**5. Laparoscopy in abdominal sepsis due to affections of the small bowel (mesenteric ischemia, intestinal obstruction and incarcerated hernias)**

 Peritonitis secondary to obstruction or ischemia of the small bowel is infrequent. According to the most recent consensus about obstructive intestinal processes, conservative treatment may be maintained for up to 72 hours as long as there is no evidence of strangulation or incarceration. After 3 days of expectant treatment, whether or not these signs are present, surgical exploration is obligatory (Catena et al., 2011).

Some evidence supports the use of the laparoscopic route in the lysis of abdominal adhesions and in the treatment of incarcerated hernias before the onset of necrosis and perforation of the intestinal loops. After the occurrence of these events, most authors recommend surgery by laparotomy (Saeurland et al., 2006).

The lysis of adhesions by laparotomy, the universally accepted route of access for this situation, leads to the later formation of new adhesions, to recurrent intestinal obstruction and to a new laparotomy in 10 to 30% of cases (Landercasper et al., 1993).

In animal models, laparoscopy showed a lower incidence and a smaller number of adhesions, as well as a less severe obstructive situation compared to open surgery. Thus, the laparoscopic approach, when viable, can be considered to prevent obstruction due to adhesions (Tittel et al., 2001). Other clinical and experimental studies have also shown

Laparoscopic Approach to Abdominal Sepsis 231

costs. The indications of DL include the suspicion of intra-abdominal injury maintained after an initial negative workup in closed traumas, stab wounds with proven or possible penetration of the cavity, gun-shot wounds with a possible intra-abdominal course, a diagnosis of diaphragm perforation in penetrating wounds of the thoraco-abdominal region, and the creation of a pericardiac transdiaphragmatic window to rule out heart injury

Absolute contraindications of DL are hemodynamic instability due to hemorrhagic shock or evisceration, and the relative contraindications include peritonitis, known or obvious intraabdominal injury, posterior penetrating trauma with a high probability of intestinal injury and, of course, the lack of experienced professionals and of appropriate equipment

The accuracy of DL in defining the need for laparotomy ranges from 75 to 100%. In a review, DL prevented non-therapeutic laparotomy in 17 to 89% (median: 57%) of traumatized patients. The procedure involved a 6% rate of false-positive results (0-44%). In addition to providing an etiologic diagnosis, laparoscopy permits the appropriate treatment of

A review of 37 studies including more than 1900 patients revealed a rate of DL complication of 1% (Villavicencio & Aucar, 1999). More recent reviews have revealed even lower rates close to zero. Intraoperative complications may occur during the creation of the pneumoperitoneum, the introduction of trochars, the occurrence of pneumothorax during inspection due to an unidentified diaphragmatic injury, during the perforation of hollow viscera, the laceration of solid viscera, during gas dissection in the subcutaneous layer of the peritoneum and vascular injuries (more frequently of the epigastric or epiploic arteries)

**8. Laparoscopy in the perforation of diverticular disease of the colon** 

Perforation of diverticular colon disease, generally in the sigmoid colon, with localized contamination of the abdominal cavity can be treated with antibiotics during the early stages, but abscesses larger than 5 cm must be approached surgically. Sigmoidectomy is indicated in patients who have suffered at least 2 crises of diverticulitis and in patients younger than 50 years who have suffered only one episode (Saeurland et al.,2006). Even within an urgency context, this surgery can be performed by the laparoscopic route with a surgical time and results comparable to those of laparotomy and has been performed with a

Over the last few years, there has been an increased use of peritoneal washing and drainage of the cavity by the laparoscopic route without resection, allied to antibiotic treatment during the episode of peritonitis secondary to diverticular perforation. Definite treatment by colectomy can be performed in an elective manner after the resolution of the inflammatory

In a systematic literature review of 231 cases of acute diverticulitis with purulent peritonitis treated in this manner, abdominal sepsis was effectively controlled in 95.7% of the patients. Mortality was 1.7%, morbidity was 10.4% and 1.7% of the patients required a stoma. A long recurrence-free period of time was observed in the patients not subjected to colon resection, and later elective resection of the segment involved by the laparoscopic route was possible

(Stefanidis et al., 2009).

(Stefanidis et al., 2009).

(Hori, 2008).

intracavity injuries in up to 83% of cases (Hori, 2008).

conversion rate of 10% (Tonelli et al., 2009).

in most cases (Toorenvliet et al., 2010).

process (Saeurland et al., 2006; Tonelli et al., 2009).

evidence of a lesser formation of adhesions at the surgical site and on the abdominal wall when laparoscopy is used (Gadallah et al., 2001; Gamal et al., 2001).

The lysis of adhesions by the laparoscopic route has several theoretical advantages over open surgery: 1) less intense postoperative pain, 2) more rapid resolution of the ileum, 3) shorter hospitalization, 4) earlier return to daily activities, 5) lower incidence of complications of the surgical wound, and 6) a reduced formation of postoperative adhesions (Nagle et al., 2004). However, no randomized and controlled studies comparing adhesion lysis by the laparoscopic and open route were detected. Thus, the indications and the results of the less invasive procedure continue to be unclear (Catena et al., 2011).

Today laparoscopy should be reserved for well selected cases, with the use of an open technique for the initiation of pneumoperitoneum, preferentially in the upper left quadrant of the abdomen. It is preferable to use it in case of a first obstructive episode and also when a single or a few adhesions are predicted (for example, when the previous surgery was an appendectomy). A high rate of conversion is expected and the risk of damage to bowel is higher compared to surgery by laparotomy. Findings of a bowel segment larger than 4 cm, of multiple adhesions and of findings compatible with malignant neoplasias supports the option for conversion (Catena et al., 2011).

The extent of release of adhesions is a matter of debate and divides the opinion of authors between the option for lysis of all adhesions in the cavity in an attempt to prevent a new obstructive event or sufficient release for the resolution of obstruction (Scott-Coombes et al., 2003).

Treatment of abdominal wall hernias by laparoscopy has progressed considerably over the last decades and in general this is considered to be the access route of choice in an elective situation. However, it is not possible to transfer the knowledge acquired with this practice to urgency situations such as incarceration, strangulation and bowel injury with contamination of the cavity and infection. There are isolated reports of favorable results for properly selected cases treated by experienced surgeons (Saeurland et al., 2006).

The contribution of laparoscopy to mesenteric ischemia is small. For this situation, DL is less precise than angiography and CT and has not proved to be able to reduce the number of unnecessary laparotomies. DL can detect ischemia when present but cannot rule out this diagnosis when the intestinal loops have a normal appearance upon laparoscopy (Saeurland et al., 2006).
