Editing Appendectomy (section)

== Pregnancy ==
Appendicitis is the most common emergent general surgery related problem to arise during pregnancy. There is a natural elevation in white blood cell count in addition to anatomical changes of the appendix that occur during pregnancy.<ref name=":1">{{Cite web|url=https://lwwhealthlibrary.com/signin.aspx?returnurl=https%3a%2f%2fclerkship.lwwhealthlibrary.com%2fcontent.aspx%3fsectionid%3d189164570%26bookid%3d2438%26rotationId%3d0|title=Sign In {{!}} Health Library|website=lwwhealthlibrary.com|access-date=2020-01-11}}</ref> These findings, in addition to non-specific abdominal symptoms make appendicitis difficult to diagnose. Appendicitis develops most commonly in the second trimester.<ref name=":0">{{Cite journal|last1=Lee|first1=Seung Hwan|last2=Lee|first2=Jin Young|last3=Choi|first3=Yoon Young|last4=Lee|first4=Jae Gil|date=2019-04-25|title=Laparoscopic appendectomy versus open appendectomy for suspected appendicitis during pregnancy: a systematic review and updated meta-analysis|journal=BMC Surgery|volume=19|issue=1|pages=41|doi=10.1186/s12893-019-0505-9|issn=1471-2482|pmc=6482586|pmid=31023289 |doi-access=free }}</ref> If appendicitis develops in a [[pregnancy|pregnant]] woman, an appendectomy is usually performed and should not harm the [[fetus]].<ref>{{MerckHome|22|258|c|Risk Factors That Develop During Pregnancy|}}</ref> The risk of premature delivery is about 10%.<ref>Schwartz Book of General Surgery</ref> The risk of fetal death in the perioperative period after an appendectomy for early acute appendicitis is 3 to 5%. The risk of fetal death is 20% in perforated appendicitis.<ref>Sabiston Textbook of Surgery 2007.</ref>

There has been debate regarding which surgical approach is preferred during pregnancy. Overall, there is no increased risk of fetal loss or preterm delivery with the laparoscopic approach (LA) as compared to the open approach (OA). However, the LA was associated with shorter length of stay in the hospital as well as reduced risk of wound infection.<ref name=":0" />

Patient positioning is of utmost importance to ensure safety of the fetus during the procedure. This is especially important during the third trimester due to the potential of compression of the inferior vena cava leading by the enlarged uterus. Placing the patient in a 30-degree left lateral decubitus position alleviates this pressure and prevents fetal distress.<ref name=":1" />

One area of concern related to the LA during pregnancy is [[pneumoperitoneum]]. This causes an increase in the intra-abdominal pressure, leading to decreased venous return and therefore, decreased cardiac output. The decreased cardiac output may lead to fetal acidosis and cause distress. However, an animal pregnancy model demonstrated that a 10-12mmHg insufflation pressure demonstrated no adverse effects on the fetus. SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) currently recommends an insufflation pressure of 10-15mmHg during pregnancy.<ref name=":0" />