Laparoscopy in Emergency

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This entry is adapted from the peer-reviewed paper 10.3390/life11090917

Laparoscopy must be considered a safe, extremely versatile and prompt surgical approach suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorder and non-specific abdominal pain (NSAP). For the remaining surgical emergencies, the role of laparoscopy is still a matter of debate.

laparoscopy emergency surgery trauma immune system DAMPs multiple organ dysfunction ARDS

1. Introduction

Why should laparoscopy be preferred in emergency?

The modern concept of diagnostic laparoscopy for trauma began in the 1960s, when Heselson proclaimed its safety, efficacy and economic benefits, and demonstrated decreased hospitalisation, avoiding unnecessary laparotomies^[1].
The advantages of laparoscopy in several emergency situations are clearly stated, undoubtedly whenever the surgical procedure is standardised. On the other hand, the benefits are lesser or unclear when only a basic plan of the procedure is definable and the surgical technique strictly depends on the intra-abdominal findings. In terms of contraindication of laparoscopy, these do not differ from those clearly defined for elective surgery in the case of an abdominal emergency. In general, stability of hemodynamic and respiratory parameters are required to perform laparoscopic procedures.^[2]

Our aim is to review the latest evidence for laparoscopy in emergency scenarios and to clarify the pathomechanism underlying the choice.

The available evidence clearly demonstrates the superiority of a laparoscopic approach in acute cholecystitis; gastroduodenal perforated ulcers; acute appendicitis; gynaecological disorders and non-specific abdominal pain (NSAP). In these scenarios, laparoscopy guarantees the main advantage of having a faster recovery and shorter hospital stay. In addition to those scenarios in which the superiority of the laparoscopic approach is clearly stated, the authors reviewed the use of laparoscopy in the abdominal trauma and in pediatric emergencies.

2. Surgical Emergencies

Acute Cholecystitis

The laparoscopic approach was initially considered to be contraindicated for acute cholecystitis. Increases in surgical experience led to the laparoscopic approach becoming the preferred procedure, even in complicated settings. Regarding the timing of surgery, in the latest guidelines from the World Society of Emergency Surgery it is stated that ELC is superior to either intermediate laparoscopic cholecystectomy, performed between seven days and six weeks of hospital admission, or delayed laparoscopic cholecystectomy which performed between six weeks and three months of the initial hospital admission. ELC should be the standard of care whenever possible, even for patients at high risk for surgery. ^[3] The absence of the critical view of safety (CVS) is the most important factor for conversion to open surgery. Mandatory indicators for conversion include a complete buried gallbladder, an impacted stone and the inability to retract the gallbladder.^[4] In cases of severe inflammation, the identification and the dissection of the Calot’s triangle could be difficult. In such situations a laparoscopic fundus first anterograde approach is used to avoid bile duct injury. An alternative solution that could be used in particularly adverse conditions is the execution of a subtotal cholecystectomy. ^[5] An intraoperative cholangiography could also be performed to better clarify the anatomy or in case of a suspicion of a common bile duct stone.

Gastroduodenal Ulcer

A recent meta-analysis from Cirocchi et al. compared laparoscopic to open surgery for patients with perforated peptic ulcers. They reported a significant advantage of laparoscopic repair in terms of postoperative pain in the first 24 h after surgery and regarding the incidence of wound infections. No significant differences between laparoscopic and open surgery were found for overall postoperative mortality, leak of the suture repair, intra-abdominal abscesses and reoperation rate. This suggests that it is reasonable to utilise a laparoscopic approach for stable patients and in the presence of appropriate surgical skills. ^[6] The laparoscopic approach is an important diagnostic tool, allowing for defining the ulcer in its location, size and, in some cases helping to establish the aetiology of the ulcer. After the exploratory laparoscopy if a perforated ulcer is found, the surgeon could perform a laparoscopic repair. repair. In patients with a perforated peptic ulcer smaller than 2 cm, it is recommended that a primary repair is performed. The use of the omental patch is still a matter of debate.

Acute Appendicitis

Several systematic reviews of randomised control trials comparing laparoscopic with open appendectomy have reported that the laparoscopic approach is associated with longer operative times and higher operative costs, but it leads to less postoperative pain, lower rates of surgical site infection and shorter hospital stays. In addition, the laparoscopic approach is the favourable treatment for obese, elderly and pregnant patients. The laparoscopic appendectomy is feasible for complicated appendicitis, in which it could reduce the hospital stay and lower the risk of surgical site infection. ^[7]

Gynaecologic Emergencies

The main gynaecologic conditions that may present to the general surgeon in an emergency scenario are pelvic inflammatory disease (PID), ovarian diseases, ectopic pregnancy and endometriosis. The laparoscopic approach for gynaecologic conditions has the advantage over laparotomy of shorter hospitalisation and a faster recovery. In addition, it permits a complete exploration of the abdominal cavity, allowing the treatment of different diseases through using the same access, reducing the risk of post-surgical adhesions and surgical site infections. It is also indicated to perform lavage and drainage of the infected collections, adhesiolysis and debridement of necrotic tissue in case of PID.

Nonspecific Abdominal Pain

Selective indication to laparoscopy after a short period of active observation reduces the need for surgery without significant clinical disadvantages in patients affected by NSAP. Open surgery has a limited role in the management of NSAP; it is associated with low diagnostic accuracy, high morbidity and costs and long hospital stay. ^[2]

3. Pathophysiological Considerations

Pathophysiological considerations are important to understand the underlying mechanisms that could modify the outcome of the patients. Any abdominal urgency, as well as traumatic injury events, causes a high level of cell death with the consequential release of cell’s debris fragments. These fragments act as damage associated molecular patterns (DAMPs). DAMPs as well as the pathogen associated molecular patterns (PAMPs) are recognized by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. Between the causes of triggering the inflammatory response and beside the danger molecules, the formation of neutrophil-associated extracellular traps (NETs) seems to play an emerging role. Although NETs play important roles in host defence by trapping pathogens, extensive formation of NETs with increased amounts of extracellular DNA may contribute to the perpetuation of inflammation and tissue damage. This may result in the development of a progressive and multiple organ dysfunctions manifesting with ARDS, coagulopathy, liver dysfunction and renal failure. ^[8] In the light of this overview and following the basic principles of any efficacious treatment after an abdominal acute emergency, there is not only the ability to resolve the injury itself, but also the capability to clear the damaged tissues which limits the release of DAMPs.

References

Heselson, J.; Peritoneoscopy in abdominal trauma.. S. Afr. J. Surg 1970, 8, 53-61.
Sauerland, S.; Agresta, F.; Bergamaschi, R.; Borzellino, G.; Budzynski, A.; Champault, G.; Fingerhut, A.; Isla, A.; Johansson, M.; Lundorff, P.; et al.et al. Laparoscopy for abdominal emergencies: Evidence-based guidelines of the European Association for Endoscopic Surgery. Surg. Endosc 2006, 20, 14-29.
Pisano, M.; Allievi, N.; Gurusamy, K.; Borzellino, G.; Cimbanassi, S.; Boerna, D.; Coccolini, F.; Tufo, A.; Di Martino, M.; Leung, J.; et al.et al. World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis.. World J. Emerg. Surg. 2020, 15, 1-26, https://doi.org/10.1186/s13017-020-00336-x.
Mannino, M.; Toro, A.; Teodoro, M.; Coccolini, F.; Sartelli, M.; Ansaloni, L.; Catena, F.; Di Carlo, I.; Open conversion for laparoscopically difficult cholecystectomy is still a valid solution with unsolved aspects.. World J. Emerg. Surg. 2019, 14, 7.
Strasberg, S.M.; Pucci, M.J.; Brunt, L.M.; Deziel, D.J.; Subtotal Cholecystectomy–“Fenestrating” vs “Reconstituting” Subtypes and the Prevention of Bile Duct Injury: Definition of the Optimal Procedure in Difficult Operative Conditions.. J. Am. Coll. Surg 2016, 222, 89-96.
Cirocchi, R.; Søreide, K.; Di Saverio, S.; Rossi, E.; Arezzo, A.; Zago, M.; Abraha, I.; Vettoretto, N.; Chiarugi, M.; Meta-analysis of perioperative outcomes of acute laparoscopic versus open repair of perforated gastroduodenal ulcers.. J. Trauma Acute Care Surg. 2018, 85, 417-425.
Tiwari, M.M.; Reynoso, J.F.; Tsang, A.W.; Oleynikov, D.; Comparison of Outcomes of Laparoscopic and Open Appendectomy in Management of Uncomplicated and Complicated Appendicitis. Ann. Surg. 2011, 254, 927-932.
Xiao, W.; Mindrinos, M.N.; Seok, J.; Cuschieri, J.; Cuenca, A.G.; Gao, H.; Hayden, D.L.; Hennessy, L.; Moore, E.E.; Minei, J.P.; et al.et al. A genomic storm in critically injured humans. J. Exp. Med. 2011, 208, 2581–2590.

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Valentina Iori

Giuseppe Ietto

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Update Date: 10 Dec 2021

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