**4.5 Pregnant patients**

Acute appendicitis is the most common cause of nonobstetric acute abdomen during pregnancy. Some investigators report that the incidence is identical to that of the nonpregnant population, while others suggest that it is less, with the third trimester being particularly protective (Anderson & Lambe, 2001). Non the less, a perforation of the appendix is reported to occur twice as often in the third trimester (69%) compared with the first two (Weingold, 1983). The role of laparoscopic appendectomy during pregnancy remains controversial. Laparoscopy for suspected appendicitis is considered to have less complications and a higher diagnostic value compared to the open procedure. The ongoing debate is whether the laparoscopic procedure leads to a higher percentage of fetal loss as is reported in a systematic review from the UK (Walsh et al., 2008) or not, as is stated in a review from the United States (Jackson et al., 2008). More recent studies consider the laparoscopic approach to be safe and effective with a low rate of complications for the mother and the fetus (Corneille et al., 2010; Jeing et al., 2011; Kirshtein et al., 2009; Lemieux et al, 2009; Machado et al., 2009; Moreno-Sanz, 2007; Sadot et al.). It has to be stated that long-term consequences of the pneumoperitoneum for the fetus have not yet been studied. Also, one should stress the importance of a very good diagnostic work-up in order to avoid

In the literature it is suggested that overweight patients seem to profit from laparoscopic appendectomy in terms of postoperative pain, postoperative recovery (Enochson et al., 2001), and septic wound complication rate (Stolzing et al., 2000, Corneille et al., 2007). In a more recent comparative study no significant differences in terms of complications were found between the two groups (Clarke et al., 2011). We did not perform a separate analysis

Employed patients profit from laparoscopic appendectomy as it is superior to open appendectomy in terms of return to normal activities and full activity (Sauerland et al, 2010).

Elderly patients have more overall complications after conventional appendectomy (especially regarding pulmonary function impairment and return to normal activities), and seem to benefit from laparoscopic appendectomy (Agresta et al., 2011; Guller et al, 2004;

**Patient Population Level of Evidence** 

Women of childbearing age LOE Ia Employed Patients LOE Ia Elderly Patients LOE IIb Obese Patients LOE III Men LOE III

Table 1. Adult patient subpopulations that profit from laparoscopic appendectomy

Acute appendicitis is the most common cause of nonobstetric acute abdomen during pregnancy. Some investigators report that the incidence is identical to that of the nonpregnant population, while others suggest that it is less, with the third trimester being particularly protective (Anderson & Lambe, 2001). Non the less, a perforation of the appendix is reported to occur twice as often in the third trimester (69%) compared with the first two (Weingold, 1983). The role of laparoscopic appendectomy during pregnancy remains controversial. Laparoscopy for suspected appendicitis is considered to have less complications and a higher diagnostic value compared to the open procedure. The ongoing debate is whether the laparoscopic procedure leads to a higher percentage of fetal loss as is reported in a systematic review from the UK (Walsh et al., 2008) or not, as is stated in a review from the United States (Jackson et al., 2008). More recent studies consider the laparoscopic approach to be safe and effective with a low rate of complications for the mother and the fetus (Corneille et al., 2010; Jeing et al., 2011; Kirshtein et al., 2009; Lemieux et al, 2009; Machado et al., 2009; Moreno-Sanz, 2007; Sadot et al.). It has to be stated that long-term consequences of the pneumoperitoneum for the fetus have not yet been studied. Also, one should stress the importance of a very good diagnostic work-up in order to avoid

**4.2 Obese patients** 

on overweight patients.

**4.3 Employed patients** 

**4.4 Elderly patients** 

**4.5 Pregnant patients** 

Kim et al., 2011; Yeh et al. 2011).

unnecessary procedures without missing pathologic conditions. Walsh et al. report that the negative appendectomy rate in their series was 27%, which is higher than in the nonpregnant population. Regarding the diagnostic tools it has been reported that the sensitivity of ultrasound is inversely correlated to the gestational age, while CT scan retains a high sensitivity and specificity throughout pregnancy. It seems reasonable to perform an ultrasound first, in order to exclude an obstetric pathology, and to proceed with a CT if necessary (Butala, 2010).
