Retention of Benefit: Laparoscopic Appendectomy in the Gravid Female

James C Iannuzzi, MD, Dylan R Nieman, MD, PhD, Kristin N Kelly, MD, Aaron S Rickles, MD, Veerabhadram Garimella, MD, MRCS, Emily S Barrett, PhD, John RT Monson, MD, Fergal J Fleming, MD

Surgical Health Outcomes

Pregnant women undergoing surgery are at elevated risk of surgical complications. Changes in vascular physiology, danger to the fetus, and rare necessity to operate in these patients creates a mystique and surgical discomfort that pervades today. Little data exists on surgical outcomes in gravid patients due to the relative rarity of the need for surgery in this typically young and healthy population. The most common reason for operating on pregnant women in ACS National Surgical Quality Improvement Program (NSQIP) is acute appendicitis, and this study sought to elucidate outcomes in this patient population.

The 2005-2010 NSQIP database was queried for pregnant patients (a variable within NSQIP), and cases of appendectomy using Common Procedural Terminology Codes (CPT) for open and laparoscopic appendectomy (CPT= 44950, 44970). Relevant outcomes were life threatening complications, incisional infections, operative time, and length of stay. Univariate analysis was performed for each end point using chi-square, Student’s T-test, and Fisher’s Exact test where appropriate. Factors with p value<0.1 were included in multivariate logistic or linear regression as appropriate. A 2-sided p-value of 0.05 was considered significant.

In an age and gender matched cohort (ALL) 28,275 appendectomies were performed, 1,079 (3.8%) of which were in pregnant women(PW). Pregnancy was not associated with increased major complications, incisional infections, or increased operative time, but was associated with increased length of stay (1.6 ALL vs. 2.5 days PW, p <0.001). Laparoscopic appendectomy in pregnant patients was performed in 735 (68.1%) cases and 344 (31.9%) cases were performed open. Mean age for PW laparoscopic cases was 27.3 years and for open cases was 28.1 years (p=0.06) Major complication rates in PW were 2.7% in laparoscopic cases and 4.7% in open cases (p=0.098). On multivariate analysis of PW the strongest predictors of major complications included ASA class (III/IV/V vs. I/II) (OR 3.89, CI 1.8, 10.9, p=0.01), and resident involvement in the case (OR 3.35, CI 1.12, 9.98, p=0.03). Incisional infections were decreased in laparoscopic cases when compared to open (1.5% vs. 4.4%, p=0.004) and no other factors were associated with development of incisional infection. Laparoscopic cases were associated shorter length of stay (1.9 days vs. 2.8 days) and with decreased mean operative time (47 minutes vs. 51 minutes p=0.015).

Gravid females who undergo appendectomy may benefit from a laparoscopic approach due to decreased incisional infections, decreased length of stay, decreased operative time, and a trend towards lower major complication rates. Predictors of major complications include ASA class and resident involvement in the case. This data is limited by lack of data on fetal outcomes, and stage of pregnancy. Overall outcomes were similar to a matched cohort, suggesting appendectomy in pregnant women is safe for the mother when necessary.

Session: Poster Presentation

Program Number: P625

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