**4. Laparoscopy in acute appendicitis**

Appropriate clinical history and physical examination are sufficient for the correct diagnosis of acute appendicitis with typical clinical presentation, a context within which imaging exams are of little value. Computed tomography (CT) is the most valuable exam when there is a diagnostic doubt in acute appendicitis and its complications. CT has 94 to 98%

DL can be performed by the bedside, a fact that avoids the risk associated with the transportation of intensive care patients. The contraindications of DL are the same as those for any laparoscopic intervention: hypercapnia, clotting disorder with no possibility of correction, mutliple previous abdrominal surgeries with adhesions, and abdominal surgery in the last 30 days. The use of pneumoperitoneum pressure of 8 to 12 mmHg is recommended, although some authors have used pressures of up to 15 mm Hg with no

The diagnostic accuracy of DL in intensive care patients is 90 to 100% (Almeida et al., 1995; Brandt et al., 1993; Brandt et al., 1994; Gagne et al., 2002; Hackert et al., 2003; Jaramillo et al., 2006; Kelly et al., 2000; Orlando & Crowell, 1997; Pecoraro et al., 2001; Walsh & Hoadley, 1998). These success rates are due to the more frequent abdominal diseases occurring in this population (acalculous acute cholecystitis and mesenteric ischemia). The method may fail to

Several studies which evaluated the resolutive capacity of laparoscopy in different clinical

**abdomen** Perri et al., 2002 221 Review 87% 3 0,5

**Laparoscopy Resolution (%)** 

(retrospective) 8 0

<sup>1997</sup>107 Review 87,9 14 4,6

Willson, 2005 <sup>1320</sup> Retrospective 83 0,9 0,07

<sup>1997</sup>100 Prospective 92 9 5

al., 1995 103 Prospective 95,1 10,7 0

<sup>1997</sup>221 Retrospective 90 13,5 0,9

<sup>2003</sup>44 Retrospective 52 6,4 4,5

<sup>2010</sup>231 Review 95,7% 10,4 1,7

**Morbidity (%)** 

**Mortality (%)** 

adverse consequences under these circumstances (Stefanidis et al., 2009).

detect retroperitoneal processes such as pancreatitis (Stefanidis et al., 2009).

1993 25 Clinical series

Table 1. Evidence for the use of laparoscopy for diagnosis and for some therapeutic

Appropriate clinical history and physical examination are sufficient for the correct diagnosis of acute appendicitis with typical clinical presentation, a context within which imaging exams are of little value. Computed tomography (CT) is the most valuable exam when there is a diagnostic doubt in acute appendicitis and its complications. CT has 94 to 98%

situations are summarized in Table 1.

**Setting Study N Study type** 

Cueto et al.,

Golash &

Druart et al.,

Z'Graggen et

Colonval et al. ,

Kirshtein et al.,

Torenvliet et al.,

**4. Laparoscopy in acute appendicitis** 

**ICU** Brandt et al.,

**Clinical** 

**Acute abdomen** 

**Acute** 

**Acute Abdomen** 

**Perforated duodenal ulcer** 

**Acute Cholecystitis** 

**Acute Cholecystitis** 

**Small Bowel Obstruction** 

**Diverticular disease** 

purposes in clinical practice.

sensitivity, 83 to 100% specificity and 93 to 96% accuracy and can reduce the number of unnecessary laparoscopiess and laparotomies (Spirit et al., 2010).

Appendectomy by the laparoscopic route yields better results than treatment by laparotomy, especially in patients with disease in the gangrenous phase or with perforation and localized peritonitis. There are isolated reports of the limitation of laparoscopic appendectomy in patients with diffuse peritonitis due to the difficulty in cleaning the peritoneal cavity, the debris and the infected secretion, whereas most reports emphasize the resources of laparoscopic surgery in terms of providing a view of the peritoneal cavity and its recesses, with similar or even more satisfactory conditions for washing the peritoneal cavity compared to laparotomy (Saeurland et al., 2006).

For acute appendicitis, the laparoscopic approach reduces the levels of infection of the surgical wound and favors a more rapid return to habitual activities for the patient compared to laparotomy. Women of reproductive age benefit more from laparoscopy, but other groups also experience this advantage. Laparoscopic treatment of acute appendicitis is also recommended in cases of perforation and contamination of the cavity (Saeurland et al., 2006).

A cohort study was conducted at various academic and private medical centers in the United States to compare laparoscopy and laparotomy for appendectomy. There was no difference in mortality between groups and the group subjected to laparoscopy had a lower incidence of infection of the surgical wound and of episodes of sepsis. The group subjected to laparotomy had a lower incidence of abdominal abscesses and, according to the authors, the approaches yielded similar results (Hemmila et al., 2010).

Among the advantages of the laparoscopic method are the possibility of complete inspection of the abdominal cavity, the preservation of the appendix when normal, and the opportunity to also treat by the laparoscopic route or by guided laparotomy other inflammatory processes or processes of varied characteristics detected on the occasion of inspection (Saeurland et al.,2006).
