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Nonobstetrical abdominal surgery during pregnancy
Nonobstetrical
abdominal surgery
during pregnancy C.
C.
Honolulu,
McCORRISTON,
M.D.
Hawaii
T H E purpose of this paper is to evaluate the nonobstetrical abdominal surgical procedures performed during pregnancy at the Kapiolani Maternity and Gynecological Hospital, Honolulu, during the IO-year period from 1952 to 1961. During the last 10 years, there were 42,510 deliveries of women of the many races which make up the population of our community. Of 83 pregnant women admitted with symptoms or signs suggesting the possibility of disease best treated surgically, 68 were operated upon. Table I shows the breakdown of the various diseases involved.
however, our observations confirm those of West,’ who noted that pain frequently began in the right flank area. Of 23 patients whose condition was correctly diagnosed, 4 were in the first, 11 in the second, and 8 in the third trimester of pregnancy. In the first trimester of pregnancy, maximum tenderness was usually in the region of McBurney’s point or nearby; in the second and third trimesters, usually above McBurney’s point in the right flank, frequently as high as the umbilicus. Two-thirds of the white blood cell counts were between 12,000 and 20,000, with polymorphonuclear percentages between 80 and 90. The temperature on admission was below 100’ F. in two thirds and between 100’ F. and 102’ F. in one third of these patients. Of the 32 operations, 21 were done under spinal anesthesia and 11 under general anesthesia. Intravenous muscle-relaxing drugs were also utilized. Varying incisions were chosen by the several operators (Table II). Of 8 operations performed with the preoperative diagnosis of appendicitis in the first trimester, a right paramedian incision was made in 4. In the middle or third trimesters, a midline hypogastric incision was not adequate for exposure of the appendix in 2 cases and resulted in the performance of additional surgical procedures, extensions of the wound, damage due to excessive traction with retractors, and unavoidable manipulation of the uterus. In both instances the cecal serosa was lacerated, and in one instance, in the third trimester, a T-shaped extension of the
Appendicitis The diagnosis of appendicitis was established in 23 (72 per cent) of 32 patients operated upon for appendicitis during pregnancy, an incidence of 0.05 per cent, which is comparable with that cited in previous l, 2 Careful history taking revealed reports. anorexia in all patients, and in most instances nausea with or without vomiting. In the first and second trimesters of pregnancy, pain usually began in the midumbilical area, but occasionally in the epigastrium, later progressing to the right lower quadrant or right flank. In the last trimester,
From the Department of Obstetrics and Gynecology, Straub Clinic and Kapiolani Maternity and Gynecological Hospital. Presented by inuitation at the Twenty-ninth Ann4 Meeting Pacific Coast Obstetrical and Gynecological Society, Portland, Oct. 3-6, 1962.
of the
Oregon,
593
594
July 1, 1963 Am. J. Obst. & Gynec.
McCorriston
Table I. Abdominal of pregnancy
surgical
complications
/
of
/ No. i
Appendicitis Ovarian cyst (one. malignant) Ureteral or renal disease Gastric and duodenal disease: Perforated ulcer Bleeding duodenal ulcer Active duodenal ulcer or duodenitis Biiiary tract disease : Biliary dyskinesia Acute cholecystitis l’ancreatitis Infectious mononucleosis with splenitis Iiydrosalpinx Uterine l&myoma (subserous) Intra-abdominal hemorrhage, cause undetermined Intestinal obstruction Trauma
Carcinoma
(nongynecological)
Stomach Si,moid
colon
EASES
1
No. operated UfiOTl
23 20 9
32 19 7
0 1
0 1
3
0
‘4 2
0 1
3
1
:
0 1 1
1 3 0
1 2 0
1 1
1 1
:
73
68
abdominal wound still did not permit adequate exposure of the appendix. The operator finally emptied the uterus by cesarean section to permit adequate visualization of the appendix. A high, muscle-splitting incision over the point of maximal tenderness c$as utilized in 17 of 24 patients operated upon in the second and third trimesters with the preoperative diagnosis of appendicitis. In each. exposure was adequatts. Experience at this hospital indicates that if the preoperative diagnosis of acute appendicitis is not a firm one? ;t right paramedian incision is best in that it can be easily c~stcndcti upward or downward, the initial incision bt,ing ma& with consideration of I!W maGmurn point of tenderness. In the i’irst trirricstrr it was the incision of choice, ;Jlordinq :tccess ICI both adncxa as well as to the iLppc'lLdiX. LVith a firm diagnosis of ;>ctltcb ;rppenclic,itic in the swrmd and third trimesters. w prefer a high rnusclc-splitting
incision centered over the point of maximal tenderness, usually at the level of the umbilicus and lateral to the right rectus muscle, which, because of the gestation, may be stretched rather widely laterally. To obtain the maximum benefts from this incision the patient, after anesthetization, is rolled over on the left side so that the right side is elevated approximately 30 degrees, her back supported in this manner. The frequency with which the operator comes right down and the avoidance of on the appendix, handling or packing off the uterus at all make this approach a desirable one. This proper positioning of the patient is the key to the best use of this incision. BIood pressure and cardiac output are also best maintained in the left lateral position.” ‘The postoperative course of 32 patients operated upon for appendicitis, in whom 23 cases of appendicitis were found, was essentially uneventful. The stump was buried in only 9 cases. Antibiotics were given postoperatively to half the patients. Those who did not receive them had an equally rapid recovery. There were no wound infections and no dehiscences. There was no apparent difference in the welfare of the patient whether or not hormones were used. The appendix had ruptured in 2 of the 23 cases of proved appendicitis. Each patient recovered uneventfully, treated with antibiotics, the correction of acidosis by intravenous feeding of electrolytes and dextrose, and gastric suction. Twenty-six of the 32 patients were ambulatory within 48 hours. Neither labor nor abortion ensued in any. We have felt that cesarean section should bc reserved for an obstetrical indication and that should cesarean section be necessary in the face of acute appendicitis, an extraperitoneal cesarean section is probably the method of choice unless there is lack of time because of fetal distress, in which instance a low-segment section is indicated. Ovarian
tumors
Nineteen precgnant patients, ranging in ase from 18 to 35 years, were operated upon for ot,arian cysts larger than 5 cm. in cliam-
Volume Number
86 5
rter (‘l’able III). No definite racial predominance was noted. Ovadan masses were discovered at prenatal clsamination without symptoms in 6, and 7 of the 20 patients complained of abdominal pain. In 3 instances, this pain was described as being very crampy in character. Two masses were discovered during labor, obstructing the descent of the presenting part. One cyst was found at the time of postpartum sterilization. In the absence of pain which may suggest hemorrhage or rupture or twist of an ovarian cyst, WC have followed the policy of watching the asymptomatic cyst until approsimatrly 14 to 16 lreeks’ gestation, allowing generous time for development of the placenta before sacrificing an ovary which may contain the corpus luteum of pregnancy. In spite of this policy it was necessary to operate upon 6 women in the first trimester. Seven were operated upon in the second trimester, 4 in the third, and 2 post partum after a full-term delivery (Table IV). There were no cases of postpartum acute torsion of the ovarian pedicle. Three patients were optarated upon with a final diagnosis of corpus luteal cyst; operations were done at 10, 16, and 19 weeks’ gestation. Seven cysts were benign teratomas, 2 of which were twisted, causing acute synlptoms. One was a serous cystoma, 3 were pseudomucinous cyst.adenomas, one of which had ruptured, and one was a pseudomutinous cystadenocarcinoma. We believe that both ovaries should be not only inspected but palpated, as a small invisible tumor may occasionally be felt in the contralateral ovary. In such a situation the ovary is split at its antimesenteric border and esplorrd. Routine splitting oi the contralateral o\xry is not practiced. Under these conditions no bilateral benign teratomas or cystadenomas were found. No solid tumors of t.he ovary were encountered. In one patient a large abdominal mass was found at 39 weeks’ gestation prior to labor, laparotomy was done, and a cyst excised. The patient was subsequently delivered through the birth canal.
Nonobstetrical
abdominal
surgery
595
Table II. Type
of incision in cases with diagnosis of appendicitis
preoperative
Midline hypogastric Right rectus-splitting retracting Usual McBurney High right flank muscle-splitting
~_--~( Ivt
Trimester -;-2nd
1
4
k 3
1 1
, I
a
3rd 1
or
0
I:!
5
Total
8
18
6
Table III. Types of ovarian
lesions
Benign
teratoma
7 (2 twisted, symptoms)
Benign serous cystadenoma Benign pseudomucinous cystadenoma Pseudomucinous cystadenocarcinoma Corpus luteal cyst
acute
1 3 1 (one ruptured) 4 (operated on at 10. 16, and 19 weeks’ gestation; one not operated on) 2 (one bilateral) 1
Endometrioma Infarct of ovary “Hypertrophy” of ovary
1
Total
20
TabIe IV. Week ovarian
of gestation
in cases of
disease W-epk
8th 10th 11th
‘,
16th 17th 19th 21 st “2nd 26th
7 I 1 I -. 1 7 1 (post partum) 3 (all 3 cesarean
Sttb 39th
section)
4 Full
term,
No -.
operation
post
partum
2 ( 1 carcinoma, 1 teratoma) 1 __--..~ _-
-----
596
July 1, 1963 Am. J. Obst. & Gynec.
McCorriston
Transverse cervical cesarean sections were performed in 2 cases of obstructed labor and the cystic masses removed at the same time. Careful prenatal examination and earlier surgical action might well have made these cesarean sections unnecessary. At the time of any cesarean section the adnexa are inspectrd and the posterior surface of the llwrus and both ovaries palpated. In ov(hr half of the patients no hormone medication was used. In this study there was MI apparent difference between the use and nonusc of hormone medication, though adequate doses of parentera progesterone might hi helpful in the first 3 months of gestation, lest placental hormone production lag. In the case of benign cystic teratoma or c~ndomctrioma, e\.en if largr, a certain amount of normal ovarian tissue can usually 1~ ltrcatc~d in the wall and preserved for purposes of well-being, delay of the menopusc‘, and future childbearing.” This was tlonc except in the 2 cases of acute torsion of the ovary in which the adnexa involved v.x’re excised. Postoperati\,t: complications were limited I0 one case of acute postoperative pyelonc$lritis and one superficial wound abscess \vith ccta,sulasr-positive Stap~~.$ococcus au~c’~r. phage type 80-81, in 1958. None of the group went into premature labor following opr~ration. Urinary
tract
complications
Nine women had urinary complications whic11 rni,ght havr required. or did require, operation. Of these, 6 had renal or ureteral calc111i. In one of these. there was a. suspicion of possible hyperparathyroidism. ‘I’hrrp nephrectomirs were done, one for a Inrye hydronephrosis. one for renal carbuncle. and onrh for a chronic Proteus inf<,ctian in :j nonfunctioning kidntby,
where indicated. Before operation on either kidney, the function of the contralateral kidney was evaluated. A series of renograms done at intervals of 2 or 3 days with I131-tagged iodohippurate sodium (Hippuran) 5 has been most helpful, particularly in following pregnant patients with partial or complete renal block, for this procedure can be done repeatedly with a minimum of radiation effect to the fetus and to the ovaries. When the urinary tract is not infected, when pain can be controlled, and when a urcteral calculus is small, we have waited a reasonable length of time, hoping that this calculus will pass or descend to a level where it can be removed through cystoscopic manipulation. Provided there is no infection, the kidney, even if completely blocked, will not die if the complete block does not exceed 2 weeks. Following this policy, two of four calculi passed spontaneously and two were removed by ureterolithotomy. On the other hand, if the urine is infected and if renal block is complete, renal drainage must be instituted promptly by lithotomy or renal pyelotomy lest a serious infection or kidney destruction result. One ureterolithotomy was done in this category and one where there was no compIete renal block but persistent infection accompanied an immobile ureteral calculus. .411 urine was strained to obtain any passed c-alculus for chemical examination. The patients were investigated for the possibility of specific metabolic disease causing calculi, such as hyperparathyroidism and gout. Though the incidence of gout is extremely high in Filipino men, we have seen no gouty calculi in Filipino women in pregnancy. Our patients were operated upon as early as the eighteenth week of gestation, and as late as the second postpartum day. One patient had pulmonary atelectasis, from which she recovered. No fetal distress was encountered. Premature labor did not occur. Gastric and duodenal complications There were no cases of perforated I>clenal or gastric ulcer. One patient
duwas
Volume Number
86 5
Nonobstetrical
admitted with profuse uncontrollable bleeding from a duodenal ulcer. Emergency subtotal gastrectomy was required, as multiple transfusions were of no avail. Cardiac arrest occurred, but prompt cardiac massage through a thoracotomy re-established cardiac rhythm. The fetus was stillborn. The patient recovered with all her mental faculties. One acute gastric dilatation was relieved by gastric suction. Three patients with active duodenal ulcer or duodenitis were successfully treated medically. Acute
pancreatitis
Acute pancreatitis was diagnosed 3 times. One severe attack occurring a few hours post partum with severe upper abdominal pain was interpreted as being due to a ruptured gall bladder. This patient was operated upon and unfortunately succumbed during operation to shock., possibly aggra\,ated by reaction to local anesthesia. Remembering the disease is the first step in diagnosis. Upper abdominal pain and tenderness varied from mild to severe, and shock was prominent in the severe attack. We agree that nonsurgical treatment is best.Gb i Two patients were treated medically with bland diets, rest, and anticholinergic drugs. Alcohol was avoided. In severe attacks, gastric suction, attention to electrolyte imbalance, relief of pain, and treatment of shock are necessary. We would consider operation only for those few who progress to necrosis and abscess formation.F Inasmuch as biliary disease is concomitant with pancreatitis in a considerable number of cases, roentgen examination of the biliary tract is advised post partum. Biliary
tract
abdominal
surgery
597
Medical management during pregnancy is advised unless attacks are recurrent or there is empyema or threatened rupture of the gall bladder, or common duct obstruction. Disease
of the spleen
There was one patient with acute upper abdominal pain with mononucleosis. This pain subsided on symptomatic therapy. Spontaneous rupture of the spleen has been reported in this disease.” There were no traumatic ruptures of the spleen or liver in this series. In the last 10 years, there have been no known admissions for idiopathic thrombocytopenic purpura. Intestinal
obstruction
One patient with a partial intestinal obstruction responded to gastric suction alone. Two patients were operated upon and obstructing adhesive bands excised. All 3 had had previous pelvic laparotomies; one patient had had three previous classical cesarean sections. These patients with intestinal obstruction ilhtstrate the necessity for careful peritonization, gentle handling in the abdominal cavity, avoidance of overheated laparotomy pads, and-the most frequently overlooked disadvantage of classical cesarean section-the frequency of omental and intestinal adhesions which ensue. If obstruction is complete, prompt relief is mandatory. Delay may result in gangrene and the necessity of bowel resection and a greater morbidity and mortality.g In neither of the patients operated upon was bowel resection necessary.
disease
Four patients were admitted with biliary tract dyskinesia. All attacks subsided with rest, low-fat diets, anticholinergic and painrelieving drugs. Diagnostic x-ray work-up was delayed until after pregnancy. One patient had a second attack of acute cholecystitis during the current pregnancycholecystectomy was performed without complication at 25 weeks’ gestation.
Carcinoma,
nongynecologic
There were 2 cases of carcinoma, one of the stomach and one of the sigmoid. The latter patient was a Japanese woman, 28 years of age. Both were treated with appropriate operation, the one with carcinoma of the sigmoid being operated on following delivery, which was imminent at the time of the diagnosis. It is surprising that we have
598
McCorriston
Am.
not seen more cases of carcinoma of the stomach during pregnancy, inasmuch as carcinoma of the stomach occurs approximately twice as frequently in the JapaneselO’ I1 who make up approximately one third of our population. A recent study in our city re\:caied that most of the cases of carcinoma of the stomach which occur under 35 years of age are in women,l” although usually it is predominant in older men. Trauma Though penetrating wounds or severe nonpenetrating trauma with suspected ruptured abdominal viscus may require abdominal exploration,13 none have occurred in the last 10 years in our hospital. Miscellaneous Only one uterine myomectomy (subserous) for uncontrollable pain was necessary during pregnancy. One indirect hernia of 2 months’ duration, increasingly painful, was repaired at 16 weeks’ gestation. One unilateral hydrosalpinx was excised. One case of severe intra-abdominal bleeding was unique in that thorough exploration by a qualified surgeon and a qualified obstetrician resulted in neither being able to find the bleeding point. Both the upper and lower parts of the abdomen were thoroughly investigated. Over 1,000 ml. of blood was found in the abdominal cavity. The patient recovertd.
Summary
and
July 1, 1963 J. Obst. & Cynec.
conclusion
At the Kapiolani Maternity and Gynecological Hospital, acute appendicitis was the most common abdominal surgical emergency during pregnancy. Prompt intervention on the establishment of the diagnosis was the most important factor in minimizing serious maternal consequences and fetal wastage. The proper selection, and localization of the incision and the positioning of the patient on the operating table were technically most helpful. Ovarian cystectomy and urinary tract complications were the next most common entities. In the case of ovarian tumor, careful visual and manual inspection of the contralateral ovary is most important. The results were equally good with and without the use of hormone therapy. The radioisotope renogram is a most helpful adjunct in following the passage of ureteral calculi, thus reducing the radiation rxposure to the mother and fetus. Some expectancy regarding passage of ureteral caIcuIi is permissible, even with total renal blockage, provided total blockage is not accompanied by infection. Necessary surgery can be performed if good anesthesia and the maintenance of adequate oxygenation of the mother and fetus throughout operation are maintained. Operation which is completely elective in most instances should be delayed until after the termination of pregnancy.
REFERENCES
I.
Bassett, .J. W: fI”R 19hl.
A&f.
J. OBST.
2. 3.
\Qeit, R. T.: Am. Surgeon
& GYNEC.
82:
26: 425, 1960. Hanusek, G. E.: AM. .I. OBST. & GYNEC. 82: 1312. 1961. i. Mr(.:;zrislon, (:. C.: Proc. Staff &feet. Clin., Honolulu 12: 206. 1946. ‘1. Kordyke. R. A.: J. Nuclear Med. 3:67, 1962. 6. Child, C. G., III, and Kahn, D. R.: J. A. Voryst
S.. Ullcry,
J. C., and
9. 10. 11. 12. 13.
Harer, W. B.? Jr.: Obst. & Gynec. 19: 11, 1962. Strode, J. E.: Surgery 49: 573, 1961. Strode, J. E.: Hawaii M. J. 10: 173, 1951. Tamura, P. Y., and Curt&s, C.: Cancer 13: 379, 1960. Dyer, I., and Barclay, D. L.: AM. J. OBST. & GYNEC. 83: 907, 1962.
M. A. 179: 363. 1962. 7 :i
Probst, Ii Hoagland. 1 P60.
F:.: Obst. & Gynec. R. J.: Am. J. M
18: 291, 1961. SC. 240: 21,
IO00 Ward Avenue Honolulu 14. Hawaii
Nonobstetrical
Discussion
I)K. CaaRLEs L.\NG.ZIAuE, Pasadena, California. We have had a series of 36 cases of acute appendicitis in pregnancy in our hospital. In the first series, 4 patients came into the hospital jvith ruptured appendices ant1 generalized peritonitis. The appendectomies were done, intcnsive antibiotic therapy carried out, and in this group we lost 3 infants soon after operation, and one mother. These patients all came into the hospital with good fetal hearr. tones, each went into labor 24 to 48 hours following operation, and NYU delivered‘of a stillborn infant. In a second series of similar size, with generalizecl peritonitis, the patients were treated by induction and delivery from. below following the appendectomy, or by transperitoneal cesarean section. This was a small series, and we lost no babies and no mothers. \Ve have all been advised by our colleagues at times to do appendectomies during pregnancy, either through McBurney or transverse incisions. We believe that Dr. McCorriston in using all types of incisions and adapting the incision to the problem used sound surgical judgment. We feel this is the reason that his results were SO good. All cases of upper abdominal pain in the pregnant or the nonpregnant patient should be studied by amylase and diastase determinations. Most cases of pancreatitis seen in pregnancy will be of the subacute edematous type. With certain stimuli, however, such as hypertonic glu-
abdominal
surgery
599
case solution, or abdominal exploration, we may convert the edematous type to the acute hemorrhagic irreversible type. The differential diagnosis between a ruptured gall bladder and pancrcatitis in a pregnant patient may be difficult. We would like to know whether the amylase studies in Dr. McCorriston’s particular patient were in some way misleading. The complete or partial ureteral block in the presence of pyelonephritis is difficult to diagnose. We all worry about the loss of a kidney with a complete block and the presence of infection. We feel Dr. McCorriston is very generous in referring to the renogram studies in this particular paper. Dr. McCorriston had no neglected cases of intestinal obstruction. When we study the symptoms of intestinal obstruction, we realize that all pregnant women have a certain amount of nausea and vomiting, some abdominal distention, some change in the bowel habits, and when we review films of the abdomen for intestinal obstruction during pregnancy, we find that 50 per cent of the films are not diagnostic. In spite of these difficulties, none of Dr. McCorriston’s patients required small bowel resection. Most acute perforated or bleeding gastric or duodenal ulcers occur in the patients with toxemia of pregnancy. The acute epigastric pain of the toxemic patient is, we feel, due to acute esophageal, gastric or duodenal erosions. In the acute burn cases, such as Curling described vears ago, we have the same type of ulcers.
abdominal surgery
during pregnancy C.
C.
Honolulu,
McCORRISTON,
M.D.
Hawaii
T H E purpose of this paper is to evaluate the nonobstetrical abdominal surgical procedures performed during pregnancy at the Kapiolani Maternity and Gynecological Hospital, Honolulu, during the IO-year period from 1952 to 1961. During the last 10 years, there were 42,510 deliveries of women of the many races which make up the population of our community. Of 83 pregnant women admitted with symptoms or signs suggesting the possibility of disease best treated surgically, 68 were operated upon. Table I shows the breakdown of the various diseases involved.
however, our observations confirm those of West,’ who noted that pain frequently began in the right flank area. Of 23 patients whose condition was correctly diagnosed, 4 were in the first, 11 in the second, and 8 in the third trimester of pregnancy. In the first trimester of pregnancy, maximum tenderness was usually in the region of McBurney’s point or nearby; in the second and third trimesters, usually above McBurney’s point in the right flank, frequently as high as the umbilicus. Two-thirds of the white blood cell counts were between 12,000 and 20,000, with polymorphonuclear percentages between 80 and 90. The temperature on admission was below 100’ F. in two thirds and between 100’ F. and 102’ F. in one third of these patients. Of the 32 operations, 21 were done under spinal anesthesia and 11 under general anesthesia. Intravenous muscle-relaxing drugs were also utilized. Varying incisions were chosen by the several operators (Table II). Of 8 operations performed with the preoperative diagnosis of appendicitis in the first trimester, a right paramedian incision was made in 4. In the middle or third trimesters, a midline hypogastric incision was not adequate for exposure of the appendix in 2 cases and resulted in the performance of additional surgical procedures, extensions of the wound, damage due to excessive traction with retractors, and unavoidable manipulation of the uterus. In both instances the cecal serosa was lacerated, and in one instance, in the third trimester, a T-shaped extension of the
Appendicitis The diagnosis of appendicitis was established in 23 (72 per cent) of 32 patients operated upon for appendicitis during pregnancy, an incidence of 0.05 per cent, which is comparable with that cited in previous l, 2 Careful history taking revealed reports. anorexia in all patients, and in most instances nausea with or without vomiting. In the first and second trimesters of pregnancy, pain usually began in the midumbilical area, but occasionally in the epigastrium, later progressing to the right lower quadrant or right flank. In the last trimester,
From the Department of Obstetrics and Gynecology, Straub Clinic and Kapiolani Maternity and Gynecological Hospital. Presented by inuitation at the Twenty-ninth Ann4 Meeting Pacific Coast Obstetrical and Gynecological Society, Portland, Oct. 3-6, 1962.
of the
Oregon,
593
594
July 1, 1963 Am. J. Obst. & Gynec.
McCorriston
Table I. Abdominal of pregnancy
surgical
complications
/
of
/ No. i
Appendicitis Ovarian cyst (one. malignant) Ureteral or renal disease Gastric and duodenal disease: Perforated ulcer Bleeding duodenal ulcer Active duodenal ulcer or duodenitis Biiiary tract disease : Biliary dyskinesia Acute cholecystitis l’ancreatitis Infectious mononucleosis with splenitis Iiydrosalpinx Uterine l&myoma (subserous) Intra-abdominal hemorrhage, cause undetermined Intestinal obstruction Trauma
Carcinoma
(nongynecological)
Stomach Si,moid
colon
EASES
1
No. operated UfiOTl
23 20 9
32 19 7
0 1
0 1
3
0
‘4 2
0 1
3
1
:
0 1 1
1 3 0
1 2 0
1 1
1 1
:
73
68
abdominal wound still did not permit adequate exposure of the appendix. The operator finally emptied the uterus by cesarean section to permit adequate visualization of the appendix. A high, muscle-splitting incision over the point of maximal tenderness c$as utilized in 17 of 24 patients operated upon in the second and third trimesters with the preoperative diagnosis of appendicitis. In each. exposure was adequatts. Experience at this hospital indicates that if the preoperative diagnosis of acute appendicitis is not a firm one? ;t right paramedian incision is best in that it can be easily c~stcndcti upward or downward, the initial incision bt,ing ma& with consideration of I!W maGmurn point of tenderness. In the i’irst trirricstrr it was the incision of choice, ;Jlordinq :tccess ICI both adncxa as well as to the iLppc'lLdiX. LVith a firm diagnosis of ;>ctltcb ;rppenclic,itic in the swrmd and third trimesters. w prefer a high rnusclc-splitting
incision centered over the point of maximal tenderness, usually at the level of the umbilicus and lateral to the right rectus muscle, which, because of the gestation, may be stretched rather widely laterally. To obtain the maximum benefts from this incision the patient, after anesthetization, is rolled over on the left side so that the right side is elevated approximately 30 degrees, her back supported in this manner. The frequency with which the operator comes right down and the avoidance of on the appendix, handling or packing off the uterus at all make this approach a desirable one. This proper positioning of the patient is the key to the best use of this incision. BIood pressure and cardiac output are also best maintained in the left lateral position.” ‘The postoperative course of 32 patients operated upon for appendicitis, in whom 23 cases of appendicitis were found, was essentially uneventful. The stump was buried in only 9 cases. Antibiotics were given postoperatively to half the patients. Those who did not receive them had an equally rapid recovery. There were no wound infections and no dehiscences. There was no apparent difference in the welfare of the patient whether or not hormones were used. The appendix had ruptured in 2 of the 23 cases of proved appendicitis. Each patient recovered uneventfully, treated with antibiotics, the correction of acidosis by intravenous feeding of electrolytes and dextrose, and gastric suction. Twenty-six of the 32 patients were ambulatory within 48 hours. Neither labor nor abortion ensued in any. We have felt that cesarean section should bc reserved for an obstetrical indication and that should cesarean section be necessary in the face of acute appendicitis, an extraperitoneal cesarean section is probably the method of choice unless there is lack of time because of fetal distress, in which instance a low-segment section is indicated. Ovarian
tumors
Nineteen precgnant patients, ranging in ase from 18 to 35 years, were operated upon for ot,arian cysts larger than 5 cm. in cliam-
Volume Number
86 5
rter (‘l’able III). No definite racial predominance was noted. Ovadan masses were discovered at prenatal clsamination without symptoms in 6, and 7 of the 20 patients complained of abdominal pain. In 3 instances, this pain was described as being very crampy in character. Two masses were discovered during labor, obstructing the descent of the presenting part. One cyst was found at the time of postpartum sterilization. In the absence of pain which may suggest hemorrhage or rupture or twist of an ovarian cyst, WC have followed the policy of watching the asymptomatic cyst until approsimatrly 14 to 16 lreeks’ gestation, allowing generous time for development of the placenta before sacrificing an ovary which may contain the corpus luteum of pregnancy. In spite of this policy it was necessary to operate upon 6 women in the first trimester. Seven were operated upon in the second trimester, 4 in the third, and 2 post partum after a full-term delivery (Table IV). There were no cases of postpartum acute torsion of the ovarian pedicle. Three patients were optarated upon with a final diagnosis of corpus luteal cyst; operations were done at 10, 16, and 19 weeks’ gestation. Seven cysts were benign teratomas, 2 of which were twisted, causing acute synlptoms. One was a serous cystoma, 3 were pseudomucinous cyst.adenomas, one of which had ruptured, and one was a pseudomutinous cystadenocarcinoma. We believe that both ovaries should be not only inspected but palpated, as a small invisible tumor may occasionally be felt in the contralateral ovary. In such a situation the ovary is split at its antimesenteric border and esplorrd. Routine splitting oi the contralateral o\xry is not practiced. Under these conditions no bilateral benign teratomas or cystadenomas were found. No solid tumors of t.he ovary were encountered. In one patient a large abdominal mass was found at 39 weeks’ gestation prior to labor, laparotomy was done, and a cyst excised. The patient was subsequently delivered through the birth canal.
Nonobstetrical
abdominal
surgery
595
Table II. Type
of incision in cases with diagnosis of appendicitis
preoperative
Midline hypogastric Right rectus-splitting retracting Usual McBurney High right flank muscle-splitting
~_--~( Ivt
Trimester -;-2nd
1
4
k 3
1 1
, I
a
3rd 1
or
0
I:!
5
Total
8
18
6
Table III. Types of ovarian
lesions
Benign
teratoma
7 (2 twisted, symptoms)
Benign serous cystadenoma Benign pseudomucinous cystadenoma Pseudomucinous cystadenocarcinoma Corpus luteal cyst
acute
1 3 1 (one ruptured) 4 (operated on at 10. 16, and 19 weeks’ gestation; one not operated on) 2 (one bilateral) 1
Endometrioma Infarct of ovary “Hypertrophy” of ovary
1
Total
20
TabIe IV. Week ovarian
of gestation
in cases of
disease W-epk
8th 10th 11th
‘,
16th 17th 19th 21 st “2nd 26th
7 I 1 I -. 1 7 1 (post partum) 3 (all 3 cesarean
Sttb 39th
section)
4 Full
term,
No -.
operation
post
partum
2 ( 1 carcinoma, 1 teratoma) 1 __--..~ _-
-----
596
July 1, 1963 Am. J. Obst. & Gynec.
McCorriston
Transverse cervical cesarean sections were performed in 2 cases of obstructed labor and the cystic masses removed at the same time. Careful prenatal examination and earlier surgical action might well have made these cesarean sections unnecessary. At the time of any cesarean section the adnexa are inspectrd and the posterior surface of the llwrus and both ovaries palpated. In ov(hr half of the patients no hormone medication was used. In this study there was MI apparent difference between the use and nonusc of hormone medication, though adequate doses of parentera progesterone might hi helpful in the first 3 months of gestation, lest placental hormone production lag. In the case of benign cystic teratoma or c~ndomctrioma, e\.en if largr, a certain amount of normal ovarian tissue can usually 1~ ltrcatc~d in the wall and preserved for purposes of well-being, delay of the menopusc‘, and future childbearing.” This was tlonc except in the 2 cases of acute torsion of the ovary in which the adnexa involved v.x’re excised. Postoperati\,t: complications were limited I0 one case of acute postoperative pyelonc$lritis and one superficial wound abscess \vith ccta,sulasr-positive Stap~~.$ococcus au~c’~r. phage type 80-81, in 1958. None of the group went into premature labor following opr~ration. Urinary
tract
complications
Nine women had urinary complications whic11 rni,ght havr required. or did require, operation. Of these, 6 had renal or ureteral calc111i. In one of these. there was a. suspicion of possible hyperparathyroidism. ‘I’hrrp nephrectomirs were done, one for a Inrye hydronephrosis. one for renal carbuncle. and onrh for a chronic Proteus inf<,ctian in :j nonfunctioning kidntby,
where indicated. Before operation on either kidney, the function of the contralateral kidney was evaluated. A series of renograms done at intervals of 2 or 3 days with I131-tagged iodohippurate sodium (Hippuran) 5 has been most helpful, particularly in following pregnant patients with partial or complete renal block, for this procedure can be done repeatedly with a minimum of radiation effect to the fetus and to the ovaries. When the urinary tract is not infected, when pain can be controlled, and when a urcteral calculus is small, we have waited a reasonable length of time, hoping that this calculus will pass or descend to a level where it can be removed through cystoscopic manipulation. Provided there is no infection, the kidney, even if completely blocked, will not die if the complete block does not exceed 2 weeks. Following this policy, two of four calculi passed spontaneously and two were removed by ureterolithotomy. On the other hand, if the urine is infected and if renal block is complete, renal drainage must be instituted promptly by lithotomy or renal pyelotomy lest a serious infection or kidney destruction result. One ureterolithotomy was done in this category and one where there was no compIete renal block but persistent infection accompanied an immobile ureteral calculus. .411 urine was strained to obtain any passed c-alculus for chemical examination. The patients were investigated for the possibility of specific metabolic disease causing calculi, such as hyperparathyroidism and gout. Though the incidence of gout is extremely high in Filipino men, we have seen no gouty calculi in Filipino women in pregnancy. Our patients were operated upon as early as the eighteenth week of gestation, and as late as the second postpartum day. One patient had pulmonary atelectasis, from which she recovered. No fetal distress was encountered. Premature labor did not occur. Gastric and duodenal complications There were no cases of perforated I>clenal or gastric ulcer. One patient
duwas
Volume Number
86 5
Nonobstetrical
admitted with profuse uncontrollable bleeding from a duodenal ulcer. Emergency subtotal gastrectomy was required, as multiple transfusions were of no avail. Cardiac arrest occurred, but prompt cardiac massage through a thoracotomy re-established cardiac rhythm. The fetus was stillborn. The patient recovered with all her mental faculties. One acute gastric dilatation was relieved by gastric suction. Three patients with active duodenal ulcer or duodenitis were successfully treated medically. Acute
pancreatitis
Acute pancreatitis was diagnosed 3 times. One severe attack occurring a few hours post partum with severe upper abdominal pain was interpreted as being due to a ruptured gall bladder. This patient was operated upon and unfortunately succumbed during operation to shock., possibly aggra\,ated by reaction to local anesthesia. Remembering the disease is the first step in diagnosis. Upper abdominal pain and tenderness varied from mild to severe, and shock was prominent in the severe attack. We agree that nonsurgical treatment is best.Gb i Two patients were treated medically with bland diets, rest, and anticholinergic drugs. Alcohol was avoided. In severe attacks, gastric suction, attention to electrolyte imbalance, relief of pain, and treatment of shock are necessary. We would consider operation only for those few who progress to necrosis and abscess formation.F Inasmuch as biliary disease is concomitant with pancreatitis in a considerable number of cases, roentgen examination of the biliary tract is advised post partum. Biliary
tract
abdominal
surgery
597
Medical management during pregnancy is advised unless attacks are recurrent or there is empyema or threatened rupture of the gall bladder, or common duct obstruction. Disease
of the spleen
There was one patient with acute upper abdominal pain with mononucleosis. This pain subsided on symptomatic therapy. Spontaneous rupture of the spleen has been reported in this disease.” There were no traumatic ruptures of the spleen or liver in this series. In the last 10 years, there have been no known admissions for idiopathic thrombocytopenic purpura. Intestinal
obstruction
One patient with a partial intestinal obstruction responded to gastric suction alone. Two patients were operated upon and obstructing adhesive bands excised. All 3 had had previous pelvic laparotomies; one patient had had three previous classical cesarean sections. These patients with intestinal obstruction ilhtstrate the necessity for careful peritonization, gentle handling in the abdominal cavity, avoidance of overheated laparotomy pads, and-the most frequently overlooked disadvantage of classical cesarean section-the frequency of omental and intestinal adhesions which ensue. If obstruction is complete, prompt relief is mandatory. Delay may result in gangrene and the necessity of bowel resection and a greater morbidity and mortality.g In neither of the patients operated upon was bowel resection necessary.
disease
Four patients were admitted with biliary tract dyskinesia. All attacks subsided with rest, low-fat diets, anticholinergic and painrelieving drugs. Diagnostic x-ray work-up was delayed until after pregnancy. One patient had a second attack of acute cholecystitis during the current pregnancycholecystectomy was performed without complication at 25 weeks’ gestation.
Carcinoma,
nongynecologic
There were 2 cases of carcinoma, one of the stomach and one of the sigmoid. The latter patient was a Japanese woman, 28 years of age. Both were treated with appropriate operation, the one with carcinoma of the sigmoid being operated on following delivery, which was imminent at the time of the diagnosis. It is surprising that we have
598
McCorriston
Am.
not seen more cases of carcinoma of the stomach during pregnancy, inasmuch as carcinoma of the stomach occurs approximately twice as frequently in the JapaneselO’ I1 who make up approximately one third of our population. A recent study in our city re\:caied that most of the cases of carcinoma of the stomach which occur under 35 years of age are in women,l” although usually it is predominant in older men. Trauma Though penetrating wounds or severe nonpenetrating trauma with suspected ruptured abdominal viscus may require abdominal exploration,13 none have occurred in the last 10 years in our hospital. Miscellaneous Only one uterine myomectomy (subserous) for uncontrollable pain was necessary during pregnancy. One indirect hernia of 2 months’ duration, increasingly painful, was repaired at 16 weeks’ gestation. One unilateral hydrosalpinx was excised. One case of severe intra-abdominal bleeding was unique in that thorough exploration by a qualified surgeon and a qualified obstetrician resulted in neither being able to find the bleeding point. Both the upper and lower parts of the abdomen were thoroughly investigated. Over 1,000 ml. of blood was found in the abdominal cavity. The patient recovertd.
Summary
and
July 1, 1963 J. Obst. & Cynec.
conclusion
At the Kapiolani Maternity and Gynecological Hospital, acute appendicitis was the most common abdominal surgical emergency during pregnancy. Prompt intervention on the establishment of the diagnosis was the most important factor in minimizing serious maternal consequences and fetal wastage. The proper selection, and localization of the incision and the positioning of the patient on the operating table were technically most helpful. Ovarian cystectomy and urinary tract complications were the next most common entities. In the case of ovarian tumor, careful visual and manual inspection of the contralateral ovary is most important. The results were equally good with and without the use of hormone therapy. The radioisotope renogram is a most helpful adjunct in following the passage of ureteral calculi, thus reducing the radiation rxposure to the mother and fetus. Some expectancy regarding passage of ureteral caIcuIi is permissible, even with total renal blockage, provided total blockage is not accompanied by infection. Necessary surgery can be performed if good anesthesia and the maintenance of adequate oxygenation of the mother and fetus throughout operation are maintained. Operation which is completely elective in most instances should be delayed until after the termination of pregnancy.
REFERENCES
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Bassett, .J. W: fI”R 19hl.
A&f.
J. OBST.
2. 3.
\Qeit, R. T.: Am. Surgeon
& GYNEC.
82:
26: 425, 1960. Hanusek, G. E.: AM. .I. OBST. & GYNEC. 82: 1312. 1961. i. Mr(.:;zrislon, (:. C.: Proc. Staff &feet. Clin., Honolulu 12: 206. 1946. ‘1. Kordyke. R. A.: J. Nuclear Med. 3:67, 1962. 6. Child, C. G., III, and Kahn, D. R.: J. A. Voryst
S.. Ullcry,
J. C., and
9. 10. 11. 12. 13.
Harer, W. B.? Jr.: Obst. & Gynec. 19: 11, 1962. Strode, J. E.: Surgery 49: 573, 1961. Strode, J. E.: Hawaii M. J. 10: 173, 1951. Tamura, P. Y., and Curt&s, C.: Cancer 13: 379, 1960. Dyer, I., and Barclay, D. L.: AM. J. OBST. & GYNEC. 83: 907, 1962.
M. A. 179: 363. 1962. 7 :i
Probst, Ii Hoagland. 1 P60.
F:.: Obst. & Gynec. R. J.: Am. J. M
18: 291, 1961. SC. 240: 21,
IO00 Ward Avenue Honolulu 14. Hawaii
Nonobstetrical
Discussion
I)K. CaaRLEs L.\NG.ZIAuE, Pasadena, California. We have had a series of 36 cases of acute appendicitis in pregnancy in our hospital. In the first series, 4 patients came into the hospital jvith ruptured appendices ant1 generalized peritonitis. The appendectomies were done, intcnsive antibiotic therapy carried out, and in this group we lost 3 infants soon after operation, and one mother. These patients all came into the hospital with good fetal hearr. tones, each went into labor 24 to 48 hours following operation, and NYU delivered‘of a stillborn infant. In a second series of similar size, with generalizecl peritonitis, the patients were treated by induction and delivery from. below following the appendectomy, or by transperitoneal cesarean section. This was a small series, and we lost no babies and no mothers. \Ve have all been advised by our colleagues at times to do appendectomies during pregnancy, either through McBurney or transverse incisions. We believe that Dr. McCorriston in using all types of incisions and adapting the incision to the problem used sound surgical judgment. We feel this is the reason that his results were SO good. All cases of upper abdominal pain in the pregnant or the nonpregnant patient should be studied by amylase and diastase determinations. Most cases of pancreatitis seen in pregnancy will be of the subacute edematous type. With certain stimuli, however, such as hypertonic glu-
abdominal
surgery
599
case solution, or abdominal exploration, we may convert the edematous type to the acute hemorrhagic irreversible type. The differential diagnosis between a ruptured gall bladder and pancrcatitis in a pregnant patient may be difficult. We would like to know whether the amylase studies in Dr. McCorriston’s particular patient were in some way misleading. The complete or partial ureteral block in the presence of pyelonephritis is difficult to diagnose. We all worry about the loss of a kidney with a complete block and the presence of infection. We feel Dr. McCorriston is very generous in referring to the renogram studies in this particular paper. Dr. McCorriston had no neglected cases of intestinal obstruction. When we study the symptoms of intestinal obstruction, we realize that all pregnant women have a certain amount of nausea and vomiting, some abdominal distention, some change in the bowel habits, and when we review films of the abdomen for intestinal obstruction during pregnancy, we find that 50 per cent of the films are not diagnostic. In spite of these difficulties, none of Dr. McCorriston’s patients required small bowel resection. Most acute perforated or bleeding gastric or duodenal ulcers occur in the patients with toxemia of pregnancy. The acute epigastric pain of the toxemic patient is, we feel, due to acute esophageal, gastric or duodenal erosions. In the acute burn cases, such as Curling described vears ago, we have the same type of ulcers.