancy: a survey of two army medical activities. Mil Med 164(10):671–674 Epub 1999/11/02

    CAS  PubMed  Google Scholar 

  4. Gilo NB, Amini D, Landy HJ (2009) Appendicitis and cholecystitis in pregnancy. Clin Obstet Gynecol 52(4):586–596 Epub 2010/04/16

    Article  PubMed  Google Scholar 

  5. Biscette S, Yoost J, Hertweck P, Reinstine J (2011) Laparoscopy in pregnancy and the pediatric patient. Obstet Gynecol Clin N Am 38(4):757–776 Epub 2011/12/03

    Article  Google Scholar 

  6. Iafrati MD, Yarnell R, Schwaitzberg SD (1995) Gasless laparoscopic cholecystectomy in pregnancy. J Laparoendosc Surg 5(2):127–130 Epub 1995/04/01

    Article  CAS  PubMed  Google Scholar 

  7. Sesti F, Pietropolli A, Sesti FF, Piccione E (2013) Gasless laparoscopic surgery during pregnancy: evaluation of its role and usefulness. Eur J Obstet Gynecol Reprod Biol 170(1):8–12 Epub 2013/06/12

    Article  PubMed  Google Scholar 

  8. Bhavani-Shankar K, Steinbrook RA, Brooks DC, Datta S (2000) Arterial to end-tidal carbon dioxide pressure difference during laparoscopic surgery in pregnancy. Anesthesiology 93(2):370–373 Epub 2000/07/26

    Article  CAS  PubMed  Google Scholar 

  9. Khuri SF, Daley J, Henderson W, Barbour G, Lowry P, Irvin G et al (1995) The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg 180(5):519–531 Epub 1995/05/01

    CAS  PubMed  Google Scholar 

  10. Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB et al (1998) The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg 228(4):491–507 Epub 1998/10/28

    PubMed Central  Article  CAS  PubMed  Google Scholar 

  11. Ross SW, Oommen B, Wormer BA, Walters AL, Matthews BD, Heniford BT et al (2015) National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events. Surg Endosc. Epub 2015/01/16

  12. Moreno-Sanz C, Pascual-Pedreno A, Picazo-Yeste JS, Seoane-Gonzalez JB (2007) Laparoscopic appendectomy during pregnancy: between personal experiences and scientific evidence. J Am Coll Surg 205(1):37–42 Epub 2007/07/10

    Article  PubMed  Google Scholar 

  13. Eom JM, Hong JH, Jeon SW, Choi JS, Lee JH, Kim HO et al (2012) Safety and clinical efficacy of laparoscopic appendectomy for pregnant women with acute appendicitis. Ann Acad Med Singap 41(2):82–86 Epub 2012/04/14

    PubMed  Google Scholar 

  14. Holzer T, Pellegrinelli G, Morel P, Toso C (2011) Appendectomy during the third trimester of pregnancy in a 27-year old patient: case report of a “near miss” complication. Patient Saf Surg 5(1):11 Epub 2011/05/18

    PubMed Central  Article  PubMed  Google Scholar 

  15. Walsh CA, Tang T, Walsh SR (2008) Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg 6(4):339–344 Epub 2008/03/18

    Article  PubMed  Google Scholar 

  16. Machado NO, Grant CS (2009) Laparoscopic appendicectomy in all trimesters of pregnancy. J Soc Laparoendosc Surg 13(3):384–390 Epub 2009/10/02

    Google Scholar 

  17. Schreiber JH (1987) Early experience with laparoscopic appendectomy in women. Surg Endosc 1(4):211–216 Epub 1987/01/01

    Article  CAS  PubMed  Google Scholar 

  18. Schreiber JH (1990) Laparoscopic appendectomy in pregnancy. Surg Endosc 4(2):100–102 Epub 1990/01/01

    Article  CAS  PubMed  Google Scholar 

  19. Gurbuz AT, Peetz ME (1997) The acute abdomen in the pregnant patient. Is there a role for laparoscopy? Surg Endosc 11(2):98–102 Epub 1997/02/01

    Article  CAS  PubMed  Google Scholar 

  20. Lemieux P, Rheaume P, Levesque I, Bujold E, Brochu G (2009) Laparoscopic appendectomy in pregnant patients: a review of 45 cases. Surg Endosc 23(8):1701–1705 Epub 2008/12/06

    Article  PubMed  Google Scholar 

  21. Jeong JS, Ryu DH, Yun HY, Jeong EH, Choi JW, Jang LC (2011) Laparoscopic appendectomy is a safe and beneficial procedure in pregnant women. Surg Laparosc Endosc Percutan Tech 21(1):24–27 Epub 2011/02/10

    Article  PubMed  Google Scholar 

  22. Chung JC, Cho GS, Shin EJ, Kim HC, Song OP (2013) Clinical outcomes compared between laparoscopic and open appendectomy in pregnant women. Can J Surg 56(5):341–346 Epub 2013/09/27

    PubMed Central  Article  PubMed  Google Scholar 

  23. Peled Y, Hiersch L, Khalpari O, Wiznitzer A, Yogev Y, Pardo J (2014) Appendectomy during pregnancy—is pregnancy outcome depending by operation technique? J Matern Fetal Neonatal Med 27(4):365–367 Epub 2013/06/26

    Article  PubMed  Google Scholar 

  24. Rollins MD, Chan KJ, Price RR (2004) Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care. Surg Endosc 18(2):237–241 Epub 2003/12/24

    Article  CAS  PubMed  Google Scholar 

  25. Abuabara SF, Gross GW, Sirinek KR (1997) Laparoscopic cholecystectomy during pregnancy is safe for both mother and fetus. J Gastrointest Surg 1(1):48–52 discussion Epub 1997/01/01

    Article  CAS  PubMed  Google Scholar 

  26. Glasgow RE, Visser BC, Harris HW, Patti MG, Kilpatrick SJ, Mulvihill SJ (1998) Changing management of gallstone disease during pregnancy. Surg Endosc 12(3):241–246 Epub 1998/04/16

    Article  CAS  PubMed  Google Scholar 

  27. Buser KB (2009) Laparoscopic surgery in the pregnant patient: results and recommendations. J Soc Laparoendosc Surg 13(1):32–35 Epub 2009/04/16

    Google Scholar 

  28. Othman MO, Stone E, Hashimi M, Parasher G (2012) Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits. Gastrointest Endosc 76(3):564–569 Epub 2012/06/27

    Article  PubMed  Google Scholar 

  29. Dhupar R, Smaldone GM, Hamad GG (2010) Is there a benefit to delaying cholecystectomy for symptomatic gallbladder disease during pregnancy? Surg Endosc 24(1):108–112 Epub 2009/06/12

    Article  PubMed  Google Scholar 

  30. Kirshtein B, Perry ZH, Avinoach E, Mizrahi S, Lantsberg L (2009) Safety of laparoscopic appendectomy during pregnancy. World J Surg 33(3):475–480 Epub 2009/01/13

    Article  PubMed  Google Scholar 

  31. Sadot E, Telem DA, Arora M, Butala P, Nguyen SQ, Divino CM (2010) Laparoscopy: a safe approach to appendicitis during pregnancy. Surg Endosc 24(2):383–389 Epub 2009/06/25

    Article  PubMed  Google Scholar 

  32. McGory ML, Zingmond DS, Tillou A, Hiatt JR, Ko CY, Cryer HM (2007) Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg 205(4):534–540 Epub 2007/10/02

    Article  PubMed  Google Scholar 

  33. Corneille MG, Gallup TM, Bening T, Wolf SE, Brougher C, Myers JG et al (2010) The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy. Am J Surg 200(3):363–367 Epub 2010/08/31

    Article  PubMed  Google Scholar 

  34. Ventura SJ, Curtin SC, Abma JC, Henshaw SK (2012) Estimated pregnancy rates and rates of pregnancy outcomes for the United States, 1990-2008. Natl Vital Stat Rep 60(7):1–21 Epub 2012/09/14

    PubMed  Google Scholar 

  35. Cheng HT, Wang YC, Lo HC, Su LT, Soh KS, Tzeng CW et al (2014) Laparoscopic appendectomy versus open appendectomy in pregnancy: a population-based analysis of maternal outcome. Surg Endosc. Epub 2014/08/31

  36. Friedman JD, Ramsey PS, Ramin KD, Berry C (2002) Pneumoamnion and pregnancy loss after second-trimester laparoscopic surgery. Obstet Gynecol 99(3):512–513 Epub 2002/02/28

    Article  PubMed  Google Scholar 

  37. Affleck DG, Handrahan DL, Egger MJ, Price RR (1999) The laparoscopic management of appendicitis and cholelithiasis during pregnancy. Am J Surg 178(6):523–529 Epub 2000/02/12

    Article  CAS  PubMed  Google Scholar 

  38. Flum DR, Morris A, Koepsell T, Dellinger EP (2001) Has misdiagnosis of appendicitis decreased over time? A population-based analysis. JAMA 286(14):1748–1753 Epub 2001/10/12

    Article  CAS  PubMed  Google Scholar 

  39. Ito K, Ito H, Whang EE, Tavakkolizadeh A (2012) Appendectomy in pregnancy: evaluation of the risks of a negative appendectomy. Am J Surg 203(2):145–150 Epub 2011/07/26

    Article  PubMed  Google Scholar 

  40. Tamir IL, Bongard FS, Klein SR (1990) Acute appendicitis in the pregnant patient. Am J Surg 160(6):571–575 discussion 5-6. Epub 1990/12/01

    Article  CAS  PubMed  Google Scholar 

  41. Pates JA, Avendanio TC, Zaretsky MV, McIntire DD, Twickler DM (2009) The appendix in pregnancy: confirming historical observations with a contemporary modality. Obstet Gynecol 114(4):805–808 Epub 2009/11/06

    Article  PubMed  Google Scholar 

  42. House JB, Bourne CL, Seymour HM, Brewer KL (2014) Location of the appendix in the gravid patient. J Emerg Med 46(5):741–744 Epub 2014/02/04

    Article  PubMed  Google Scholar 

  43. Hodjati H, Kazerooni T (2003) Location of the appendix in the gravid patient: a re-evaluation of the established concept. Int J Gynaecol Obstet 81(3):245–247 Epub 2003/05/28

    Article  CAS  PubMed  Google Scholar 

  44. Kastenberg ZJ, Hurley MP, Luan A, Vasu-Devan V, Spain DA, Owens DK et al (2013) Cost-effectiveness of preoperative imaging for appendicitis after indeterminate ultrasonography in the second or third trimester of pregnancy. Obstet Gynecol 122(4):821–829 Epub 2013/10/03

    PubMed Central  Article  PubMed  Google Scholar 

  45. Pucci RO, Seed RW (1991) Case report of laparoscopic cholecystectomy in the third trimester of pregnancy. Am J Obstet Gynecol 165(2):401–402 Epub 1991/08/01

    Article  CAS  PubMed  Google Scholar 

  46. Barone JE, Bears S, Chen S, Tsai J, Russell JC (1999) Outcome study of cholecystectomy during pregnancy. Am J Surg 177(3):232–236 Epub 1999/04/29

    Article  CAS  PubMed  Google Scholar 

  47. Curet MJ, Allen D, Josloff RK, Pitcher DE, Curet LB, Miscall BG et al (1996) Laparoscopy during pregnancy. Arch Surg 131(5):546–550 discussion 50-1. Epub 1996/05/01

    Article  CAS  PubMed  Google Scholar 

  48. Lu EJ, Curet MJ, El-Sayed YY, Kirkwood KS (2004) Medical versus surgical management of biliary tract disease in pregnancy. Am J Surg 188(6):755–759 Epub 2004/12/28

    Article  PubMed  Google Scholar 

  49. Cosenza CA, Saffari B, Jabbour N, Stain SC, Garry D, Parekh D et al (1999) Surgical management of biliary gallstone disease during pregnancy. Am J Surg 178(6):545–548 Epub 2000/02/12

    Article  CAS  PubMed  Google Scholar 

  50. Sungler P, Heinerman PM, Steiner H, Waclawiczek HW, Holzinger J, Mayer F et al (2000) Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy. Surg Endosc 14(3):267–271 Epub 2000/03/31

    Article  CAS  PubMed  Google Scholar 

  51. Karthikesalingam A, Markar SR, Weerakkody R, Walsh SR, Carroll N, Praseedom RK (2009) Radiation exposure during laparoscopic cholecystectomy with routine intraoperative cholangiography. Surg Endosc 23(8):1845–1848 Epub 2009/01/02

    Article  CAS  PubMed  Google Scholar 

  52. Kahaleh M, Hartwell GD, Arseneau KO, Pajewski TN, Mullick T, Isin G et al (2004) Safety and efficacy of ERCP in pregnancy. Gastrointest Endosc 60(2):287–292 Epub 2004/07/28

    Article  PubMed  Google Scholar 

  53. Mossman KL, Hill LT (1982) Radiation risks in pregnancy. Obstet Gynecol 60(2):237–242 Epub 1982/08/01

    CAS  PubMed  Google Scholar 

  54. Machi J, Tateishi T, Oishi AJ, Furumoto NL, Oishi RH, Uchida S et al (1999) Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: review of the literature and a comparison with open intraoperative ultrasonography. J Am Coll Surg 188(4):360–367 Epub 1999/04/09

    Article  CAS  PubMed  Google Scholar 

  55. Committee SG (1998) Guidelines for laparoscopic surgery during pregnancy. Society of American Gastrointestinal Endoscopic Surgeons (SAGES). Surg Endosc 12(2):189–190. Epub 1998/02/28

  56. Fatum M, Rojansky N (2001) Laparoscopic surgery during pregnancy. Obstet Gynecol Surv 56(1):50–59 Epub 2001/01/05

    Article  CAS  PubMed  Google Scholar 

  57. Date RS, Kaushal M, Ramesh A (2008) A review of the management of gallstone disease and its complications in pregnancy. Am J Surg 196(4):599–608 Epub 2008/07/11

    Article  CAS  PubMed  Google Scholar 

  58. Guidelines Committee of the Society of American G, Endoscopic S, Yumi H (2008) Guidelines for diagnosis, treatment, and use of laparoscopy for surgical problems during pregnancy: this statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), September 2007. It was prepared by the SAGES Guidelines Committee. Surg Endosc 22(4):849–861. Epub 2008/02/22

  59. Jackson H, Granger S, Price R, Rollins M, Earle D, Richardson W et al (2008) Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review. Surg Endosc 22(9):1917–1927 Epub 2008/06/17

    Article  PubMed  Google Scholar 

  60. de Perrot M, Jenny A, Morales M, Kohlik M, Morel P (2000) Laparoscopic appendectomy during pregnancy. Surg Laparosc Endosc Percutan Tech 10(6):368–371 Epub 2001/01/09

    PubMed  Google Scholar 

  61. Malangoni MA (2003) Gastrointestinal surgery and pregnancy. Gastroenterol Clin N Am 32(1):181–200 Epub 2003/03/15

    Article  Google Scholar 

  62. Nezhat FR, Tazuke S, Nezhat CH, Seidman DS, Phillips DR, Nezhat CR (1997) Laparoscopy during pregnancy: a literature review. J Soc Laparoendosc Surg 1(1):17–27 Epub 1997/01/01

    CAS  Google Scholar 

  63. Chohan L, Kilpatrick CC (2009) Laparoscopy in pregnancy: a literature review. Clin Obstet Gynecol 52(4):557–569 Epub 2010/04/16

    Article  PubMed  Google Scholar 

  64. Shah KH, Simons RK, Holbrook T, Fortlage D, Winchell RJ, Hoyt DB (1998) Trauma in pregnancy: maternal and fetal outcomes. J Trauma 45(1):83–86 Epub 1998/07/29

    Article  CAS  PubMed  Google Scholar 

  65. Drost TF, Rosemurgy AS, Sherman HF, Scott LM, Williams JK (1990) Major trauma in pregnant women: maternal/fetal outcome. J Trauma 30(5):574–578 Epub 1990/05/01

    Article  CAS  PubMed  Google Scholar 

Download references

Disclosures

Drs. Heniford, Augenstein, and Lincourt have previously been awarded surgical research and education grants and honoraria from W.L. Gore and Associates, Ethicon, Novadaq, Bard/Davol, and LifeCell Inc. Drs. Cox, Huntington, Blair, and Tanushree Prasad have no potential conflicts or disclosures relevant to this work.

Author information

Authors and Affiliations

Authors

Corresponding authors

Correspondence to T. C. Cox or B. T. Heniford.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Cox, T.C., Huntington, C.R., Blair, L.J. et al. Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients. Surg Endosc 30, 593–602 (2016). https://doi.org/10.1007/s00464-015-4244-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-015-4244-4

Keywords

  • Pregnancy
  • Appendectomy
  • Cholecystectomy
  • Outcomes
  • Laparoscopy
  • NSQIP