**2. Laparoscopy in peritonitis**

Although DL represents a standard procedure for critically ill patients with an acute abdomen (Pecoraro et al., 2001), there is controversy about its therapeutic use in the presence of sepsis and of hemodynamic repercussions. The insufflation of CO2 into the

Laparoscopic Approach to Abdominal Sepsis 227

indicating that the overall result of the laparoscopic method may be superior

Today, hemodynamic instability is still a limiting factor regarding the use of laparoscopy. The lack of appropriate equipment and of a qualified team continues to be an absolute contraindication of the method. Abdominal distention poses additional risks and reduces

The early use of laparoscopy in an acute abdomen is defended as an appropriate method to prevent a delay in obtaining a definitive diagnosis. Diagnostic laparoscopy within 48 h of hospital admission provided a definitive diagnosis in 90% of cases and modified the clinical diagnosis in 30% of them. A significant portion of patients (83%) were submitted to the laparoscopic procedure as the final treatment of their conditions, with a 7% rate of conversion to open surgery. Peritonitis was present in 180 patients and there was one postoperative death involving a patient with a perforated gastric neoplasia (Golash &

An etiologic diagnosis of a non-traumatic acute abdomen by laparoscopy was obtained in 98.6% of cases. The surgical treatment was performed by the laparoscopic route in 75% of the patients and by laparotomy directed by the laparoscopic diagnosis in 13%. Due to a diagnostic error in 2 cases of intestinal obstruction in patients with no abdominal surgery, in this situation the authors recommend laparotomy or investigation by means of other exams

The 2005 Consensus of the European Association of Endoscopic Surgery recommends the use of all non-surgical diagnostic means in order to obtain the etiologic diagnosis in patients with a non-traumatic acute abdomen. If the etiology is not detected, DL should be indicated. A perforated peptic ulcer, appendicitis, acute cholecystitis and pelvic inflammatory disease should be treated by the laparoscopic route. The benefits regarding other etiologies have not

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

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

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

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

(Chatzimavroudis et al.,2009).

Willson, 2005).

al., 2009).

al., 1997).

laparotomy (Stefanidis et al., 2009).

(Kirshtein et al., 2003).

the yield of this access route (Stefanidis et al., 2009).

been sufficiently clarified (Sauerland et al., 2006).

peritoneal cavity reduces the peritoneal immunity mediated by macrophages, with lower production of inflammatory cytokines (IL-1, IL-6, TNF-α). However, laparoscopic surgery is associated with a lower systemic inflammatory response compared to open surgery (Buunen et al., 2004). Studies of the effect of laparoscopy in an animal model of severe peritonitis have obtained conflicting results (Bloechle et al., 1998; Gurtner et al., 1995; Salgado Jr et al., 2008; Wichterman et al., 1979).

There is experimental evidence that pneumoperitoneum predisposes to bacterial translocation and increases the systemic inflammatory response (Bloechle et al., 1998), but other studies have not confirmed this finding (Gurtner et al., 1995; Wichterman et al., 1979).

 In a model of peritonitis induced by bacterial inoculation in rats subjected to laparoscopy, elevation of the abdominal wall and laparotomy, the changes of the peritoneal immune system in response to the abdominal infection were lower in the group treated by laparoscopy (Targarona et al., 2006). In a similar study, the number of bacterial colonies obtained in the peritoneal fluid, the rates of positive blood cultures and the peritoneal levels of IL-1 and IL-6 were significantly lower after 24 and 72 hs in the groups subjected to laparoscopy. CO2 did not appear to influence bacterial growth (Balague et al., 1999)

 The incidence of bacteremia due to *B. fragilis* and *E. faecalis* was lower in secondary experimental bacterial peritonitis submitted to washing of the cavity by laparoscopy compared to laparotomy even when the duration of peritonitis exceeded 3 hs, suggesting that laparoscopy produces a lower local trauma and preserves the intra-abdominal conditions (Linhares et al., 2001)

In an experimental rat model of severe bacterial peritonitis (Figure 1) it was demonstrated that antibiotic therapy and an early approach to the abdominal cavity by laparotomy or laparoscopy had similar effects on survival. The approach to the abdominal cavity by laparoscopy induces a greater elevation of the pro-inflammatory cytokines TNF-alpha and IL-6 compared to laparotomy, but when the procedures are associated with the use of broad spectrum antibiotic therapy (gentamicin and metronidazole) there is no difference between them (Salgado Jr et al., 2008).

Fig. 1. Experimental model for bacterial peritonitis in rats. Cecal ligation against a rigid mold and 17 gauge needle puncture (Salgado Jr et al., 2008).

Pneumoperitoneum induces an increase in circulating endotoxin but the survival of animals treated by the laparoscopic route is greater than that of animals subjected to laparotomy,

peritoneal cavity reduces the peritoneal immunity mediated by macrophages, with lower production of inflammatory cytokines (IL-1, IL-6, TNF-α). However, laparoscopic surgery is associated with a lower systemic inflammatory response compared to open surgery (Buunen et al., 2004). Studies of the effect of laparoscopy in an animal model of severe peritonitis have obtained conflicting results (Bloechle et al., 1998; Gurtner et al., 1995;

There is experimental evidence that pneumoperitoneum predisposes to bacterial translocation and increases the systemic inflammatory response (Bloechle et al., 1998), but other studies have not confirmed this finding (Gurtner et al., 1995; Wichterman et al., 1979). In a model of peritonitis induced by bacterial inoculation in rats subjected to laparoscopy, elevation of the abdominal wall and laparotomy, the changes of the peritoneal immune system in response to the abdominal infection were lower in the group treated by laparoscopy (Targarona et al., 2006). In a similar study, the number of bacterial colonies obtained in the peritoneal fluid, the rates of positive blood cultures and the peritoneal levels of IL-1 and IL-6 were significantly lower after 24 and 72 hs in the groups subjected to

laparoscopy. CO2 did not appear to influence bacterial growth (Balague et al., 1999)

 The incidence of bacteremia due to *B. fragilis* and *E. faecalis* was lower in secondary experimental bacterial peritonitis submitted to washing of the cavity by laparoscopy compared to laparotomy even when the duration of peritonitis exceeded 3 hs, suggesting that laparoscopy produces a lower local trauma and preserves the intra-abdominal

In an experimental rat model of severe bacterial peritonitis (Figure 1) it was demonstrated that antibiotic therapy and an early approach to the abdominal cavity by laparotomy or laparoscopy had similar effects on survival. The approach to the abdominal cavity by laparoscopy induces a greater elevation of the pro-inflammatory cytokines TNF-alpha and IL-6 compared to laparotomy, but when the procedures are associated with the use of broad spectrum antibiotic therapy (gentamicin and metronidazole) there is no difference between

Fig. 1. Experimental model for bacterial peritonitis in rats. Cecal ligation against a rigid

Pneumoperitoneum induces an increase in circulating endotoxin but the survival of animals treated by the laparoscopic route is greater than that of animals subjected to laparotomy,

mold and 17 gauge needle puncture (Salgado Jr et al., 2008).

Salgado Jr et al., 2008; Wichterman et al., 1979).

conditions (Linhares et al., 2001)

them (Salgado Jr et al., 2008).

indicating that the overall result of the laparoscopic method may be superior (Chatzimavroudis et al.,2009).

Today, hemodynamic instability is still a limiting factor regarding the use of laparoscopy. The lack of appropriate equipment and of a qualified team continues to be an absolute contraindication of the method. Abdominal distention poses additional risks and reduces the yield of this access route (Stefanidis et al., 2009).

The early use of laparoscopy in an acute abdomen is defended as an appropriate method to prevent a delay in obtaining a definitive diagnosis. Diagnostic laparoscopy within 48 h of hospital admission provided a definitive diagnosis in 90% of cases and modified the clinical diagnosis in 30% of them. A significant portion of patients (83%) were submitted to the laparoscopic procedure as the final treatment of their conditions, with a 7% rate of conversion to open surgery. Peritonitis was present in 180 patients and there was one postoperative death involving a patient with a perforated gastric neoplasia (Golash & Willson, 2005).

An etiologic diagnosis of a non-traumatic acute abdomen by laparoscopy was obtained in 98.6% of cases. The surgical treatment was performed by the laparoscopic route in 75% of the patients and by laparotomy directed by the laparoscopic diagnosis in 13%. Due to a diagnostic error in 2 cases of intestinal obstruction in patients with no abdominal surgery, in this situation the authors recommend laparotomy or investigation by means of other exams (Kirshtein et al., 2003).

The 2005 Consensus of the European Association of Endoscopic Surgery recommends the use of all non-surgical diagnostic means in order to obtain the etiologic diagnosis in patients with a non-traumatic acute abdomen. If the etiology is not detected, DL should be indicated. A perforated peptic ulcer, appendicitis, acute cholecystitis and pelvic inflammatory disease should be treated by the laparoscopic route. The benefits regarding other etiologies have not been sufficiently clarified (Sauerland et al., 2006).
