**6. Laparoscopy in peritonitis due to gynecological causes**

Gynecological affections should always be part of the clinical reasoning in the evaluation of abdominal pain in women. The more frequent causes of abdominal and pelvic pain are ectopic pregnancy, salpingo-oophoritis, pelvic adhesions, endometriosis, and ovarian cysts. In contrast to abdominal processes, CT is less valuable in these conditions. Transvaginal and conventional ultrasonography with a pregnancy test for women of reproductive age are part of the initial evaluation. DL is superior to all other tests and can correct the preoperative diagnosis in up to 40% of cases (Saeurland et al., 2006).

#### **7. Laparoscopy in trauma**

DL has been indicated for victims of trauma with suspected intra-abdominal injuries in order to reduce the rate of non-therapeutic laparotomies with their morbidity, mortality and

evidence of a lesser formation of adhesions at the surgical site and on the abdominal wall

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

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

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.,

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

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

Gynecological affections should always be part of the clinical reasoning in the evaluation of abdominal pain in women. The more frequent causes of abdominal and pelvic pain are ectopic pregnancy, salpingo-oophoritis, pelvic adhesions, endometriosis, and ovarian cysts. In contrast to abdominal processes, CT is less valuable in these conditions. Transvaginal and conventional ultrasonography with a pregnancy test for women of reproductive age are part of the initial evaluation. DL is superior to all other tests and can correct the preoperative

DL has been indicated for victims of trauma with suspected intra-abdominal injuries in order to reduce the rate of non-therapeutic laparotomies with their morbidity, mortality and

when laparoscopy is used (Gadallah et al., 2001; Gamal et al., 2001).

of the less invasive procedure continue to be unclear (Catena et al., 2011).

selected cases treated by experienced surgeons (Saeurland et al., 2006).

**6. Laparoscopy in peritonitis due to gynecological causes** 

diagnosis in up to 40% of cases (Saeurland et al., 2006).

**7. Laparoscopy in trauma** 

option for conversion (Catena et al., 2011).

2003).

et al., 2006).

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 (Stefanidis et al., 2009).

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 (Stefanidis et al., 2009).

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

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) (Hori, 2008).
