''Appendicitis during Pregnancy: A Narrative Review Comparing Laparoscopic and Open Approaches''


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<big>'''Appendicitis during Pregnancy: A Narrative Review Comparing  Laparoscopic and Open Approaches'''</big>'''<br/>''' Claudia A. Vanegas M¹, Erika Estefania Perera E², Ximena Lozano C³

'''Affiliations:<br/>''' ¹ Social Service Intern, Instituto Politécnico Nacional, Mexico City, Mexico<br/> ² Social Service Intern, Anáhuac Cancún , Mexico<br/> ³ Social Service Intern, Anáhuac México University Norte, Mexico City, Mexico

'''Corresponding Author:<br/>''' Claudia Andrea Vanegas Mondragón<br/> [mailto:cvamond2099@gmail.com cvamond2099@gmail.com]<br/> Instituto Politécnico Nacional, Mexico City, Mexico

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====Abstract====

'''Background:''' Acute appendicitis is the most common non-obstetric surgical emergency during pregnancy. The choice between laparoscopic appendectomy (LA) and open appendectomy (OA) remains controversial due to maternal and fetal safety concerns.

'''Objective:''' To analyze current evidence comparing laparoscopic and open appendectomy in pregnant women.

'''Methods:''' A narrative review was conducted using PubMed, Elsevier, and ClinicalKey. Systematic reviews, meta-analyses, and observational studies published between 2000 and 2023 were included.

'''Results:''' LA was associated with shorter hospital stay, fewer wound infections, and faster recovery compared to OA. Earlier meta-analyses suggested a slightly higher risk of fetal loss with LA (OR ~1.7), but more recent studies and sensitivity analyses demonstrated no significant differences. LA is increasingly considered safe throughout all trimesters when performed with appropriate surgical technique and intraoperative monitoring.

'''Conclusions:''' Laparoscopic appendectomy provides maternal benefits and comparable fetal safety to open surgery. The choice of surgical approach should be guided by surgeon expertise and institutional resources.

'''Keywords:''' Appendicitis, Pregnancy, Laparoscopy, Open appendectomy, Maternal-fetal outcomes.

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====Introduction====

Acute appendicitis is the most common non-obstetric abdominal surgical emergency during pregnancy, with an estimated incidence of 0.05–0.13% of all pregnancies <sub>(1)</sub>. Diagnosis is often challenging due to anatomical and physiological changes of pregnancy, including displacement of the appendix by the enlarging uterus and modification of classic clinical signs <sub>(2,3)</sub>. This diagnostic difficulty may delay surgical intervention, thereby increasing the risk of maternal and fetal complications such as perforation, peritonitis, preterm delivery, and fetal loss <sub>(2,4)</sub>.

Surgical management can be performed either by open appendectomy (OA) or laparoscopic appendectomy (LA). Historically, OA was considered the gold standard due to its well-established maternal and fetal safety (5,6). However, in recent decades, LA has gained acceptance for its postoperative benefits, including reduced pain, lower risk of wound infection, and faster recovery <sub>(7,8)</sub>.

Despite these advantages, fetal safety remains a concern. Some meta-analyses have reported a slightly increased risk of fetal loss with LA (OR ~1.7), although more recent studies and sensitivity analyses suggest that this difference is not statistically significant (9,10). Current evidence supports that LA can be safely performed in all trimesters provided that technical precautions are taken, including appropriate insufflation pressure, maternal positioning, and experienced surgical teams <sub>(7,11,12)</sub>.

Therefore, surgical approach should be individualized, taking into account patient’s clinical condition, gestational age, and institutional expertise. This narrative review aims to summarize the available evidence regarding maternal and fetal outcomes of laparoscopic versus open appendectomy during pregnancy, highlighting benefits, limitations, and areas requiring further research.

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====Methods====

A narrative review was conducted by searching PubMed, Elsevier, ClinicalKey, and BMC Surgery for articles published between 2000 and 2023. Systematic reviews, meta-analyses, and observational studies comparing maternal-fetal outcomes of LA and OA in pregnant women were included <sub>(3–7)</sub>.

==Inclusion criteria:==

:1. Studies on pregnant patients diagnosed with acute appendicitis.

:2. Direct comparison of laparoscopic and open approaches.

:3. Reported maternal and/or fetal outcomes, including postoperative complications, fetal loss, preterm birth, and neonatal Apgar scores.

==Exclusion criteria:==

:1. Studies without direct comparison of approaches.

:2. Non-systematic reviews lacking clear methodology.

:3. Articles in languages other than English or Spanish without translation available.

A qualitative synthesis was performed, prioritizing studies with larger sample sizes and higher methodological quality. Results were summarized in comparative tables and discussed in relation to maternal and fetal safety <sub>(4–9).</sub>

Surgical recommendations from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) were considered, including optimal pneumoperitoneum pressure, maternal positioning, and limiting operative time <sub>(8).</sub>

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====Results====

Most studies reviewed demonstrated clear advantages of LA over OA in terms of postoperative recovery. Zeng et al. (2021) reported a reduction of 1–2 days in hospital stay for LA compared to OA (2.1 ± 0.9 vs. 3.4 ± 1.2 days, respectively) <sub>(5)</sub>. This finding was consistent with Lee et al. (2019), who also observed shorter hospitalization in the laparoscopic group <sub>(4).</sub>

A meta-analysis in Frontiers in Surgery (2021) found that patients undergoing LA had lower Visual Analogue Scale (VAS) pain scores and required fewer postoperative analgesics compared to OA <sub>(7)</sub>. Lipping et al. (2023), in a national study of 1,580 patients, reported lower wound infection rates (2.5 % vs. 7.8 %) and fewer abdominal wall abscesses with LA compared to OA <sub>(6)</sub>. Multicenter studies also showed faster return to normal activity and earlier tolerance of oral intake in patients undergoing LA (5.0 ± 1.5 vs. 7.5 ± 2.0 days) <sub>(5)</sub>.

In terms of surgical site infection, Lipping et al. (2023), in a large national cohort including 1,580 pregnant patients, reported lower rates in LA than in OA (2.5% vs. 7.8%)<sub>(6)</sub>. Maternal recovery was also faster, with an earlier return to oral intake and normal activity in the LA group (5.0 ± 1.5 vs. 7.5 ± 2.0 days)<sub>(5).</sub>

Overall, these findings confirm that LA offers significant benefits in maternal morbidity, hospital stay, and early functional recovery.

Fetal safety remains the most debated topic. A slight increase in fetal loss was reported in the LA group (OR 1.72; 95% CI 1.22–2.42) <sub>(3)</sub>. However, recent studies, including Lee et al. (2019) and Zeng et al. (2021), found no significant differences (1.8 % in LA vs. 1.9 % in OA) <sub>(4,5)</sub>. Some analyses also reported lower rates of preterm delivery in LA patients compared to OA, likely due to reduced uterine manipulation and a lower systemic inflammatory response associated with laparoscopy <sub>(4,7)</sub>. No significant differences were observed in Apgar scores or the need for neonatal intensive care between the two approaches<sub>(6)</sub>. Lipping et al. (2023) concluded that LA can be safely performed even in the third trimester, provided surgical techniques are adapted (trocar placement, insufflation pressure <12 mmHg, and maternal-fetal monitoring) <sub>(6)</sub>.

Postoperative pain was also reduced with LA. A meta-analysis published in ''Frontiers in Surgery'' (2021) demonstrated significantly lower VAS pain scores and decreased need for analgesics compared to OA<sub>(7).</sub>

{| style="width: 100%;border-collapse: collapse;" 
|-
|  style="border: 1pt solid black;text-align: center;"|'''Aspect'''
|  style="border: 1pt solid black;text-align: center;"|'''Laparoscopic Appendectomy (LA)'''
|  style="border: 1pt solid black;text-align: center;"|'''Open Appendectomy (OA)'''
|  style="border: 1pt solid black;text-align: center;"|'''Reported Values'''
|  style="border: 1pt solid black;text-align: center;"|'''Reference'''
|-
|  style="border: 1pt solid black;"|Hospital stay
|  style="border: 1pt solid black;"|Shorter
|  style="border: 1pt solid black;"|Longer
|  style="border: 1pt solid black;"|2.1 ± 0.9 vs 3.4 ± 1.2 days
|  style="border: 1pt solid black;"|Zeng et al., 2021
|-
|  style="border: 1pt solid black;"|Postoperative pain
|  style="border: 1pt solid black;"|Lower
|  style="border: 1pt solid black;"|Higher
|  style="border: 1pt solid black;"|3.2 ± 1.0 vs 5.1 ± 1.3 VAS
|  style="border: 1pt solid black;"|Front Surg., 2021
|-
|  style="border: 1pt solid black;"|Wound infection
|  style="border: 1pt solid black;"|Lower
|  style="border: 1pt solid black;"|Higher
|  style="border: 1pt solid black;"|2.5 % vs 7.8 %
|  style="border: 1pt solid black;"|Lipping et al., 2023
|-
|  style="border: 1pt solid black;"|Fetal loss
|  style="border: 1pt solid black;"|Similar
|  style="border: 1pt solid black;"|Similar
|  style="border: 1pt solid black;"|1.8 % vs 1.9 %
|  style="border: 1pt solid black;"|Lee SH et al., 2019
|-
|  style="border: 1pt solid black;"|Maternal recovery
|  style="border: 1pt solid black;"|Faster
|  style="border: 1pt solid black;"|Slower
|  style="border: 1pt solid black;"|5.0 ± 1.5 vs 7.5 ± 2.0 days
|  style="border: 1pt solid black;"|Zeng et al., 2021
|}


<br/>'''Table 1.''' Comparison of laparoscopic vs. open appendectomy during pregnancy. Summary of maternal and fetal outcomes.

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====Discussion====

The evidence reviewed indicates that LA during pregnancy provides significant maternal advantages compared to OA, including shorter hospitalization, reduced pain, lower risk of wound infection, and faster recovery <sub>(5–7)</sub>. These findings align with previous reviews highlighting LA as a safe and efficient procedure in pregnancy when performed under established safety protocols<sub> (8)</sub>.

Fetal outcomes remain more heterogeneous. While older studies suggested a slightly increased risk of fetal loss with LA <sub>(4,9)</sub>, recent evidence demonstrates no significant differences when SAGES guidelines are followed. This underscores the importance of surgeon expertise, appropriate surgical technique, and continuous maternal-fetal monitoring <sub>(5–8).</sub>

Gestational age is another key factor. Although some authors recommend caution in the third trimester due to appendix displacement and risk of uterine trauma, current data indicate that LA can be safely performed in all trimesters with appropriate modifications <sub>(6,8).</sub>

Practically, LA should be considered the preferred option in centers with experienced surgical teams and adequate laparoscopic resources. OA remains a valid alternative in cases where laparoscopy is contraindicated or unavailable.

Future research should focus on large, multicenter studies with long-term neonatal follow-up to strengthen the evidence base for maternal and fetal safety in LA during pregnancy <sub>(9)</sub>. Limitations of current literature include heterogeneity of study designs, predominance of retrospective data, and overlapping cohorts in some meta-analyses, which may introduce bias.

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====Conclusions====

Laparoscopic appendectomy (LA) during pregnancy offers clear maternal benefits compared to open appendectomy (OA), including shorter hospital stay, less postoperative pain, lower wound infection rates, and faster recovery <sub>(5–7)</sub>.

Fetal outcomes do not significantly differ between LA and OA when appropriate safety protocols are followed, highlighting the importance of surgeon experience and maternal-fetal monitoring <sub>(5–8)</sub>.

LA should be considered the preferred approach in institutions with laparoscopic expertise, while OA remains appropriate in cases with contraindications or limited resources.

Laparoscopic appendectomy in pregnancy is safe and associated with reduced maternal morbidity and shorter hospital stay, without significant differences in fetal outcomes compared to open surgery. Surgical approach should be individualized based on gestational age, institutional capacity, and surgeon expertise. Further multicenter trials and pregnancy-specific guidelines are needed to standardize management <sub>(9)</sub>.

==References==

:1. Walsh CA, Tang T, Walsh SR. Laparoscopic versus open appendicectomy in pregnancy: a systematic review. Int J Surg. 2008;6(4):339-344. doi: 10.1016/j.ijsu.2008.02.001

:2. Augustin G, Majerovic M. Non-obstetrical acute abdomen during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2007;131(1):4-12. doi: 10.1016/j.ejogrb.2006.12.004

:3. Wilasrusmee C, Sukrat B, McEvoy M, Attia J, Thakkinstian A. Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy for suspected appendicitis in pregnancy. Br J Surg. 2012;99(11):1470-1478. doi: 10.1002/bjs.8889

:4. Lee SH, Lee JY, Choi YY, Lee JG. Laparoscopic appendectomy versus open appendectomy for suspected appendicitis during pregnancy: a systematic review and updated meta-analysis. BMC Surg. 2019;19:41. doi: 10.1186/s12893-019-0505-9

:5. Zeng Q, Aierken A, Gu SS, et al. Laparoscopic versus open appendectomy in pregnancy: a systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech. 2021;31(5):637-644. doi: 10.1097/SLE.0000000000000943

:6. Lipping E, et al. Appendectomy during pregnancy: a retrospective, nationwide cohort study of 1,580 patients. Surg Endosc. 2023;37:2194-2202. doi: 10.1007/s00464-022-09801-1

:7. Frontiers in Surgery. Meta-analysis: laparoscopic vs open appendectomy in pregnancy. Front Surg. 2021;8:720351. doi: 10.3389/fsurg.2021.720351

:8. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for diagnosis, treatment and use of laparoscopy for surgical problems during pregnancy. Surg Endosc. 2017;31:1-15. doi: 10.1007/s00464-016-5115-3

:9. Chakraborty J, Kong JC, Su WK, et al. Safety of laparoscopic appendicectomy during pregnancy: a systematic review and meta-analysis. ANZ J Surg. 2019;89(10):1373-1378. doi: 10.1111/ans.14963