Abdominal surgery in pregnancy--an interdisciplinary challenge

Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach.

This review is based on pertinent articles retrieved by a selective search in the PubMed database.

The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth.

Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.