Successful interval laparoscopic appendectomy for walled-off perforated appendicitis during pregnancy: a case report

Acute appendicitis is the most common non-obstetric surgical emergency during pregnancy, with an incidence of approximately 0.067% (1 in 1493 pregnancies). Although prompt laparoscopic appendectomy is the standard treatment, optimal management of walled-off perforated appendicitis (WOPA) during pregnancy is unclear.

A 28-year-old woman presented with a 1-week history of abdominal pain and fever at 9 weeks of gestation. Ultrasonography demonstrated an ill-defined right lower quadrant mass, and contrast-enhanced computed tomography revealed WOPA with a localized abscess clearly separated from the uterus. Following a multidisciplinary discussion with the obstetric team, initial nonoperative management (NOM) with intravenous antibiotics was considered because the patient was clinically stable and the inflammation was localized. The patient's symptoms resolved without complications, and she was discharged after 11 days. Elective laparoscopic interval appendectomy (IA) was successfully performed 9 weeks later, at 18 weeks of gestation during the second trimester. Only mild adhesions were observed intraoperatively, and the postoperative course was uneventful. The pregnancy progressed without any maternal or fetal complications.

In this case, delayed presentation, localized abscess formation, clinical stability, and anatomical separation of the inflammatory lesion from the uterus supported the initial conservative approach. Elective IA performed during the second trimester avoided technically demanding emergency surgery and was safely completed. This case, together with the limited published literature, suggests that staged management may be appropriate among carefully selected pregnant women.

In carefully selected pregnant patients with WOPA, initial NOM followed by interval laparoscopic appendectomy may be safe and feasible. Additional case studies are required to establish the optimal management recommendations for this rare clinical condition.