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Acute appendicitis is the most common surgical pathology in women with
multiple pregnancies, which threatens the life of the mother and the newborns.
The incidence of acute appendicitis in women with multiple pregnancies is,
according to different data. In a timely manner, appendectomy is not
always possible to avoid obstetric and surgical complications, which occur in
17% of cases. According to the
latest data, 50% of pregnant women with acute appendicitis enter surgical
hospitals 48 h after the onset of the disease, as they are initially
hospitalized in gynecological hospitals with suspicion of the threat of
termination of pregnancy. Thus, in most pregnant women appendectomy is
performed more than a day after the onset of the disease.
Keywords: Acute appendicitis,
Pregnancy, Laparoscopic appendectomy, Antibiotic therapy
INTRODUCTION
In a timely manner, appendectomy is not always possible to avoid
obstetric and surgical complications, which occur in 17% of cases [3,8-11]. The
frequency of diagnostic errors in acute appendicitis in women with multiple
pregnancies ranges from 11.9-44.0%, 12-44% with hypo- and over-diagnosis being
equally permissible, with a frequency ratio of 25% and 31%, respectively.
According to the latest data, 40-55% of pregnant women with acute
appendicitis enter surgical hospitals 48 h after the onset of the disease, as
they are initially hospitalized in gynecological hospitals with suspicion of
the threat of termination of pregnancy. Thus, in most pregnant women
appendectomy is performed more than a day after the onset of the disease
[12-14]. Therefore, in pregnant women, especially in later terms, the
destructive forms of acute appendicitis occur 5-6 times more often than in
non-pregnant ones. Primarily in the III trimester, the destructive forms of
acute appendicitis become complicated by perforation and widespread
peritonitis; occur three times more often than in first trimester and 2 times
more often than in the second trimester of pregnancy [15-13].
Emergency surgery is now impossible to imagine without laparoscopy. The
rapid development of laparoscopic surgery led to a reassessment of the role of
laparoscopy in pregnant women, as a result of which laparoscopic appendectomy
became a reasonable alternative to open surgery at different pregnancy times
[16,17]. Multiple pregnancies aren’t considered a contradiction to laparoscopy
and laparoscopic appendectomy. In acute appendicitis in patients with multiple
pregnancies, an undeniable advantage of the laparoscopic method is the
possibility of verifying the diagnosis, which often allows us to limit
diagnostic laparoscopy, avoiding unjustified appendectomy.
MATERIALS AND METHODS
Under our supervision, between 2010 and 2014 there were 48 women with
multiple pregnancies diagnosed with acute appendicitis. 18 (37.5%), women
underwent diagnostic laparoscopy and 30 (62.5%) with laparoscopically assisted
appendectomy. The range of gestation was 6 to 36 weeks. Pregnant women had 16
(33.3%) in the first trimester, 24 (50%) in the second trimester and 8 (16.7%)
in the third trimester.
In recent years, we are expanding the indications for the use of diagnostic
laparoscopy in cases of suspected acute appendicitis in women with multiple
pregnancies in order to shorten the duration of the dynamic observation of
patients, which causes the loss of time and progression of the disease,
significantly reduce the number of diagnostic errors and reduce the frequency
of unreasonable appendectomy. The patients were activated without threat of
termination of pregnancy 6-8 h after the operation; the average duration of the
bed-day in the surgical department was 4.2 to 5 after which patients were
transferred for further treatment and supervision to the obstetrics and
gynecology department.
Prevention of premature termination of pregnancy, as a rule, begins in the
preoperative period, we continue during the operation and in the postoperative
period regardless of the gestation period. In the first trimester of pregnancy,
the use of dydrogesterone or natural micronisine progesterone is indicated. In
the II-III trimesters it is advisable to use tocolytics. In order to prevent postoperative
inflammatory complications and intrauterine infection of the fetus, pregnant
women, operated on for destructive appendicitis, were prescribed antibiotic
therapy. In the first trimester, semi-synthetic penicillins and from the second
trimester, semi-synthetic penicillins or cephalosporins in average therapeutic
doses for 5-7 days.
When prescribing drug therapy in the post-operation period, the
recommendations of the American Food and Drug Administration (FDA) on the
safety of use during pregnancy, as well as the normatively-decreed documents of
the Ministry of Health of Ukraine were taken into account.
All operations were performed under endotracheal anesthesia. In the first
trimester of pregnancy, the technique of laparoscopy does not differ from the
standard technique. Carboxyperitoneum was created up to a pressure of 10-12 mm
Hg with the needle Veresa. For examination of the abdominal cavity laparoscopes
with optics of 30° were used, which make it possible to effectively inspect the
ileocecal region in most of the observations without introducing additional
manipulators. The slope of the operating table on the left side greatly
facilitates the laparoscopy.
Beginning with the second trimester of pregnancy, the Hassen open
laparoscopy technique was used to prevent needle injuries. Hearing of a
pregnant uterus [18], access was made depending on the size of the uterus [19].
Troakar was introduced along the middle line just above the upper edge of the
uterine fundus. Carrying out a diagnostic laparoscopy in late pregnancy, they
took special care, not allowing "blind" manipulation in the abdominal
cavity. If the appendix was not visualized, a 5 mm trocar for the manipulator
was inserted above the bosom [20].
Depending on the anatomical situation, the operation was performed using 2
or 3 trocar. In the case of double-barrel access, the appendix was grasped at
the apex and removed together with the trocar onto the anterior abdominal wall,
after which appendectomy was performed. One of the conditions for a successful
operation is the correct location of the second trocar above the base of the
appendix. With an insufficiently movable dome of the cecum, even a slight
deviation of the site of trocar insertion from the optimal leads to significant
technical difficulties, which usually cause the conversion or expansion of the
trocar wound [21-23].
Three trocars for appendectomy were used for a short and inactive mesentery
of the appendix, atypical appendectomy, gangrenous and perforated appendicitis,
as well as peria-pendicular fusions that limit the mobility of the appendectomy
[24]. In this case, the mesentery was crossed in the abdominal cavity, applying
regimes of mono- and bi-polar coagulation. After the intersection of the
mesentery, the mobilized process, as in the two-tube technique, was removed
from the abdominal cavity together with the trocar. Direct appendectomy was
performed in a ligature invagination way, peritonizing the stump of the
appendix with a suture seam. During laparoscopy, adequate infusion therapy was
performed with the use of tocolytic therapy [25,26].
Administration of 4-6 g of magnesium sulfate dissolved in 100 ml of
physiological solution is carried out intravenously (iv) for 30-45 min, after
which they switch to continuous iv injection at a rate of 2-4 g/h until
cessation or significant contraction of contractions [27-30]. Sometimes after
the termination of labor, minor contractions of the uterus continue. In this
case, a vaginal examination is performed regularly. If the cervical dilatation
is continued, the dose is increased or another tocolytic agent is prescribed
for the prevention of premature birth [31].
RESULTS AND DISCUSSION
In 18 (37.5%) patients with multiple pregnancies, the initial diagnosis of
acute appendicitis was not confirmed. The first trimester of pregnancy was in
10 (20, 8%), II - in 6 (12, 5%) and III - in 2 (4, 2%) women. In one patient
with a gestation period of 36 weeks, the clinical picture simulating acute
appendicitis was caused by torsion of the fallopian tube together with a
cystically altered ovary. The ovarian tube was defecated. In 4 (8, 3%) patients
in I and II trimesters there were ruptures of ovarian cysts. In 2 (4.2%)
patients in I trimester acute pancreatitis was diagnosed and 9 (18.7%) women in
I and II trimesters had no acute diseases of the abdominal cavity organs.
Of the 30 patients who underwent laparoscopically assisted appendectomy,
the first trimester of pregnancy was in 8 (26.7%), the second trimester in 16
(53.3%) and the third trimester in 6 (20%). Phlegmonous appendicitis was found
in 14 (46.7%) pregnant women, gangrenous - in 6 (20%) and perforated - in 3
(10%).
The appendix was located in the right iliac region in 36 (75%) patients, of
which 20 (41.7%) of women had a pregnancy period corresponding to the second
and third trimesters. Atypical location was observed only in 8 (16.7%) pregnant
women. Localizations of the appendix in the small pelvis - in 12 (25%)
patients, in the subhepatic space - in 4 (8.3%), retrocetically - in 1 (2%) did
not complicate the laparoscopic operation. In the first case, we observed in
the right ileal fossa moderate subcutaneous emphysema within 2 days,
spontaneously resolved without the use of any measures. Subcutaneous emphysema
was caused by gas injection through the Veresk needle. There were no
intraoperative complications. In the postoperative period, an inflammatory
infiltrate in the anterior abdominal wall appeared in one patient. To prevent
purulent-inflammatory complications, avoid contact of the appendix with the
tissues of the anterior abdominal wall. No intra-abdominal complications were
noted [32].
In 6 patients with gangrenous appendicitis complicated by unrestricted
serous and serous-fibrinous peritonitis and in 3 patients with perforated
appendicitis, the operation became more complicated. The exudate was carefully
aspirated; the places of its accumulation (right lateral canal and small
pelvis) were washed with physiological solution with dioxidine to clean wash
water [33]. We consider the indication in such situations of mandatory drainage
of the abdominal cavity with the introduction of 4 aseptic per day. Drainage in
all cases was removed after 2-3 days. Video laparoscopy makes it possible to
adequately place the drainage in the abdominal cavity under the vision control,
providing conditions for complete drainage.
Laparoscopically assisted appendectomy using 2 trocars managed to perform
12 (40%), 3 trocars - 18 (37.5%) to pregnant women. Conversions to the open
operation were not conducted. In 3 (10%) patients there was a transition from a
two-barreled technique of laparoscopically assisted appendectomy to a
three-barrel. Post-operative complications were not observed [34].
The advantage of laparoscopically assisted appendectomy in comparison with laparoscopic
appendectomy is a shorter exposure to the pregnant uterus of strained
carboxyperitoneum and a decrease in its negative impact on the fetus [35]. The
procedure of the operation involves the creation of carboxyperitoneum only at
the stage of diagnostic laparoscopy and, if necessary, for the final
sanitization of the abdominal cavity. For laparoscopic appendectomy,
carboxyperitoneum is necessary throughout the operation. The average duration
of laparoscopically assisted appendectomy in pregnant women was 46.4 min, the
average duration of carboxyperitoneum was 21.8 min. The duration of
carboxyperitoneum with laparoscopically assisted appendectomy using 2 trocars
is less than using 3 trocar [36,37].
After discharge from the hospital 2 women at their request pregnancy was
artificially interrupted in the early period. Cesarean section was performed
according to obstetric indications of 6 (20%) to women and was not associated
with a delayed appendectomy or laparoscopy. In 22 (73.3%) women, the births took
place without any peculiarities. All babies were healthy.
Our experience of performing laparoscopic operations with acute
appendicitis in pregnant women suggests that surgeons performing interventions
should have extensive experience in urgent surgery, flawlessly own laparoscopic
diagnostics and the technique of endoscopic and traditional surgeries. The use
of the laparoscopic method in the surgery of acute appendicitis in pregnant
women contributes to improving the quality of diagnosis and treatment of fewer
postoperative complications, reducing the number of bed-days. The further
introduction of these methods in urgent surgery is undoubtedly promising and
deserves attention [38].
CONCLUSION
1.
Acute appendicitis
is the most common surgical pathology in women with multiple pregnancies, which
threatens the life of the mother and the fetuses.
2.
Laparoscopically
assisted appendectomy in women with multiple pregnancies provides low
invasiveness, reliability and high economic efficiency.
3.
The advantage of
laparoscopically assisted appendectomy in comparison with laparoscopic
appendectomy is a shorter exposure to a pregnant uterus of strained
carboxiperitoneum and a decrease in its negative impact on the fetus.
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