Best Practice & Research Clinical Gastroenterology 28 (2014) 317

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Best Practice & Research Clinical

Gastroenterology

Laparoscopy in the acute abdomen

Benoit Navez, MD, Professor *, Julie Navez, MD, Resident
Department of Abdominal Surgery and Transplantation, Cliniques universitaires Saint-Luc,
10 Avenue Hippocrate, 1200 Brussels, Belgium

a b s t r a c t
Keywords:
Acute abdomen
Laparoscopy
Peritonitis
Obstruction
Trauma

Laparoscopy has become a routine procedure in the management

of acute abdominal disease and can be considered both an excellent therapeutic and additional diagnostic tool in selected cases.
However, a high level of expertise in laparoscopic and emergency
surgery is required. Hemodynamic instability, huge abdominal
distension, fecal peritonitis and perforated cancer are relative
contraindications for the laparoscopic approach. In recent years,
abdominal emergencies have increasingly been managed successfully by laparoscopy. In acute appendicitis, acute cholecystitis
and perforated peptic ulcer, randomized controlled trials have
proven that the laparoscopic approach is as safe and as effective as
open surgery, with fewer complications and a quicker postoperative recovery. Other indications such as blunt and penetrating trauma to the abdomen, small bowel occlusion and
perforated diverticular disease are under debate, indicating that
more randomized controlled trials comparing laparoscopic and
open surgery are still necessary.
2013 Elsevier Ltd. All rights reserved.

An acute abdomen results usually from peritoneal irritation due to inammation or rupture of an
abdominal organ or obstruction of a hollow organ. In hospital practice, patients with acute abdominal
pain either go spontaneously to the emergency room or are sent there by their family doctor with a
provisional diagnosis, which reportedly has no more than a 50% chance of being correct [1]. After an
accurate diagnostic workup including blood sample, ultrasound and/or computed tomodensitometry
(CT), an etiologic diagnosis can be established, leading or not to a surgical indication. In some patients,
the reason for the acute abdomen remains unclear and there are two options: either the patient is

* Corresponding author. Tel.: 32 2 764 14 00.

E-mail address: benoit.navez@uclouvain.be (B. Navez).
1521-6918/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bpg.2013.11.006

B. Navez, J. Navez / Best Practice & Research Clinical Gastroenterology 28 (2014) 317

observed clinically and re-examined after a few hours to detect any change, or a diagnostic laparoscopy
(DL) is performed. However, laparoscopy should not be considered as a routine diagnostic tool for every
case of acute abdomen, as it carries its own morbidity and requires a general anaesthesia.
Although it is incorrect to hypothesize that all patients with acute abdominal pain would benet
from laparoscopic surgery, it is evident that over the years an increasing number of patients has been
managed successfully in emergency thanks to the laparoscopic approach [2]. The aim of this review
was to dene the best indications for laparoscopy in acute abdominal disease.
Is laparoscopy safe in a patient with abdominal sepsis?
In the early nineties, the routine use of laparoscopy in case of abdominal sepsis was controversial for
several reasons: risk of bacteraemia and endotoxemia, risk of hypercapnia and risk of missing purulent
abdominal collections. However, many authors have since demonstrated its safe use [3,4].
Animal studies showed that the inuence of pneumoperitoneum on bacteraemia and endotoxemia
was controversial and no conclusion could be drawn [5]. In the vast majority of published series,
pneumoperitoneum did not appear to increase massive bacteraemia and/or septic shock. In a recent
comparative study including 115 consecutive patients with generalized peritonitis from perforated
peptic ulcer (PPU), open peptic ulcer repair increased the incidence of bacteraemia, endotoxemia and
systemic inammation compared with laparoscopic repair. Moreover, it was hypothesized that early
enhanced postoperative systemic inammation might cause transient decrease in immunologic
defence after laparotomy leading to enhanced sepsis in these patients [6]. Similar results were reported
by the same author in patients with generalized appendicular peritonitis [7].
In routine practice, when performing a laparoscopy for sepsis, it is preferable to keep the intraabdominal pressure under 12 mmHg and sometimes between 6 and 8 mmHg in very high-risk patients. Moreover, intravenous antibiotic therapy should be started in all cases of suspected sepsis prior
to inducing a pneumoperitoneum. By taking these measures, both the dissemination of infection and
the negative hemodynamic effects of a pneumoperitoneum are limited. A good collaboration with the
anaesthesiology team is also mandatory. Concerning the risk of missing purulent collections, it is
advised to explore the entire abdominal cavity by rotating the operating table to each side, as well as by
putting the patient in the Trendelenburg position to check the Douglas pouch and the intermesenteric
spaces.
Indications and contraindications
Irreversible septic shock and/or huge abdominal distension due to ileus, as well as suspected
perforated cancer are currently considered contraindications for a laparoscopic approach. Fecal peritonitis is also usually considered as a relative contraindication. Lack of expertise in laparoscopy is an
absolute contraindication in emergency surgery. In high-risk patients, whether to use a laparoscopic
approach or not will depend on how the patient responds to the pneumoperitoneum. In case of
abdominal distension, the quality of exposure will inuence the decision to proceed with a
laparoscopy.
The best indications for laparoscopy in case of an emergency are appendicitis, cholecystitis and PPU.
The use of laparoscopy in cases of perforated diverticulitis, small bowel obstruction (SBO) and
abdominal trauma is still under debate. Laparoscopy can also occasionally be used in cases of postcolonoscopy perforation, mesenteric ischaemia, complicated Meckels diverticulum, intra-abdominal
abscess inaccessible to percutaneous drainage, postoperative peritonitis, necrotic pancreatitis.
Acute appendicitis
Appendicitis is the most common abdominal emergency. To establish the diagnosis, investigations
such as C-Reactive Protein, White Blood Count, ultrasound and sometimes CT are helpful in addition to
clinical exam.
Laparoscopy is also useful as a diagnostic tool. In 1427% cases of suspected appendicitis, another
diagnosis is found at laparoscopic exploration, such as salpyngitis, ovarian cyst, diverticulitis, ileitis,

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SBO, ileo-colic intussusception, intestinal infarction, perforated duodenal ulcer. In that situation, a
normal appendix can be left in place. According to the literature, 10%15% of the appendectomies are
carried out for a healthy appendix [810]. A macroscopically normal appendix can certainly be left in
place when other lesions can explain the symptoms. In contrast, it could be acceptable to do the appendectomy if any other pathology cannot be found because of the risk of missing an early endoappendicitis [11]. Some authors think that inammatory changes only conned to the mucosa could be
undetectable by laparoscopy and responsible for acute abdominal pain. In two studies, when the
surgeon assessed the appendix as being non-inamed, the rates of endoappendicitis were 11 and 26%
[12,13]. But the key questions are rst whether endoappendicitis truly represents a pre-stage of acute
suppurative appendicitis, and second, how can mucosal inammation of the appendix causes right
lower quadrant pain?
Barrat et al observed the impact of leaving a normal appendix in place in 65 cases [9]. Patients were
followed-up during three years on average, and only one patient (1.5%) had to undergo an appendectomy (with minor histological lesions). Moberg et al had the same results in a series of 66 patients
with a median follow-up period of 19 months, only one patient (1.5%) came back with true appendicitis
[14]. In a series of 109 patients with suspected appendicitis without removal of the appendix at laparoscopy because of negative exploration or another diagnosis, Van den Broek et al showed after a
median time of eight months, that six of these patients underwent an appendectomy for recurrent pain
in the right lower quadrant. As only one of these appendices was really inamed, the authors
concluded it was safe not to remove a normal-looking appendix at laparoscopy, the overall risk of
developing acute appendicitis post-laparoscopy being low and non-signicant [15].
According to the European Association for Endoscopic Surgery (EAES) recommendations, patients
with symptoms and diagnostic ndings suggestive of acute appendicitis should undergo DL (Grade of
Recommendation GoR A) and if the diagnosis is conrmed, a laparoscopic appendectomy (LA) (GoR A).
If a DL shows that symptoms cannot be ascribed to appendicitis, the appendix may be left in situ
(GoR B) [2].
LA does offer many advantages over open appendectomy (OA): easier localization and removal of an
ectopic appendix, reduced abdominal wall morbidity especially in obese patients, complete evaluation
of the abdominal cavity in case of diagnostic doubt, and better assessment of the extent of sepsis
(subphrenic collection, generalized peritonitis). Other advantages are decreased postoperative pain,
faster recovery, earlier return to normal activity and better cosmetic results [16]. In terms of postoperative complications, Li et al reported in a meta-analysis of randomized controlled trials (RCT)
that the rate of wound infection was signicantly reduced following a laparoscopic approach compared
to an open approach (3.81% vs. 8.41%), while intraoperative bleeding, postoperative intra-abdominal
abscess and urinary tract infection occurred slightly more frequently in the laparoscopic group. The
overall conversion rate from laparoscopy to open appendectomy was 9.51% [17].
LA is advantageous in obese patients. Mason et al showed in a series of 13,330 obese patients with a
BMI above 30 kg/m2 that LA was associated with a 57% reduction in overall morbidity and a length of
stay shortened by 1.2 days [18]. Also in a US nationwide database of 42,426 obese patients, Masoomi
et al compared LA versus OA. In non-perforated cases, the overall complication rate was signicantly
lower in the LA group (7.2% vs. 11.7%) as well as the mortality rate (0.09% vs. 0.23%). Length of stay was
also shorter (2.0 vs. 3.1 days). The same results were observed for LA performed in case of perforation:
lower overall complication rate (22.3% vs. 34.6%), lower mortality rate (0% vs. 0.50%) and shorter mean
length of stay (4.4 vs. 6.5 days) [19].
In appendicular peritonitis, laparoscopic exploration is able to determine the severity of peritonitis
(localized or generalized) more accurately than the preoperative clinical examination and work-up.
Markides et al published a systematic review and meta-analysis of laparoscopic versus open appendectomy in complicated appendicitis, and concluded that a laparoscopic approach was linked to fewer
surgical site infections, to a shorter time to oral intake and to a shorter length of hospital stay. Contrary
to LA for uncomplicated appendicitis, postoperative intra-abdominal abscess rate after perforated
appendicitis was not statistically signicantly different in LA versus OA [20].
From the technical point of view, a proper identication of the entire appendix and of its healthy
base is essential. This point can be tricky at laparoscopy because of the absence of digital palpation,
mostly in case of a subserosal appendix. In case of necrosis of the proximal part of the appendix, partial

B. Navez, J. Navez / Best Practice & Research Clinical Gastroenterology 28 (2014) 317

resection of the caecum may be necessary using the stapling technique, taking care not to damage the
ileocaecal valve. In perforated appendicitis, the need for peritoneal irrigation becomes nowadays
controversial. Initially performed to reduce infectious postoperative complications, no study has ever
proven any benet from this technique. Hartwich et al reported in a recent retrospective comparative
study of 248 children with perforated appendicitis that suction alone signicantly decreased the rate of
abscess formation and wound infections compared to irrigation [21]. St Peter et al demonstrated in a
prospective randomized survey including 220 children undergoing LA for perforated appendicitis that
peritoneal irrigation offered no advantage over suction alone: rates of intra-abdominal abscess were
19.1% for the suction only group vs. 18.3% for the irrigation group (p 1.0) [22]. An alternative technique is the so-called reverse laparoscopy (switch from open to laparoscopic surgery): having performed a 23 cm McBurney incision and found the presence of purulent uid in the peritoneal cavity or
of an ectopic appendix, the surgeon may then pursue by laparoscopic surgery, inserting a trocar
through the small incision, there by avoiding an unnecessary large opening of the abdominal wall [4].

Practice points: acute appendicitis

- The main advantage of using the laparoscopic approach in suspected appendicitis is to
decrease the rate of abdominal wall complications, mostly in obese patients and in case of a
perforated or an ectopic appendix.
- The risk of postoperative intra-abdominal abscess after appendectomy by laparoscopy for
uncomplicated appendicitis is higher than by open surgery.
- In case of suspected appendicitis and a negative laparoscopic exploration, the risk of developing an acute appendicitis after leaving the appendix in place is very low.

Acute calculous cholecystitis (AC)

Acute cholecystitis (AC) often manifests itself by acute right upper quadrant pain for more than 6
hours associated with fever above 38  C. Blood analysis shows white blood cells > 10  103/mm3,
CRP > 1 mg/dl. Ultrasonographic characteristics are a positive Murphys sign, gallstones and a thickened gallbladder wall. Standard treatment of AC consists in laparoscopic cholecystectomy (LC), because
of its safety, faster recovery and shortened hospital stay. Usually, an open approach is still reserved to
gangrenous cholecystitis. In a randomized trial comparing open versus LC for AC, Johansson et al found
no signicant difference in the rate of postoperative complications [23]. In a recent large survey in
Belgium, it was reported that wound infection rate was signicantly higher in the open group than in
the laparoscopic group (10.8% vs. 2.3%), possibly due to the fact that patients treated by open surgery
were signicantly older, at greater operative risk, and with more severe cholecystitis. The overall
mortality rate was 0.8%, proving that AC remains a severe and potentially lethal disease, especially in
elderly and high-risk patients [24].
Surgery is usually performed either within the rst four days after the onset of acute symptoms
(early cholecystectomy, EC) or six to eight weeks after the acute event (delayed cholecystectomy,
DC). A percutaneous cholecystostomy can occasionally be proposed in the acute phase, in high-risk
patients or in case of poor response to medical treatment, to relieve symptoms and cool the inammatory process until denitive surgery can be performed a few weeks later. Hadad et al
showed that conversion rates to laparotomy increased with duration of symptoms, from 9.5%
during the rst two days up to 38.9% for delays of 56 days, and therefore advised cholecystectomy within two days of onset of symptoms [25]. In a previous multicenter study, both overall and
local complication rates were shown to be statistically higher if the delay before operation was
more than four days (19.8% vs. 13.3% and 13.2% vs. 6.5% for >4 days vs. <4 days respectively) [26].
In a meta-analysis of RCT, Gurusamy et al reported no statistical difference between early and
delayed cholecystectomy for AC in terms of bile duct injury (BDI) or conversion rate to open
cholecystectomy, although total hospital stay was shorter by four days in the early group.

B. Navez, J. Navez / Best Practice & Research Clinical Gastroenterology 28 (2014) 317

Galbladder wall
left in place

Inflammation
& fibrosis

Suture of
Cystic duct

Common
Bile
Duct

Fig. 1. Subtotal cholecystectomy.

Concerning BDI, there was a trend towards a higher risk in DC (DC: 1.4% vs. EC: 0.5%) [27].
Furthermore, 17.5% of the patients who underwent the delayed surgical approach were operated as
an emergency because of nonresolving or recurrent cholecystitis. In a previous meta-analysis of
RCT, Siddiqui et al reached the same conclusions favouring early operation for AC [28]. In 2006, the
EAES recommended also LC for patients with AC as early as possible after admission (GoR A). In
patients unsuitable for early surgery, conservative treatment or percutaneous cholecystostomy
should be considered (GoR B) [2].
Conversion to an open approach was reported to occur in 11.4% of cases in a recent survey [24], more
frequently than in elective LC for uncomplicated cholecystolithiasis. It is indicated when there is poor
visualization within Calots triangle because of severe inammation, when excessive bleeding or when
a BDI is suspected. Borzellino et al conrmed in a meta-analysis that the severity of AC was a major
predictive factor of conversion to open surgery [29].
The role of routine intraoperative cholangiogram (IOC) during LC remains controversial. It does not
prevent BDI but it helps to clarify the biliary anatomy. Using IOC ensures the absence of migrated stones

Fig. 2. Endovesicular suture of the cystic duct.

B. Navez, J. Navez / Best Practice & Research Clinical Gastroenterology 28 (2014) 317

in the common bile duct (CBD) and occasionally enables early diagnosis and repair of BDI. According to
the recent clinical practice guidelines of the EAES, there was no signicant difference in the incidence
of BDI with or without use of IOC, but it was strongly agreed that IOC allows early identication of BDI if
it is correctly interpreted [30].
In case of severe cholecystitis, subtotal cholecystectomy is a good alternative to reduce the risk of
BDI and avoid conversion during a technically difcult operation. Hubert et al reported the safety of the
endovesicular approach with subtotal cholecystectomy for gallbladder dissection as an alternative to
the classic Calots triangle dissection (Figs. 1 and 2), with no postoperative biliary or infectious complications in a series of 39 patients [31].
Associated CBD stone migration in AC is more frequent than in elective cases, with an incidence
ranging from 9 to 16% [32,33]. Laparoscopic CBD exploration in AC is challenging because of inammatory changes in Calots triangle, which can make the transcystic approach or choledocotomy difcult
and sometimes hazardous. Stone extraction after endoscopic sphincterotomy is probably more
appropriate but this point has never been demonstrated in the setting of AC.
The main feared perioperative complication of cholecystectomy remains BDI. Nuzzo et al reported in a multicenter national survey that the overall BDI incidence was statistically higher in
cholecystitis (0.56%) than in simple cholelithiasis (0.32%) [34]. In a recent nationwide multicenter
survey from Belgium, the overall incidence of BDI following cholecystectomy for AC was 1.2%. This
high rate was probably closer to reality because of the anonymous inclusion of patients. Cholecystitis must be considered as a risk factor for BDI, as shown by Gigot et al in a previous national
survey of 65 BDI [35].
Practice points: acute calculous cholecystitis
- Early laparoscopic cholecystectomy within 4 days after the onset of acute cholecystitis is
recommended.
- Cholecystitis is a risk factor for bile duct injury during cholecystectomy.
- In case of severe cholecystitis, a laparoscopic subtotal cholecystectomy with an endovesicular
approach is a good alternative to reduce the risk of bile duct injury and avoid conversion to
laparotomy.
- In case of acute cholecystitis and associated common bile duct stones, endoscopic extraction
is probably the best approach.

Perforated peptic ulcer (PPU)

Because of the eradication of Helicobacter pylori (Hp) and the common use of Proton Pump
Inhibitors (PPI), the prevalence of peptic ulcer disease has signicantly decreased. However, the
number of patients requiring emergency surgical intervention for PPU remains relatively unchanged [36,37]. Perforation occurs in 210% of peptic ulcers and related mortality is between 10
and 15% [38]. Emergency surgery is the treatment of choice in most patients with PPU. The most
common procedure is duodenorrhaphy or gastrorrhaphy. Emergency gastric resection is nowadays
rare and reserved to giant perforated gastric ulcer and/or associated bleeding. Implementation of
the laparoscopic approach in PPU has evolved slowly and is still not available on 24-hours in many
surgical departments. In Western Denmark, only 6% of patients with PPU are treated laparoscopically, although the mortality rate reported for the laparoscopic group was 4% compared to
26% according to the national database. However, the laparoscopic group was observed to have a
higher risk of reperforation [39].
The standard therapy of PPU is ulcer closure, PPI and Hp eradication. The prevalence of Hp infection
in studies of PPU ranges from 47 to 100%. In two randomized controlled trials (RCT), Ng et al and ElNakeeb et al have shown that ulcer relapse one year after PPU was signicantly less common in patients treated with anti-Helicobacter therapy than in those who received omeprazole alone (respectively 4.8% vs. 38.1% and 6.1% vs. 29.6%) [40,41].

B. Navez, J. Navez / Best Practice & Research Clinical Gastroenterology 28 (2014) 317

Plain abdominal X-ray has gradually been replaced by abdominal CT as imaging modality of choice.
A recent study showed that pneumoperitoneum was diagnosed by plain lm in 75% and by CT in 98% of
cases (p < 0.001). However, 20% of patients with a pneumoperitoneum diagnosed by CT had no clinical
suspicion of perforation [36]. Some of these patients who show no signs of either clinical peritonitis or
severe sepsis have a covered perforation sealed with omentum or gastroduodenal ligament and can be
treated conservatively (Taylors method).
According to EAES guidelines, if symptoms and diagnostic ndings are suggestive of PPU, DL and
laparoscopic repair are recommended (GoR A) [2]. In a recent Cochrane review including three RCT
of acceptable quality, Sanabria et al found no statistically signicant difference between laparoscopic and open surgery with respect to abdominal septic complications and pulmonary complications. The authors concluded that one could observe a trend towards a decrease in septic
complications when laparoscopy was used, but that more RCTs with a greater number of patients
would be necessary to conrm the data, guaranteeing a long learning curve for participating surgeons [42].
In a review of 56 papers including 2786 patients, Bertleff and Lange found that the laparoscopic
approach was associated with less postoperative pain, lower morbidity, less mortality and shorter
hospital stay, and should be considered as the treatment of choice [43]. However, in the laparoscopic
groups, operating time was signicantly longer (70.8 min versus 59.3 min) and incidence of recurrent
leakage at the repair site was signicantly higher (6.3% versus 2.6%). The overall conversion rate to open
surgery was 12.4%, the main reason for conversion being the diameter of perforation. Other reasons to
convert were failure to localize the perforation, e.g. posterior ulcer location, and postoperative adhesions. These studies were published between January 1989 and May 2009 and included probably the
surgeons learning curve.
It is important to preselect patients who are good candidates for laparoscopic surgery, as all patients
are not necessarily suitable for laparoscopic repair. The Boey scoring system appears to be a helpful tool
in decision-making: it represents a sum of risk factors such as shock on admission (systolic blood
pressure < 90 mmHg), severe medical illness or score ASA (American Society of Anaesthesiologists) III,
IV or V, and duration of symptoms of more than 24 hours. The minimum Boey score is 0 and the
maximum score is 3 [44]. The Boey score is a simple and precise predictor of postoperative mortality
and morbidity. In his study, Lohsiriwat scored 152 patients. He showed that the mortality rate
increased progressively with increasing the Boey score: 1%, 8%, 33% and 38% for scores 0, 1, 2, and 3,
respectively (p < 0.001). The morbidity rates for Boey scores 0, 1, 2, and 3 were 11%, 47%, 75%, and 77%,
respectively (p < 0.001) [45]. Interestingly, data from retrospective studies showed that the conversion
rate to laparotomy was also inuenced by the Boey score: 21.4% for score 0, 30.2% for score 1 and 81.8%
for score 2 [46]. A preoperative score of 1 is a good indication for a laparoscopic intervention, whereas
scores of 2 or 3 should be considered relative contraindications. Other indications for immediate
laparotomy are the presence of a massive associated ileus, associated acute bleeding from the ulcer site
and suspected perforated cancer.
From the technical point of view, laparoscopic simple suture repair of PPU with an omental patch is
the most commonly used procedure (66% of surgeons) [43]. Lo et al showed in their study that in terms
of leakage and surgical outcome, covering the suture repair of PPU with omentoplasty did not show any
additional advantage compared to simple closure alone [37]. Alternative techniques have been
described such as sutureless repair, in which the perforation is closed with gelatin sponge and brin
glue or with the round hepatic ligament. Transluminal endoscopic omental patch closure has also
recently been described [38]. Nowadays, the need for denitive ulcer surgery has decreased
signicantly.

Practice points: perforated peptic ulcer

 The standard therapy of PPU is simple ulcer closure, PPI and Hp eradication.
 Laparoscopic repair of PPU is feasible, safe and supported by 3 RCTs.
 The Boey score can predict mortality and risk of conversion.

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B. Navez, J. Navez / Best Practice & Research Clinical Gastroenterology 28 (2014) 317

Small bowel obstruction (SBO)

Etiologies of SBO can be classied into four types: (1) simple mechanical obstruction linked to
adhesions, neoplasm, bile stones, bezoar .; (2) obstruction by strangulation linked to a volvulus,
strangulated hernias, ...; (3) obstruction by intussusception, and (4) paralytic ileus. This results in
electrolyte and uid disturbances associated with a third spacing, intestinal ischaemia and stasis
leading to microbial proliferation in the intestinal lumen and bacterial translocation across the bowel
wall [47].
Acute SBO is a common surgical emergency and is most frequently linked to postoperative adhesions. In a series of 500 patients operated for adhesive SBO, Fevang et al showed that recurrence rate
after a laparotomy for SBO was 7% within 1 year, 18% after 10 years and 29% after 30 years [48].
Recurrence rate increased with the number of previous episodes of acute SBO, and the risk of new
surgically treated episodes of acute SBO was the same regardless of the method of treatment (conservative or surgical). The conclusion was that prophylactic surgery was useless.
In the absence of clinical, biological and radiological signs of intestinal ischaemia, a conservative
treatment can be attempted. After having assessed the diagnosis of mechanical SBO by CT scan (Fig. 3),
a gastrogran test can be performed to check the progression of contrast material within the next 24
hours. Gastrogran, a hyperosmolar water-soluble agent of 1900 mOsm/l, about 6 times the osmolarity
of extracellular uid, can also have a therapeutic effect by increasing the pressure gradient across the
site of obstruction, there by resulting in the occasional resolution of the obstruction [49]. Surgical
exploration is required if there is no contrast material in the colon after 24 hours or if no response to
medical treatment is observed after 2448 hours (Fig. 4).
Safety and feasibility of the laparoscopic approach in acute SBO has been reported in several
studies with various outcomes. According to the EAES recommendations, laparoscopic treatment of
SBO can be successfully accomplished in selected patients who are not responding to conservative
management (GoR C) [2]. But neither randomized control trials nor prospective controlled studies
are available in the literature [50]. In a review of 19 retrospective studies including 1061 patients
having had a laparoscopic approach for acute SBO, adhesive disease was the causal factor in 83.2%.
Conversion rate to open surgery was 33.5%, principally due to dense adhesions, need for bowel

Fig. 3. Diagnosis of SBO on CT scan.

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11

Fig. 4. Therapeutic algorithm in SBO.

resection, iatrogenic injury, malignancy, inadequate visualization or incarcerated hernia. Overall

morbidity and mortality were respectively 15.5% and 1.5%. There were 45 recognized intraoperative
small bowel injuries (6.5%), and early recurrence occurred in 2.1% [51]. In a personal series of 151
acute SBO (unpublished data), 98 were due to bands or adhesions (65%), of which 70% were treated
surgically. Laparoscopy was only performed in 23% of these cases (23/98), with a conversion rate to
laparotomy of 22% (5/23).
Laparoscopic management of acute SBO is challenging because of the reduced working space due to
ileus, the fragility of dilated intestinal loops and the difculty to identify the cause of obstruction in
some cases. Manipulation of bowel should be done very carefully as intestinal injuries can have
disastrous consequences. Feasibility of the laparoscopic approach is variable, with conversion rates
ranging from 0% to 52% according to surgeons skill and patient selection [52]. The main causes of
conversion are limited visualization caused by distended bowel and multiple or deep bands/adhesions

Fig. 5. Obstruction site on a previous anterior abdominal scar.

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B. Navez, J. Navez / Best Practice & Research Clinical Gastroenterology 28 (2014) 317

Fig. 6. Bowel adherent to the anterior abdominal wall.

rendering access difcult. Other causes for conversion are presence of small bowel necrosis and
accidental enterotomies. A prospective nationwide series from Switzerland of 537 laparoscopies for
SBO reported a conversion rate of 32.4% for the following reasons: inability to visualize the site of
obstruction or matted adhesions in 53.4%, intraoperative complications in 21.3% and small target incisions for resection in 25.3%. Intraoperative complications and conversion were associated with
signicantly increased postoperative morbidity [53].
Best cases for laparoscopy are patients with:
-

Few previous abdominal scars

Proximal obstruction
Moderate abdominal distension
Bowel distension with a diameter <5 cm
Single band or site of obstruction on a previous abdominal wall scar (Figs. 5 and 6)

Laparoscopy remains contraindicated in patients with high operative risk or hemodynamic instability, in massive abdominal distension, in perforation and/or bowel necrosis, and in case of limited
laparoscopic experience.
Finally, advantages of laparoscopy are reduction of the number of laparotomies resulting in a
shorter hospital stay, a more rapid return to oral intake, and a lower postoperative morbidity. There is
no difference in terms of recurrence of bowel obstruction after laparoscopy versus laparotomy [2].
In conclusion, according to the Cochrane recommendations, retrospective clinical controlled trials
suggest that laparoscopy in acute SBO appears feasible and better in terms of hospital stay and mortality reduction, but high quality RCTs are needed, assessing relevant outcomes including overall
mortality, morbidity, hospital stay and conversion rate [54].

Practice points: small bowel obstruction

- Laparoscopic management of acute small bowel obstruction is feasible and safe in experienced hands with signicant advantages for the patient.
- Best cases are patients with proximal obstruction, a small bowel diameter less than 5 cm, few
abdominal scars, moderate abdominal distension and no suspicion of bowel necrosis.

B. Navez, J. Navez / Best Practice & Research Clinical Gastroenterology 28 (2014) 317

13

Perforated diverticular disease (PDD)

Peritonitis caused by PDD is a particularly serious condition and is classied according to Hinchey
into pericolic abscess (Hinchey I), pelvic abscess (Hinchey II), generalized purulent peritonitis (Hinchey
III) or fecal peritonitis (Hinchey IV). Standard treatment is sigmoid resection with or without a colostomy [55]. Hinchey IV is an indication for a Hartmanns procedure. Hinchey I is usually treated by
sigmoidectomy with colorectal anastomosis. In case of a huge pelvic abscess not amenable to percutaneous drainage (Hinchey II) and in Hinchey III cases, it has been suggested that laparoscopic peritoneal lavage and drainage could be used to avoid a colostomy.
According to the EAES recommendations, patients with presumed acute uncomplicated diverticulitis should not undergo emergency laparoscopic surgery (GoR B). Although colonic resection remains
the standard treatment for PDD, laparoscopic lavage and drainage may be considered in some selected
patients (GoR C) [2].
In a systematic review of laparoscopic peritoneal lavage for PDD, Toorenvliet reported in 2010 the
results of 231 patients from two prospective cohort studies and nine retrospective case series. Mortality was 1.7% and morbidity rate 10.4%, abdominal and systemic sepsis was successfully controlled in
95.7% of patients, only 37.7% of whom required secondary resection. However, the authors also
concluded that there was no publication of high methodological quality [56]. As laparoscopic peritoneal lavage may be an important new treatment for patients with peritonitis caused by PDD, it is
important to establish its value in RCT.
Despite the fact that several series have reported promising results with laparoscopic peritoneal
lavage and drainage, it seems too early to generally recommend its routine use in PDD, particularly in
Hinchey II and III. Unlike other abdominal emergencies such as appendicitis and cholecystitis where
the diseased organ is removed, the cause of infection remains in place when PDD is treated by lavage
alone. This could lead to persistent sepsis and/or stulization, with possible severe consequences,
particularly in immunosuppressed or diabetic patients. Another difculty could arise from the
frequently dilated small bowel loops that may impair a thorough exploration of the abdominal cavity
and there by lead to missed purulent collections.

Practice points: perforated diverticular disease

- In perforated diverticular disease (Hinchey II and III), laparoscopic lavage and drainage of the
peritoneal cavity could be an alternative technique to standard sigmoid resection.
- Hinchey IV remains an indication for a Hartmann procedure.

Abdominal trauma
Diagnostic laparoscopy (DL) could be interesting for the diagnosis of peritoneal injury in penetrating trauma, by avoiding a negative nontherapeutic laparotomy, which is associated with up to 5%
mortality and 20% morbidity rates [57]. DL could there by reduce length of stay and hospital costs.
According to the EAES recommendations, DL for suspected penetrating trauma is a useful tool to
assess the integrity of the peritoneum and avoid a nontherapeutic laparotomy in stable patients (GoR
B). Regarding blunt abdominal trauma, DL may be performed to exclude relevant injury (GoR C) but is
usually of less interest [2].
Fabian et al published back in 1993 a prospective study with 182 hemodynamically stable patients
with penetrating or blunt trauma who underwent DL [58]. More than half of the patients (53%) were
spared of laparotomy because the screening laparoscopy either excluded penetration of the peritoneum or because only minor injuries were observed. No complications or missed injuries were noted.
In a recent systematic review of 51 studies by OMalley et al including 2563 patients with penetrating
abdominal trauma undergoing DL, 46.1% were positive for injury. Laparoscopy was therapeutic in only
13.8%, 51.8% were spared a non-therapeutic laparotomy, while conversion to laparotomy was necessary
in 33.8% [59].

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Indications for DL in penetrating or blunt abdominal trauma are: [60]

-

suspected unproven intra-abdominal injury

transperitoneal abdominal stab wound
abdominal gunshot wound with suspicious trajectory
penetrating trauma to the thoracoabdominal area

Laparoscopic evaluation is interesting for the detection of diaphragmatic injuries, for which clinical
and radiographic ndings may be unreliable [61]. As a screening tool, laparoscopy can detect or exclude
a hemoperitoneum, penetration of the parietal peritoneum, and gastrointestinal spillage, with a high
sensitivity. It seems obvious that a good laparoscopic expertise is required. Hemodynamically unstable
patients, hemorrhagic shock, evisceration or frank peritonitis constitute absolute contraindications for
laparoscopy.
In blunt trauma where injuries tend to result in large tears more accurately diagnosed by imaging
techniques, the usefulness of DL is generally limited and when surgery is required, open exploration is
recommended [62]. CT-imaging, however, also has limitations, particularly concerning hollow organ or
diaphragmatic injuries. DL may help in the decision whether or not to pursue a conservative treatment
[6365].
In penetrating trauma, DL has a variable efcacy in the identication of specic organ lesions, with
overall missed injury rates ranging from 19% to 41% [6668]. Reported missed injuries involved the
liver, pancreas, stomach, duodenum, small bowel, mesentery, ureter and urinary bladder [60,69].
Although the primary objective of DL in abdominal trauma is screening, it has been reported as a
therapeutic procedure for the repair of diaphragmatic injuries, suture of gastro-intestinal perforations,
hemostasis of mild liver or splenic laceration, intestinal resection and stomas. However, extreme
caution and strict criteria are necessary because the risk of missing associated lesions is signicant.

Practice points: abdominal trauma

- In case of penetrating thoracoabdominal trauma in a hemodynamically stable patient,
diagnostic laparoscopy is an interesting screening tool to assess the presence of a peritoneal
and/or diaphragmatic injury, avoiding unnecessary and nontherapeutic laparotomy.
- Utility of laparoscopy in blunt abdominal trauma is more limited.

In conclusion, laparoscopic management of an acute abdomen is feasible, safe and recommended in

acute appendicitis, acute cholecystitis, and perforated peptic ulcers. The advantages of the laparoscopic
approach are diagnostic conrmation, assessment of the severity of the peritonitis, avoidance of a
formal laparotomy in many cases especially in obese patients, and a very low incidence of wound
sepsis. Value of laparoscopy is still controversial in perforated diverticular disease, small bowel
obstruction and abdominal trauma. Additional RCTs comparing laparoscopic and open approach are
needed.

Research agenda
 Randomized controlled trials comparing laparoscopic and open surgery in acute small bowel
obstruction are needed.
 The exact place of laparoscopic lavage and drainage in perforated diverticular disease has to
be dened.
 Because of the risk of missing injuries, the role of therapeutic laparoscopy in abdominal
trauma must be claried in the future.

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15

Conict of interest
None.

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