A 25-year-old woman, gravida I, in the 24th week of gestation was admitted to the emergency room due to severe right lower quadrant (RLQ) abdominal pain coinciding with nausea and vomiting. She was afebrile (36.7 C) and had urinary frequency without dysuria. The patient had no uterine contractions, vaginal bleeding, or any bowel symptoms. Stool passage was normal before the episode. The uterine height was difficult to measure due to the patient's obesity (body weight 90 Kg). Tenderness with mild rebounding pain was found on palpation of the RLQ area of the abdomen. Deep palpation on this side provoked muscle guarding. The vaginal examination showed normal cervical status. Abdominal sonography was consistent with a 24-week pregnancy without placenta or uterine abnormalities. The fetus was normal and within a 50% growth curve. No bowel dilatation or ascites were seen. The left adnexa were normal, and a right ovarian cyst measuring 6 cm in diameter was detected. The white blood cell count was slightly elevated (12 900/mm3) and showed a shift to left phenomenon (segment 85%). C-reactive protein and an ionogram were within normal limits. Urine analysis revealed bacteriuria but with a negative culture. Because adnexal torsion and appendicitis could not be diagnosed with any certainty, it was initially decided to treat the patient with supportive care. However, 24 hours later, the pain had increased. Laparoscopic exploration with possible corrective surgery was recommended. The patient was well informed of the risks of surgery, the possible need for laparotomy, and the risk of preterm labor postoperatively.
While under general endotracheal anesthesia, the patient was placed in the Trendelenburg position, and the operating table was left tilted. A Foley catheter was inserted preoperatively to enable continuous monitoring of urine output during the operation. The Veress needle with a 2-mm cannula was inserted between the xiphoid process and uterine fundus under sonographic guidance to avoid uterine injury (Figure 1). Pneumoperitoneum was created by insufflation with carbon dioxide (CO2) at a maximum intraabdominal pressure of 12 mm Hg. A 1.98-mm fiberoptic microlaparoscope (US Imagyn Laguna Niquel, California) with an attached camera was inserted through the cannula to visualize the intraabdominal organs.
Laparoscopy revealed a right ovarian cyst measuring 6 cm without torsion (Figure 2), and a slightly edematous appendix. Periappendicitis coincidental to the right ovarian tumor was diagnosed. Two 5-mm trocars were introduced under visual control, one at the left upper quadrant, and the other at the opposite site. Then the 1.98-mm microlaparoscope was replaced by a 5-mm minilaparoscope followed by wedge resection of the right ovarian cyst and appendectomy with 2 Endoloop sutures (US Ethicon, Cincinnati, Ohio). An Endobag (US Ethicon, Cincinnati, Ohio) was used to contain the appendix and ovarian cyst before removal. Monitoring of the fetal heartbeat with transvaginal sonography was carried out during the entire procedure. The operation took approximately 70 minutes and was tolerated well by the patient. Pathologic examination of the excised specimen revealed a simple serous cyst and infiltration of inflammatory cells on the serous layer of the appendix.
After the operation, the patient received Cefamezine 1 gram every 8 hours for 3 doses. Uterine contractions were noted on postoperative day 2. Tocolysis with ritodrine were administered parenterally, and the doses were adjusted depending on the severity of uterine contractility. Ritodrine was stopped on postoperative day 14, and the patient was discharged on the fifteenth postoperative day. At 41 weeks of gestation, an apparently healthy female baby was born via Cesarean delivery due to induction failure. The weight of the newborn was 3300 grams, and Apgar scores were 9 and 10 at 1 and 5 minutes. The postpartum period was uneventful.