Trends in Laparoscopy: Study of 1,999 Pregnant Patients

Tiffany C Cox, MD, Ciara R Huntington, MD, Laurel J Blair, MD, Tanushree Prasad, MA, Vedra A Augenstein, MD, FACS, B. Todd Heniford, MD, FACS. Carolinas Medical Center

Introduction: When pregnant patients require surgery, whether to perform operations open or laparoscopic is often debated. We studied the impact of laparoscopy for common general surgical problems in pregnancy to determine safety and trends of application 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, smoking, and perforation.

Results: A total of 1,999 pregnant patients between 2005-2012 were evaluated. Of 1,335 appendectomies: 894 were laparoscopic(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 27.8 years(p=0.19), diabetes(1.8%vs0.9%,p=0.24), smoking(19%vs16.1%,p=0.2)] except for BMI(27.9vs28.4kg/m2,p=0.03). LA had shorter operative times(OT), length of stay(LOS), and fewer postoperative complications compared to OA(Table 1). MVA for perforated cases alone, LA had less OT(<0.001) and LOS(p=0.009). The majority of LA were performed in the last 4 years vs first 4 years(61%vs39%,p<0.001).

For LC versus OC, patient characteristics were not different: age 28.3 years(p=0.33), BMI(31.4vs33.2kg/m2,p=0.25), diabetes(2.8%vs3.5%,p=0.68), and smoking(21.1%vs25.9%,p=0.4). LC also had a shorter OT, LOS, and fewer postoperative complications than OC(Table 2). On MVA, difference between approaches remained statistically significant for OT(<0.001), LOS(<0.01), and wound complications(<0.05). In complicated cholecystitis with perforation, LC had less LOS(p=0.047) yet similar OT(p=0.07); no difference in postoperative complications. The percentage of LC cases appeared to increase over time(89%vs93%,p=0.06).

Conclusion: While fetal events are unknown, LA and LC in pregnant patients demonstrated shorter OT, LOS, reduced wound complications, and were performed more frequently over time. Even in perforated cases with infection, laparoscopy appears safer in pregnant patients.

Table 1. Patient Outcomes for Appendectomy. (SSI=surgical site infection)
Laparoscopic n(%) Open n(%) p value
Operative Time(minutes) 47.1±20.2 52.1±25.1 <0.001
Length of Stay(days) 2.3±5.8 3.3±2.5 <0.001
Perforation 492(55) 278(63) 0.005
Superficial SSI 4(0.5) 13(3.0) <0.001
Deep SSI 2(0.2) 3(0.7) 0.34
Wound Complications 6(0.7) 17(3.9) <0.001
Minor Complications 25(2.8) 24(5.4) 0.02
Table 2.Patient Outcomes for Cholecystectomy.
Laparoscopic n(%) Open n(%) p value
Operative Time(minutes) 64.4±29.7 111±82.3 <0.001
Length of Stay(days) 3±4.1 6.5±7.8 <0.001
Peforation 132(21.8) 19(32.8) 0.056
Superficial SSI 4(0.7) 2(3.5) 0.09
Deep SSI 0 0
Wound Complications 4(0.7) 2(3.5) 0.09
Minor complications 10(1.7) 4(6.9) 0.03

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