First Report of Single Incision Laparoscopic Appendectomy in a Pregnant Patient

Jonathan D Svahn, MD FACS, Matthew R Dixon, MD, Joanna Lim, MD, Austin L Spitzer, MD. Kaiser Permanente East Bay, Oakland Campus

Single incision surgery is becoming more popular as surgeons become more comfortable with this technique. While initial series reported on cholecystectomy and appendectomy, subsequent publications described its successful application for the treatment of other surgical diseases. These include colectomy, Nissen fundoplication, splenectomy, adrenalectomy, and gastrectomy to name but a few. There has, however, been only one reported case of single incision laparoscopic surgery undertaken in a pregnant patient. This case report detailed a successful laparoscopic cholecystectomy for acute cholecystitis. We present the first report of single incision laparoscopic appendectomy in a pregnant patient.
A previously healthy 27 week pregnant patient (G6P1) presented to her obstetrician’s office with 24 hours of worsening right lower quadrant pain. Surgical consultation was obtained. On physical exam she was afebrile with tenderness to palpation in the right lower quadrant over McBurney’s point. Blood work was significant only for a mildly elevated white blood cell count. The clinical diagnosis of appendicitis was made and she was offered single incision laparoscopic surgery. CT scan was deferred due to the potential radiation risk to the fetus.
Our  technique has been previously reported and involves the use of a home made single port device. Our "gloveport" is created using a small latex free glove and one 12 mm trocar. The trocar is placed through the thumb of the glove and secured with steri-strips. Similarly, a five mm 30 degree laparoscope and a five mm atraumatic grasper are secured through alternating fingers of the glove. A vertical incision is made through the base of the umbilicus and the fascia is divided sharply under direct vision.
In this patient, the gravid uterus was easily visualized and not injured. A small wound protector was introduced into the abdomen and rolled until secure. The gloveport was then secured around the exteral portion of the wound protector. In this case, the abdomen was insufflated to only eight mm mg to allow visualization while minimizing the potential adverse effects of the pneumoperitoneum on the fetus. An inflamed and grossly suppurative appendix was identified. It was removed using two firings of an endoscope stapler in the standard fashion. The abdomen was copiously irrigated and the gloveport and wound protector were removed. The fascia was closed with interrupted sutures and a running subcutaneous stitch was used for the skin. The patient and fetus were monitored post operatively and discharged home the following day.

Laparoscopic surgery in pregnant patients was initially considered risky. Subsequently data supported the use of laparoscopy for surgical emergencies in pregnant patients and was found to be both feasible and safe. However, trocar placement either blindly or under direct vision puts the gravid uterus and fetus at risk of penetrating injury. We feel that the use of single incision laparoscopic surgery and our technique, which involves no trans-abdominal trocar placement, obviates this risk. Further study is warranted but our initial experience suggests that single incision laparoscopic surgery may provide an additional benefit to the pregnant patient when compared to standard laparoscopic surgery.
 

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