With the increase in the rate of laparoscopic surgery in Korea, laparoscopic appendectomy in pregnant women is being widely adopted by many general surgeons owing to easy access to the appendix displaced by the gravida uterus and fine visualization when compared with open appendectomy. In addition, the Society of American Gastrointestinal and Endoscopic Surgeons guideline mentions laparoscopic appendectomy as the treatment of choice for pregnant patients with appendicitis . Nevertheless, performing laparoscopic appendectomy in pregnant women is still controversial owing to weak evidence and the contradictory results of recent meta-analyses and systematic reviews.
The primary issues regarding laparoscopic surgery during pregnancy are mainly addressed in two aspects. One is maternal perioperative outcomes, and the other is fetal outcomes such as fetal loss and preterm delivery. Adverse fetal outcomes might result from the CO2 gas used for pneumoperitoneum, which might cause fetal acidosis, and from elevated abdominal pressure during laparoscopic surgery, which might cause decreased maternal venous return and consequently decreased fetal blood flow.
Among those controversial issues, most perioperative and fetal outcomes, except fetal loss, have been reported to be comparable to open appendectomy. The previous literature has mentioned no significant differences so far for fetal loss, except one study reported in 2007 by McGory et al. , which had the largest sample size (laparoscopy [n = 454] vs. open [n = 2,679]; odds ratio [OR], 2.16; 95% confidence interval, 1.41–3.29) among previous studies. Owing to this large sample size, two recent meta-analyses on this topic showed higher ORs for fetal loss after laparoscopic appendectomy compared to open appendectomy, in spite of the fact that it was the only study demonstrating worse outcome when a fixed effect model was adopted [3,4]. However, the authors of the two meta-analyses differently interpreted the results and concluded differently. Lee et al.  insisted that it is not reasonable to accept the result owing to the high weight of the study, which resulted in disproportionately high influence . The other studies included in these recent meta-analyses are mostly retrospective or prospective observational studies with small sample sizes ranging from 4 to 128 in the laparoscopic appendectomy group [3,4].
The article in the current issue, entitled “
In a population-based cohort study using the National Health Insurance Research Database in Taiwan, the patients were divided into three groups according to the types of treatment (open, laparoscopic, and nonoperative treatment). When comparing the three groups to pregnant women without appendicitis, the nonoperative treatment group showed the highest ORs for abortion and preterm labor; however, no differences were found when the laparoscopic appendectomy and open appendectomy groups were compared to each other in terms of abortion and preterm labor . Therefore, avoiding delay in operative management is much more important to achieve better fetal outcomes rather than the difference in surgical approach.
In summary, this study indirectly demonstrated the safety of laparoscopic appendectomy for acute appendicitis management during pregnancy. Owing to the nature of pregnant women as vulnerable study subjects, there is no room for a randomized controlled trial to assess this issue. However, further large-scale studies are needed to confirm the safety of laparoscopic appendectomy during pregnancy.
The author has no conflict of interest to declare.