with Dr. César Ginestà
Acute appendicitis in puerperium is often diagnosed too late, as clinical signs can be unreliable. Abdominal wall rigidity is rarely noticed in puerperium because of weak abdominal wall muscles, laboratory parameters are not sufficiently reliable, and typical appendix presentation poses difficulties in diagnosis.
Being aware of the clinical signs and symptoms of appendicitis, possible complications and early detection, provides a chance for a good surgical outcome. Taking the axillar and rectal temperature can lead to confusion, and delay surgical treatment. Leucocytosis in puerperium is not valid for diagnosis.
With respect to results of published studies, laparoscopic approach to management of acute abdomen during pregnancy and puerperium should be regarded as safe and effective.
A 41-year-old woman with no drug allergies and a history of twin births 10 days before.
She was referred to our emergency department with a history of 48 hours’ abdominal pain, predominantly in the lower abdomen, and dysthermia.
A blood test and an abdominal CT scan were performed for diagnosis. The analysis showed increased acute phase reactants and the CT scan showed an enlarged appendix with an appendicolith at the tip and some gas bubbles and free intraabdominal fluid with intra-abdominal fat trabeculation. Mesenteric lymph reagents were found in the lower right quadrant. The uterus was enlarged with respect to postpartum. There were no other findings.
It was decided to perform an exploratory laparoscopy with guidance, and acute appendicitis was diagnosed.
The patient is placed in the supine position with closed legs. The surgeon and the assistant stood on the left side of the patient.
A total of 3 trocars were used: a 12mm port in the umbilical position, an additional 12mm suprapubic port and a 5mm port on the right flank. We used the umbilical port for 30º scope and the other two trocars as working channel.
First we can see the multiple adhesions because of a purulent peritonitis throughout the abdominal cavity. Then we carefully released the adhesions between the bowel and the right parietocolic.
At this level the large size of the uterus with respect to postpartum can be observed. It is important to be very careful when releasing adhesions to avoid iatrogenic injury. We tried to suck all the pus and clean as much fibrin as possible.
Then we explored the cecum in search of the appendix. The appendix was the target, with signs of acute gangrenous appendicitis. We dissected the mesoappendix trying to find the appendicular base. We used clips to tie the vessels and continued the dissection. Then we finished the dissection of the appendicular base using the hook.
At this stage the camera was transferred to the suprapubic port. The Mechanical suture was introduced through the umbilical port, which allows a better angle. We used a EndoGIA™ for appendicular base section and proceeded to remove the appendix through a endobag.
Finally we cleaned up the remnants of fibrin and pus in the uterus and Douglas Pouch.
We used gauze to complete the washing. A Blake drain was left in the Douglas pouch and in the surgical site, completing the surgery.
The total operation time was 63 minutes, and the estimated blood loss was 0 mL. The patient was discharged with no complications on the fifth postoperative day.
This approach is minimally invasive and can be performed safely.
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