**3. Laparoscopy in nonspecific abdominal pain and abdominal sepsis**

Nonspecific acute abdominal pain is characterized by a duration of less than 7 days and by diagnostic uncertainty after basic clinical and laboratory evaluation. Under these circumstances, DL is useful for establishing the etiology by means of direct inspection of large areas of the surface of abdominal organs and for obtaining material for biopsy, culture and aspirate, with complementation by laparoscopic ultrasonography. In most cases it is also possible to perform a therapeutic intervention by the same route of access (Stefanidis et al., 2009).

The accuracy of DL ranges from 70 to 99% and its use reduces the time of hospitalization without interfering with morbidity when compared to expectant management of nonspecific abdominal pain (Cueta et al., 1998; Cueto et al., 1997; Decadt et al.,1999; Fahel et al., 1999; Gaita et al., 2002; Golash & Willson, 2005; Majewski, 2000; Navez et al., 1995; Ou & Rowbotham, 2000; Poulin et al., 2000; Sanna et al., 2003; So¨zu¨er et al., 2000; Stefa'nson et al., 1997).

DL is also useful in intensive care when the abdomen is the suspected source of sepsis, of systemic inflammatory response syndrome (SIRS) or multiple organ failure. DL can be used in critically ill patients who present abdominal pain with peritonism accompanied by some signs and symptoms of an inflammatory process, but still without an indication of laparotomy (Stefanidis et al., 2009).

Laparoscopic Approach to Abdominal Sepsis 229

sensitivity, 83 to 100% specificity and 93 to 96% accuracy and can reduce the number of

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

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.,

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,

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

**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,

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

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

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

unnecessary laparoscopiess and laparotomies (Spirit et al., 2010).

cavity compared to laparotomy (Saeurland et al., 2006).

the approaches yielded similar results (Hemmila et al., 2010).

surgical exploration is obligatory (Catena et al., 2011).

recommend surgery by laparotomy (Saeurland et al., 2006).

and to a new laparotomy in 10 to 30% of cases (Landercasper et al., 1993).

inspection (Saeurland et al.,2006).

2006).

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

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

Several studies which evaluated the resolutive capacity of laparoscopy in different clinical situations are summarized in Table 1.


Table 1. Evidence for the use of laparoscopy for diagnosis and for some therapeutic purposes in clinical practice.
