Invited Commentary: “Open or laparoscopic appendectomy in pregnancy?”

The management of abdominal pain and possible appendicitis in pregnancy is always challenging and conveys considerable risk for both mother and baby. The cause of acute abdominal pain in a pregnant patient can be difficult to determine even for an experienced surgeon, given the differential diagnosis spanning pregnancy, gynecological, gastrointestinal, and urinary tract conditions.1 Also, the interpretation of leukocytosis is more difficult given the normal physiological changes of pregnancy. The accuracy of diagnostic ultrasound is limited by the stage of pregnancy, whilst computed tomography carries some risk to the fetus until at least the third trimester, even with special protocols that minimize radiation exposure. Although magnetic resonance imaging (MRI) has no radiation risk, and may be the preferred imaging modality, it is unfortunately inaccessible in many parts of the world. Despite the above challenges, and whatever the resources available, early diagnosis and swift surgical management will minimize the risk of complicated appendicitis, which has been shown to increase fetal loss and maternal morbidity.2 However, ever since the introduction of laparoscopic appendectomy, there has been ongoing controversy as to whether the open or laparoscopic approach is safer for the mother or her fetus, and whether this varies with trimester of pregnancy. This issue of the World Journal of Surgery includes a study of the topic based on an impressively large administrative dataset from Japanese tertiary hospitals.3 Sugai et al. have appropriately controlled for trimester of pregnancy and gestational age and reported that laparoscopic appendectomy was associated with higher rates of preterm labor, preterm delivery, and spontaneous abortion compared to the open approach in the second (3.6% vs. 10.6%; p < 0.001) and third (11.3% vs. 24.2%; p = 0.015) trimesters, with no difference seen in the first trimester.3 There was no difference seen in the secondary outcomes (premature rupture of membranes, amniotic fluid infection, sepsis, and surgical complications) between the laparoscopic and open approaches throughout all trimesters of pregnancy. Unfortunately, their database did not include the pathology of the appendix and thus, as acknowledged by the authors, they could not differentiate women who had normal versus abnormal appendices nor the degree of inflammation within abnormal appendices. Their database also did not provide data on post-discharge outcomes and therefore final obstetric outcomes, so their pregnancy outcomes were limited to the index appendectomy admission. Further research that controls for the trimester of pregnancy and the pathology of the appendix matched to obstetric outcomes is still required. What should surgeons and obstetricians do when managing a pregnant women with acute abdominal pain that may be appendicitis? The obstetrician and surgeon should certainly communicate, jointly assess, consider the need for/availability of imaging, so as to collaboratively outline the options, and/or a recommended action. The patient, partner, and sometimes family need to share in the decision making after considering the benefits and potential for harm. The parity, stage of pregnancy, and family needs may all influence the decision as operating or observing carry different risks balancing a potentially negative exploration versus a delayed intervention—both of which can have a significant impact on the fetus. Once a decision has been taken to proceed to appendectomy, there should be some thought given as to where is the best place to perform it, were the patient to go into premature labor. For example, many hospitals that can competently perform an appendectomy may not be able to manage a pre-term neonate or provide the support it needs to survive. If the mother is well, not likely to soon deteriorate, there may be the opportunity to transfer to a tertiary hospital that can provide both an appendectomy and neonatal intensive care. Next is the decision about what the surgical approach for appendectomy should be—the subject of Sugai et al.'s paper.3 They reported an uptrend in the proportion of laparoscopic appendectomies between 2010 and 2022 as this approach was being increasingly employed in Japan for all appendectomies over these years. The authors hypothesized that the operative time (longer in their laparoscopic appendectomy cohort) was perhaps a contributing factor to preterm delivery, preterm labor or spontaneous abortion in the second and third trimesters. However, in the 2020s, surgeons in many countries have been trained to perform an appendectomy laparoscopically and many more recently trained surgeons have limited experience in performing an open appendectomy. Our advice is therefore to adopt an approach with which one is familiar, and can be performed safely. Currently the SAGES guidelines confirm laparoscopic management is safe.4 Various meta-analyses and large case series also tend to be inconclusive, some reporting better outcomes in open appendectomy whilst others have not found any difference. One recent systematic review found laparoscopic appendectomy was associated with a higher rate of fetal loss but a lower rate of pre-term delivery.5 Whilst the jury is out, and further evidence needs to be amassed, we recommend surgeons adopt the approach with which they can provide the safest operation, giving due consideration to the best place for the fetus to be delivered, should pre-term labor be induced. The best management for a pregnant woman with likely acute appendicitis is a safe appendectomy without delay. The best management for a pregnant woman with acute abdominal pain that is not appendicitis is to diagnose and treat the cause of the pain and avoid a negative appendectomy. When there is reasonable doubt it may be safer to avoid indecision and delay to rule out appendicitis. Sugai's findings suggest that even with preterm delivery, preterm labor or fetal loss (abortion) rates of 3.6% versus 10.6% in the second trimester and 11.3% versus 24.2% in the third trimester, the odds of an adverse outcome with appendicitis/appendectomy, though significant, are still well in favor of the mother and her baby regardless of the approach. Edward M. Clarke: Investigation; methodology; resources; visualization; writing—original draft; writing—review and editing. David A. Watters: Conceptualization; formal analysis; methodology; project administration; resources; supervision; visualization; writing—review and editing.