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Acute Surgical Abdomen
In Pregnancy
Pregnancy presents a high risk period in the reproductive life of the
female. It may be associated with complications such as ectopic
pregnancy, placental abruption, twisted ovarian cyst and red fibroid
degeneration. In addition to physiological changes, a variety of
acute surgical conditions such as appendicitis cholecystitis, pancreatitis
and intestinal obstruction could also occur during pregnancy.
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The pathology of an acute abdomen may be considered in three main
categories:
I. Inflammation.
II. Obstruction.
III. Haemorrhage.
Features of one or more of these categories may be present simultaneously.
The clinical presentation depends on the type or types of intra-abdominal
pathology.
The early symptoms of an acute abdomen could resemble the common
symptoms of early pregnancy. This is commonly attributed to the
anatomical and physiological changes of pregnancy that lead to
modification of the usual presentation of signs and symptoms.
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Another matter that complicates the management is the special
attention, which has to be paid to the fetal well-being. Therefore,
delays in diagnosis and management of acute abdomen in pregnancy
are common and continue to pose a significant risk to both mother and
fetus.
The management of acute abdomen in pregnancy could only be
achieved by close collaboration between surgeons and obstetricians to
reduce maternal morbidity and fetal loss. Surgical problems in pregnancy
are relatively less common. Appendicitis is the most common
extrauterine acute abdominal condition in pregnancy.It is the most
common non-obstetric cause of emergency surgery during pregnancy.
The delayed presentation with early non-specific symptoms of
appendicitis is often because of the pregnancy, causing change of
location of the appendix. In the second and third trimester during
pregnancy the caecum and appendix are progressively pushed to the
right upper abdominal quadrant. This displacement of the appendix
could cause right flank or back pain and may be confused with
pyelonephritis. Lower abdominal pain could be confused with torsion
of an ovarian cyst. Gangrenous appendicitis is common in pregnancy
as a result of an increased pelvic vascularity and higher risk of
appendiceal strangulation
The interference with omental migration by the gravid uterus may
explain the higher rate of perforation (2-3 times higher than usual).
Foetal loss occurs in 3-5 per cent of cases of acute appendicitis and
increases to 20-30 per cent if perforation of the appendicitis is found.
The separation of abdominal viscera from the abdominal wall by the
gravid uterus precludes some vital clinical and diagnostic signs and
contributes to further delays in diagnosis and management with higher
rate of foetal and maternal morbidity and foetal loss.
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Biliary tract diseases are the second most frequent intra-abdominal
inflammatory conditions during pregnancy.
Biliary stasis - caused by the gravid uterus – is common resulting in
gallstone formation in 3-4 % of pregnant women with fortunately less
gallstone related complications.
There are commonly slight alterations of the physiological values in
the blood during pregnancy. Such changes could create difficulties
during the initial evaluation process. An example for that is a high
leucocytosis (16.000-20.000 / mm3), during pregnancy, this may be
mistaken for an inflammatory condition such as appendicitis. Radiological
investigations are sometimes needed in emergency clinical situations
such as intestinal obstruction or perforation during pregnancy. It is
newly well accepted that one or two abdominal radiographs in emergency
conditions during pregnancy have no harmful foetal effects.
Ultrasonography is today by far the most used imaging technique for
diagnostic and follow up of a pregnant abdomen. Ultrasound imaging
helps in evaluating the maternal intra-abdominal organs, and allows
the evaluation and assessment of fetal viability and gestational age.
Magnetic resonance imaging (MRI) is considered safe during
pregnancy, but it must be avoided in the first trimester.
Acute abdomen during pregnancy presents a grate challenge to the
practicing surgeon with sometimes unpredictable consequences. Delayed
laparotomy could increase the risks of peritonitis with high rates of
maternal morbidity and fetal loss. In the same time early surgical
intervention may cause uterine contractions and could lead to abortion.
The idea of the use of tocolytics to calm the uterus was advocated, but
these tocolytics are of doubtful benefits and have serious side effects.
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Therefore tocolytics should be used with great caution and in selected
cases.
There is now a general consensus that early surgery is associated with
less abortions and preterm labors, and therefore, is emerging as the
treatment of choice for acute abdomen during pregnancy. And
accordingly the decision and timing of surgery is widely discussed.
While the rate of miscarriage is high in the first trimester, preterm
labor is common in the third trimester but without fetal loss. It is
established nowadays that the second trimester is the safest period for
any surgical intervention during pregnancy.
Recently laparoscopy has been developed and carried out in diagnosis
and management of acute abdomen. Laparoscopy today has many
advantages in pregnancy over laparotomy. It is very important that an
experienced laparoscopic surgeon should carry out the procedure to
avoid complications and to keep operation time as short as possible.
The manipulation of the uterus is kept to the minimum and fetal heart
is monitored during the operation. Laparoscopy is recommended and
indicated in the second trimester as the safest period to achieve good
maternal and fetal outcome. Laparoscopy is even successfully used in
the third trimester in special indications.
One of the possible complications of laparoscopy during pregnancy is
the injury of the gravid uterus and the following fetal loss. It is very
important to take all needed precautions during laparoscopy. It is advisable
to use the open technique for induction of pneumoperitoneum to avoid
trocar injury to uterus and fetus, and to adjust the location for trocar
placement according to the uterine size. For not urgent surgical
conditions that present in the first trimester, surgery may be delayed
until the second trimester and for those conditions in the third
trimester, surgery could be deferred, if possible, until after delivery.
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Years ago and in the initial period of laparoscopy, this was not carried
out during pregnancy and in acute abdomen. Pregnancy was considered
as an absolute contraindication for laparoscopy. Maternal morbidity
and poor fetal outcome are mostly related to the underlying pathology
and usually not to the operative procedure per se. The safest time for
laparoscopy is the second trimester. Laparoscopy becomes a good and
sufficient operative procedure and as a diagnostic and therapeutic
option for acute abdomen in pregnancy and it could be carried out
even in the third trimester if certain precautions are taken.
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Hernias of the Abdominal Wall
A hernia of the abdominal wall is a protrusion of the abdominal
contents through an acquired or congenital area of weakness or defect
in the wall. Many hernias are asymptomatic, but some become
incarcerated or strangulated, causing pain and requiring immediate
operation. Diagnosis is clinical. Treatment is elective surgical repair
or urgent in strangulated or incarcerated cases. The basic features of
all hernias are:
1. Hernia occurs at a weak point in the anterior abdominal wall.
2. Hernia reduces on lying down or with direct pressure, reducibility.
3. Hernia has expansile cough impulse (if negative does not exclude
hernia).
Abdominal hernias are extremely common, particularly in males.
Etiology:
1. Anatomical weakness in the anterior abdominal wall:
a. Where it is pierced with structure passing through it, like the
spermatic cord in the inguinal canal.
b. Muscles fail to overlap, like in linea alba
c. There is no muscle but only scar tissue like in thumbilicus
2. Acquired weakness following trauma, surgical scares
3. High intra abdominal pressure from:
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a. coughing
b. straining: chronic constipation, prostatic enlargement
c. abdominal distension: pregnancy, tumours, ascites
Composition of a hernia:
It consists of sac, covering, and the content of the sac.
1. The sac is diverticulum of the peritoneum and consisting of mouth,
neck, body, and fundus. The diameter of the neck is important
because strangulation of bowel is more likely to occur when the
neck is narrow as in femoral hernia. The body of the sac varies in
size according to the size of the hernia,
2. The covering: Is derived from the anterior abdominal wall though
which the sac passed, it becomes atrophied, may be ulcerated in
long standing hernia.
3. Contents: can be
a. omentum: omentocele.
b. Intestine: commonly the small bowel, enterocele.
c. Portion of the circumference of the bowel: Richter’s hernia.
d. Portion of the urinary bladder or sigmoid colon or the caecum,
which may form part of the wall of the sac, sliding hernia
e. The ovary with or without the tube. f. Meckle`s diverticulum,
Littre`s hernia. g. Fluid: as part of ascitis
Classification of hernias.
Tow classifications are commonly used.
A. Abdominal hernias are classified as either abdominal wall or
groin (inguinal) hernias.
I. Abdominal wall hernias include. umbilical hernias,. epigastric hernias,
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Spigelian hernias, and incisional (ventral) hernias. Umbilical hernias
(protrusions through the umbilical ring) are mostly congenital, but
some are acquired in adulthood secondary to obesity, ascites,
pregnancy, or chronic peritoneal dialysis. Epigastric hernias occur
through the linea alba. Spigelian hernias occur through defects in
the transversus abdominis muscle lateral to the rectus sheath,
usually below the level of the umbilicus. Incisional hernias occur
through an incision from previous abdominal surgery.
II. Groin hernias include inguinal hernias and femoral hernias.
Inguinal hernias occur above the inguinal ligament. Indirect
inguinal hernias traverse the internal inguinal ring into the inguinal
canal, and direct inguinal hernias extend directly forward and do
not pass through the inguinal canal.
Left Inguinal (scrotal) hernia
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