PROCEDURES AND TECHNIQUES
Emergency laparoscopy: A new emerging discipline
for treating abdominal emergencies attempting to minimize
costs and invasiveness and maximize outcomes and
patients’ comfort
Salomone Di Saverio, MD, Bologna, Italy
S urgical practice is continuously evolving mainly because
of technologic developments and better-performing in-
struments. Recent evolution of technology has dramatically
changed the range of available instruments and, subsequently,
the therapeutic options that can be offered to patients needing
surgical interventions and eventually even emergency surgery.
Laparoscopy is now well recognized worldwide as the
criterion standard approach for cholecystectomies and gyne-
cologic procedures.
The minimally invasive approach, commonly termed
keyhole surgery, refers to a surgical procedure performed
through small abdominal incisions as small as those of a ‘‘door
lock,’’ as opposed to the traditionally larger and more pain-
ful laparotomy incisions, therefore captivating the patient’s
preference.
The laparoscopic approach carries several significant
advantages for patients, both in terms of much less postoper-
ative pain (every effort should be undertaken to avoid or at least
minimize pain)Vincluding faster and better postoperative re-
covery, shorter hospital stay, earlier discharge, and earlier return
to normal daily activity, such as physical exercise (including
sports and sexual life)Vand a significantly faster return to work.
Therefore, these advantages might not only reduce the costs of
the hospital stay for the health systems but also positively in-
fluence the social costs, allowing patients to resume their work
significantly earlier and avoid long periods of inactivity.
The protocols of ERAS [enhanced recovery after surgery
program] have been best applied in conjunction with minimally
invasive and laparoscopic procedures.
In recent years, the use of laparoscopy became popular
in colorectal surgery and surgical oncology. In this setting,
From the Emergency and Trauma Surgery Unit, Department of Surgery, Maggiore
Hospital Trauma CentreYBologna Local Health District, AUSL Bologna,
Bologna, Italy.
S.D.S. presented this topic as an invited speaker at the Acute Surgical Care Conference
at John Hunter Hospital Y University of Newcastle, chaired by Dr. Cino Bendinelli
and held on November 23, 2013, during the annual Meeting of the Hunter Surgical
Society in New South Wales, Australia.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text, and links to the digital files are provided in the HTML text of
this article on the journal’s Web site (www.jtrauma.com).
Address for reprints: Salomone Di Saverio, MD, Emergency Surgery and Trauma
Surgery Unit, Maggiore Hospital Trauma Center, Bologna, Italy; email: salo75@
inwind.it, s.disaverio@ausl.bologna.it.
DOI: 10.1097/TA.0000000000000288
338
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while achieving good oncologic results and satisfying good
oncologic quality criteria in terms of radical resections and
number of lymph nodes removed, modern laparoscopy cur-
rently allows extended colectomies or wide and low rectal
resections with total mesorectal excision without negatively
affecting oncologic quality indicators such as perioperative
morbidity, short- and long-term mortality, local recurrences
rate, and tumor stageYrelated survival rate but rather improving
the postoperative quality of life, reducing pain, and improving
aesthetic results.
Further technologic improvements include the develop-
ment and refinement of laparoscopic techniques, the introduc-
tion of highly performing endoscopic staplers and endoscopic
scissors using a variety of modern energies, and the enhancement
of the laparoscopic suturing skills achieved by the new genera-
tion of ‘‘minimally invasive surgeons,’’ who made feasible
gastrointestinal anastomoses by using totally intracorporeal
techniques (see Video, Supplemental Digital Content [SDC] 1,
http://links.lww.com/TA/A428) in a ‘‘scarless’’ fashion. The
resected specimen is then extracted through dedicated mini-
incisions that can be made even smaller (if an intracorporeal
anastomosis is performed [Fig. 1C and D; Fig. 2A and B]), less
painful (if muscle-splitting rather than muscle-cutting
methods are used), and extremely low and concealed (i.e.,
so-called mini-Pfannenstiel incision in suprapubic site, just
below the ‘‘bikini’’ line or level of underwear and therefore less
apparent [Fig. 2C and D]).
Compared with oblique incisions in the right hypo-
chondrium for right colectomy with eventual extracorporeal
anastomosis, in the left iliac fossa for left colectomy, or with
enlarged midline umbilical incisions, the suprapubic mini-
Pfannenstiel incision to extract the surgical specimen has
been shown to be associated with much a lower incidence of
surgical site infections (SSIs).1 This kind of SSI often persists
for several weeks, requiring repeated wound care, outpatient
clinic appointments, delayed wound healing, and eventually
even delay to the resumption of normal independent daily
living, such as attending to personal hygiene and mobilizing.
Furthermore, when associated with intracorporeal anastomo-
sis, a suprapubic mini-incision of a few centimeters carries the
risk of postoperative incisional hernia close to 0%,2 which is
significantly lower when compared with oblique or midline
incisions3 and hypochondrial or iliac incisions.4 The transverse
muscle-preserving approach5 or muscle-splitting techniques
J Trauma Acute Care Surg
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J Trauma Acute Care Surg
Volume 77, Number 2 Di Saverio

Figure 1. A, Functional and aesthetic outcome in a 79-year-old patient operated for large-bowel obstruction from obstructing
descending colon carcinoma, after 3 days from a totally laparoscopic left colectomy with intracorporeal colocolic laterolateral
anastomosis and extraction of the surgical specimen through the umbilical access. The umbilicus is used for the camera. Operative
trocars are in the right flank and an additional port is in the left flank for the assistant surgeon and useful as well for approaching
the mobilization of the splenic flexure. This port can then be used for drain insertion. The specimen (obstructed descending colon) is
extracted through a small enlargement (3.8 cm) of the umbilical port (see also Video, SDC 1, http://links.lww.com/TA/A428). B,
The same patient is discharged on fourth postoperative day after passing stools and removal of the abdominal drain (see also Video,
SDC 1, http://links.lww.com/TA/A428). C, The obstructing carcinoma of the descending colon is clearly visible. Marked stenosis
and distension of the proximal large bowel are also evident. D, After resection, a laterolateral intracorporeal colocolic stapled
anastomosis is fashioned. The enterotomy is closed with interrupted 3/0 vycril stitches. Big bites of seromuscular layer are taken,
and the extremities are carefully closed with large margins. The assistant surgeon is holding the margins and gently pulling upwards
the enterotomy to prevent copious fecal spillage from the proximal obstructed colon, while the operating surgeon is stitching
and closing the hole.

are also advocated as an alternative for off-midline extraction
site, yielding the lowest rate of incisional hernia development6
(see Video, SDC 2, http://links.lww.com/TA/A429).
In recent years, new concepts are evolving toward even
less invasive laparoscopic surgery by total avoidance of per-
forming any skin incision for specimen extraction. This is the
so-called NOTES, or natural orifice transluminal endoscopic
surgery, which uses the natural orifices, such as the rectal stump
or the vagina, or through an endoscopy within the stomach
(transgastric) for specimen extraction,7 thereby making the
future laparoscopic surgery a true ‘‘scarless’’ surgery, per-
formed through really ‘‘invisible’’ incisions.
Another progress in the laparoscopic surgery toward a more
minimally invasive approach is the development of single-incision
laparoscopic surgery (SILS) or LESS [laparoendoscopic single-
site access]. The single-incision technique allows performing ap-
pendectomies (see Video, SDC 3, http://links.lww.com/TA/A430;
Fig. 3B) and cholecystectomies up to colorectal resections (see
Video, SDC 4, http://links.lww.com/TA/A431; Fig. 2A and B)
and left liver lobe resections, through just a small single
transumbilical incision, which accommodates both the camera
and two or more operating instruments.
LAPAROSCOPY FOR ABDOMINAL
EMERGENCIES AND MINIMALLY INVASIVE
EMERGENCY SURGERY
In the past decades, few pioneering experiences have
highlighted the potential advantages of diagnostic and thera-
peutic laparoscopy for the management of acute abdomen but
have also advocated a better definition of the exact role of
emergency laparoscopic surgery.8
However, 20 years later, emergency surgery still remains
a challenging field for using laparoscopy and minimally in-
vasive techniques, owing to numerous reasons such as the
laparoscopic skills of the operator usually limited to elective
settings, the technical struggle in the presence of diffuse
peritonitis, large purulent collections and diffuse adhesions,
anesthetic concerns in the presence of comorbidity and older
patients, and last but not least, the limited operating room

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 J Trauma Acute Care Surg
Di Saverio Volume 77, Number 2

Figure 2. A, Functional and aesthetic outcome in a 48-year-old female patient after SILS-assisted right colectomy with intracorporeal
anastomosis for cecal perforated colonic diverticulitis. The colectomy is performed laparoscopically using a surgical glove port.
The mobilization of the ascending colon is achieved with a simple Maryland monopolar dissector. The ileocolic vessels are clipped
laparoscopically, and the distal ileum is stapled and resected intracorporeally. The ascending colon is extracted through the
same 2.8-cm umbilical incision and its distal resection completed through the umbilicus protected by the wound protector used
for surgical glove port and for the SILS colectomy (see also Video, SDC 4, http://links.lww.com/TA/A431). The 2.8-cm umbilical
incision used for SILS colectomy and for extraction of the specimen (ascending colon). The pneumoperitoneum is then reestablished,
and the intracorporeal Latero-Lateral isoperistaltic ileocolic anastomosis is fashioned with aid of insertion of a further 5-mm trocar in
the left iliac fossa (see also Video, SDC 4, http://links.lww.com/TA/A431). B, Complete medialization of the ascending colon and
mobilization from the paracolic gutter (Cattel-Braash Maneuver) is still feasible in SILS with a simple monopolar Maryland dissector
and a grasper. The intracorporeal ileocolic anastomosis is fashioned laterolateral and isoperistaltic, introducing the flexible
endostapler from the umbilical glove port and entering the ileal and colonic enterotomies. C, Functional and aesthetic outcome in
a 37-year-old male patient after laparoscopic right colectomy with intracorporeal anastomosis for perforated appendiceal base with
perforated and gangrenous cecum. The procedure is started for an intended laparoscopic appendectomy, with umbilical port
for the camera and two trocars respectively in the left iliac fossa and suprapubic. After discovering a wide perforation of the
gangrenous cecum, the procedure is converted to a laparoscopic right colectomy. A further 12-mm trocar is added in the left upper
quadrant as operative port and for insertion of the endostapler. After completion of the entirely laparoscopic right colectomy
and intracorporeal anastomosis, the specimen is extracted through a mini-Pfannenstiel incision (4 cm), simply enlarging the incision
of the initial suprapubic port. Muscle splitting is preferred to decrease the postoperative pain and reduce the risk of bleeding
from the cut muscle and the incidence of wound infection, dehiscence, and incisional hernias (see also Video, SDC 2,
http://links.lww.com/TA/A429). D, The Ileocolic vessels are isolated and clipped separately. Although diffuse peritonitis and
mesenteric inflammation are present, it is always mandatory to find the correct avascular plane between the colonic mesentery
and the retroperitoneum for a safe dissection in a clean surgical field. The medial to lateral approach allows the view of the right
paracolic gutter peritoneum.

resources during night time and after-hours shifts. These and
many more issues contribute to make a laparoscopic approach
challenging and risky in an emergency setting and prevent the
development of ‘‘laparoscopic emergency surgery.’’ In many
rural hospitals, laparoscopic appendectomy for simple cases
of uncomplicated appendicitis is considered the only feasible
minimally invasive option among all emergency surgery operations.
This is even truer when the staff surgeon is young and/or is
an emergency surgeon with limited experience in laparoscopy.
Nevertheless, with adequate experience and appropriate
laparoscopic skills associated with laparoscopic techniques
that have been conveniently modified and adjusted for acute
care surgery, the laparoscopic approach can be used in cases of
appendicitis complicated with diffuse peritonitis or large pu-
rulent abscesses or for patients with acute cholecystitis, even
gangrenous or perforated, or associated with Common Bile Duct
lithiasis and/or acute pancreatitis. Edematous or fibrotic cho-
lecystitis can harbor technical challenges, but appropriate

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J Trauma Acute Care Surg
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Figure 3. A, Functional and aesthetic outcome in a 67-year-old male patient after laparoscopic reduction and mesh repair of a
strangulated paraesophageal hiatus hernia. The camera can either be placed in the umbilicus or in the epigastrium, above the
umbilicus. The remaining ports are inserted in the right and left upper quadrants. B, Intraoperative picture, after reduction of the giant
hiatal hernia and fixation of the mesh to the diaphragmatic crus with a semicircular crown of interrupted nonabsorbable
intracorporeal stitches. Big bites of the diaphragmatic muscle should be taken. Large diaphragmatic defects cannot be closed
primarily. C, Outcomes of SILS appendectomy for gangrenous appendicitis with a low-cost surgical glove port in a young patient
with multiple tattoos on both sides of the abdomen. The 1.8-cm umbilical incision is used for wound protector insertion and
surgical glove port SILS. The appendiceal specimen is then extracted and stored within a glove finger (see also Video, SDC 3,
http://links.lww.com/TA/A430). D, The internal space within the surgical glove can be used for protected retrieval of the
appendiceal specimen. The wound protector placed within the umbilical incision and used as a support for the SILS glove port
can be seen on top of the picture panel. This orifice represents also the entrance into the abdominal cavity.

skills may allow the safe completion of a laparoscopic pro-
cedure (see Videos, SDC 5 and 6, http://links.lww.com/TA/A432,
http://links.lww.com/TA/A433). Some cases, commonly defined
as ‘‘the nasty gallbladder’’, may be technically demanding
and require a ‘‘dome-down’’ technique (see Video, SDC 25,
http://links.lww.com/TA/A452). In case of suspected CBD
stones and biliary obstruction, intraoperative cholangiography
and transcystic biliary drainage are mandatory (see Video, SDC
7, http://links.lww.com/TA/A434).
Major advantages of laparoscopy can be observed in
patients with diffuse peritonitis from perforated peptic ulcers,
where laparoscopy can serve as a diagnostic tool and allow for
laparoscopic repair and effective peritoneal washout, with defi-
nite advantages and better outcomes in terms of less postoper-
ative pain, earlier mobilization with decreased postoperative
complications (e.g., pleural effusion, pneumonia etc), decreased
short- and long-term morbidity (SSI, incisional hernias), shorter
stay, and earlier return to work.9
Laparoscopy can also effectively and minimally invasively
address a wide range of acute clinical conditions. These include
bowel obstruction, particularly small-bowel obstruction due to a
single-band adhesion (Video, SDC 8, http://links.lww.com/TA/A435;
Fig. 4A); ischemic small bowel strangulated by volvulus on
a single band (Video, SDC 9, http://links.lww.com/TA/A436,
Fig. 4B); large-bowel obstructions from obstructing colon carci-
noma (Video, SDC 1 and 10, http://links.lww.com/TA/A428,
http://links.lww.com/TA/A437; Fig. 1C and D, Fig. 5); bowel
perforations, mostly perforated peptic ulcers (Video, SDC 11Y13,
http://links.lww.com/TA/A438, http://links.lww.com/TA/A439,
http://links.lww.com/TA/A440); diffuse peritonitis; evacuation
and drainage of large intra-abdominal abscesses or col-
lections not percutaneously accessible (Video, SDC 14,
http://links.lww.com/TA/A441); perforated diverticulitis treated
by laparoscopic lavage (Video, SDC 15 and 16,
http://links.lww.com/TA/A442 and http://links.lww.com/TA/A443,
Fig. 6) or laparoscopic Hartmann sigmoid resection with
end stoma (Video, SDC 17, http://links.lww.com/TA/A444;
Fig. 2A and B, Fig. 7); or even laparoscopic sigmoid resec-
tion and primary anastomosis (Hinchey Stage I, II, III, and
IV) (Video, SDC 18Y19, http://links.lww.com/TA/A445 and
http://links.lww.com/TA/A446); gastrointestinal bypasses
for unresect able intra-abdominal cancer or laparoscopic

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 J Trauma Acute Care Surg
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Figure 4. A, Outcomes after laparoscopic lysis of single band adhesion causing small bowel obstruction and volvulus in a
young female patient with previous open appendectomy. The suspected single band is presumed on the basis of finding a
transition point at computed tomographic scan in the right iliac fossa in a patient with previous appendectomy. Therefore, the
best ports triangulation is obtained from the left flank. Trocars 10 mm to 12 mm are inserted paramedian, 4 cm to 5 cm
lateral to the umbilicus, and the camera can be swapped between the paraumbilical and the left upper quadrant port. The 5-mm port
is always used for atraumatic graspers or scissors or suction tube. Both operator and assistant surgeons stay on the left side.
The assistant holding the camera is on the patient’s head side (see also Video, SDC 8 and 9, http://links.lww.com/TA/A435
and http://links.lww.com/TA/A436). B, The trocars are inserted in the left flank (Hasson trocar with open entry technique) and
two further ports in the left iliac fossa and left upper quadrant. This is the best triangulation for exploring the small bowel starting from
the cecum and running the small bowel distal to proximal until the transition point is found and the band is identified. When
exploring and searching the single band, only the mesentery should be gently grasped and pulled up. When the band is identified,
the mesentery should not be left going down and held in place with the grasper, the band is therefore underpassed using a grasper
as a ‘‘right angle’’ and lifted up. Then, while holding the band spread with a grasper, the mesentery can be released and left down and
the scissors are inserted; finally the band is cut with cold scissors, obtaining immediate relief of the bowel obstruction and
strangulation (see also Video, SDC 8 and 9, http://links.lww.com/TA/A435 and http://links.lww.com/TA/A436). C, Postoperative
result of laparoscopic adhesiolysis in a patient with adhesive small-bowel obstruction after a previous open colectomy via midline
incision, performed 4 months earlier. In patients with diffuse matted adhesions after a recent open colectomy and a transition
point at computed tomography, the adhesive small-bowel obstruction is approached always from the left flank. The port sites
are close to each other given the reduced space for trocar insertion. The left hypochondrium was the zone freer from adhesions
and the safest area to get access. The camera was in the Hasson trocar in the paraumbilical port. The operating surgeon stays on the
side of the patient’s head and uses as operative trocars mainly the two left upper quadrant ports or the 5-mm trocar in
hypochondrium and the paraumbilical Hasson port. D, A careful adhesiolysis from the midline incision is best performed
using a 30-degree camera and watching the bowel wall from below. A cold adhesiolysis is used to avoid thermal injury; staying
on the right avascular plane prevents bleeding and enterotomies. The safest method to separate the bowel loops from the
anterior abdominal wall is to use the scissors with the curve oriented upwards, opposite to the bowel wall.

gastrojejunostomy for relief of neoplastic gastric outlet ob-
struction (Video, SDC 20, http://links.lww.com/TA/A447);
and the reduction and eventual repair of incarcerated/strangulated
inguinal (Video, SDC 21, http://links.lww.com/TA/A448) and inci-
sional hernias (Fig. 8, Video, SDC 22, http://links.lww.com/TA/A449).
An example of the best advantages in avoiding a large
laparotomy is the laparoscopic approach for small-bowel ob-
struction due to postoperative adhesions. In selected cases
of ASBO, following the correct guidelines indications for
laparoscopic approach,10 the advantages from laparoscopically
freeing the strangulated bowel by simple sharp dissection of
the strangulating band11 are potentially great and can con-
tribute to significantly decrease the duration of surgery. In
fact within a few minutes the SB obstruction can be relieved
(Video, SDC 8 and 9, http://links.lww.com/TA/A435 and
http://links.lww.com/TA/A436; Fig. 4C) without need for

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J Trauma Acute Care Surg
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Figure 5. Functional and aesthetic outcome of a laparoscopic Hartmann and sigmoid resection in a 73-year-old female with
complete large-bowel obstruction for sigmoid carcinoma. A, Sigmoid colon is fully mobilized and resected laparoscopically, from
the right-side ports. On the right iliac fossa is inserted a 12-mm large port which is used for introducing the endostapler and
distal colonic resection. On the left flank, a fourth port is inserted for the assistant surgeon. The sigmoid is then extracted from
the left flank, just enlarging the left port to a 4-cm incision. B, The end colostomy is fashioned on the left flank, fixed on the fascia
of the same incision used for specimen extraction (see also Video, SDC 10, http://links.lww.com/TA/A437). C, The sigmoid is completely
obstructed from a malignant stenosis. Both large bowel and small bowel are distended. D, Diastasis of the cecum and the torn tenia
are clearly visible. The diastatic perforation of the cecum has to be feared in case of an advanced large-bowel obstruction.

opening and closing a median laparotomy, with significantly
less postoperative pain, a shorter time to recovery, and reduced
postoperative complications, either at short or long-term.12
The advantage of such a minimally invasive approach is still
significant in patients with disseminated intra-abdominal
cancer and peritoneal carcinomatosis, where laparoscopy
can be both diagnostic and therapeutic (Video, SDC 23,
http://links.lww.com/TA/A450). In such patients, laparos-
copy may provide relief of small-bowel obstruction with a
laparoscopically fashioned loop ileostomy as well as avoid
additional pain from laparotomy and facilitate an early dis-
charge for palliative care.
The acute incarceration of paraesophageal hernias can be
a life-threatening surgical emergency; it often occurs in elderly
patients with significant comorbidities who have historically
been treated with open abdominal or thoracic incisions, both of
which are associated with significant morbidity and mortality.
However, emergent laparoscopic repair of acutely symptomatic
paraesophageal hernias, even when large and incarcerated or
strangulated, is feasible, safe, and effective and may achieve
better outcomes.13 This advantage is even more significant in
elderly patients with comorbidities who may receive the greatest
advantages from minimally invasive surgery and experience less
postoperative pain (Fig. 4A).
Laparoscopy and minimally invasive techniques
have dramatically changed the perspectives in the man-
agement of acute perforated diverticulitis (Video, SDC 24,
http://links.lww.com/TA/A451; Fig. 6). Diverticular disease
is a common condition, and perforated diverticulitis was
previously associated with aggressive and significantly morbid
surgical intervention, traditionally based on a midline laparoto-
my and Hartmann’s sigmoid resection with end colostomy. Open
surgery and end colostomy increase length of stay and costs and
negatively affect quality of life. Recently, laparoscopic lavage
emerged as an effective minimally invasive alternative for pa-
tients with perforated diverticulitis with purulent peritonitis.
Laparoscopic treatment by nonresectional lavage and drainage
has potential of improving health and reducing costs. A ran-
domized controlled trial (NCT01317485)14 to investigate the
safety and efficacy of this minimally invasive approach is on-
going. Single-incision laparoscopic sigmoidectomy is an attrac-
tive alternative to either open colectomy or traditional multiport
laparoscopy for elective management of diverticular disease.
Advantages include better cosmetic results and less pain, even

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 J Trauma Acute Care Surg
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Figure 6. Functional and aesthetic outcome in a 68-year-old female patient after laparoscopic lavage and drainage for Hinchey III
perforated acute diverticulitis with purulent peritonitis and SILS elective sigmoidectomy with intracorporeal anastomosis
planned 6 months after the acute phase (see also Video, SDC 15 and 24, http://links.lww.com/TA/A442, http://links.lww.com/TA/A451).
A, Laparoscopic lavage in acute setting is performed as a laparoscopic sigmoidectomy, with operative trocars placed in the right flank
and the camera in the umbilicus. Drains may be placed from either right abdominal or left laparoscopic ports. B, The SILS elective
sigmoidectomy is performed through a 2-cm umbilical incision. The sigmoid mobilization, mesenteric dissection, and distal colonic
resection are all performed laparoscopically. From the SILS umbilical incision, the sigmoid is exteriorized, after its laparoscopic wide
mobilization and distal resection, and the proximal resection is completed. The anvil is also inserted in the proximal left colonic
stump and secured with a purse string suture. The proximal stump is then reinserted in the abdomen, and the pneumoperitoneum
is reestablished. The colorectal anastomosis is performed intracorporeally with the aid of a transanal circular stapler. C, At the time of
acute diverticulitis, a purulent peritonitis without overt perforation is found, and according to the patient’s informed consent, the
patient was randomized to the LADIES Trial, and after randomization, laparoscopic copious lavage and drainage is performed.
D, After 6 months, the patient underwent SILS sigmoidectomy. The intraoperative view shows some adhesions between the small and
the sigmoid, carefully freed. The sigmoid is adherent to the abdominal wall, and this facilitates the mesenteric dissection, holding
the colon naturally suspended, and the harmonic scissors can start the dissection from sacrum promontorium, clearly visible. The
SILS resection is completed, the specimen is extracted transumbilically with same-time anvil insertion in the proximal colon, and finally,
an intracorporeal transanal Knight Griffen anastomosis is performed.

when compared with traditional laparoscopy where multiple
ports are used and an additional incision (usually Pfannenstiel)
for specimen extraction is needed.
Therefore, in selected patients,15 laparoscopic lavage
allows avoidance of laparotomy, stoma formation, and subse-
quent morbidity.
Laparoscopy offers clear advantages and excellent results
even in patients with Hinchey IV perforated diverticulitis, where
although the Hartmann’s procedure remains the preferred and
safest choice (the Ladies Trial is currrently investigating the
safety of sigmoid resection and primary anastomosis vs end
colostomy) the sigmoid resection can be safely and enterily
performed laparoscopically and the specimen extracted from
the left flank through the same site where the end stoma will
be fashioned (Fig. 9).
A laparoscopically performed Hartmann’s resection
should always undergo a laparoscopic reversal. Often, after few
months the post-operative adhesions are much less following a
first minimally invasive procedure and the colo-rectal anasto-
mosis is quick and easy to be performed with a trans-anal
stapled end-to-end anastomosis. The final result of this modern
"two-stage" procedure guarantee good functional and aesthetic
outcomes, having the patients avoided twice a midline lapa-
rotomy (Fig. 10).
The only real contraindication to the use of laparoscopy
in an emergency setting as an acute care surgery procedure is
in patients exhibiting hemodynamic instability and severe
hemorrhagic or septic shock. The induction of pneumo-
peritoneum and venous flow return compromise may be easily
fatal in such cases. A further relative contraindication to be

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J Trauma Acute Care Surg
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Figure 7. A and B, Extraction of the sigmoid and descending colon in a laparoscopic Hartmann. The port in the left flank is slightly
enlarged to 4 cm to 5 cm, depending on the size of the colonic specimen, and the proximal resection is completed outside with
a simple electrocautery. The edges of the descending colon are then secured to the fascia and the mucosa sutured to the skin,
fashioning the final end colostomy. C and D, Postoperative results of a 79-year-old patient who underwent laparoscopic Hartmann
for fecal peritonitis from a large diverticular perforation of the sigmoid colon. Right-sided drain was removed on the fifth postoperative
day, and the colostomy was matured and functioning on the left flank, from the left port incision, used for specimen extraction.

considered remains a severe respiratory failure with severe
hypercapnia, owing to the possible reabsorption of CO2 and
development of malignant hypercapnia and toxic shock syn-
drome.16 However, a wise ventilatory strategy, increasing the
minute volume of ventilation, and further measures by de-
creasing the intra-abdominal pressure and the angle of
Trendelenburg position might be helpful in mitigating these
challenges.
For the remaining categories of patients, provided that they
are hemodynamically stable and not in septic or hemorrhagic
shock, the benefits of laparoscopy and minimally invasive tech-
niques result in an exponential increase of the advantages in terms
of postoperative recovery and fewer wound complications. These
benefits are relevant not only in young patients but, contrary to
commonly held beliefs, even more significant in the elderly
patients.
The advantages of laparoscopy will be greater in an el-
derly patient presenting with diffuse peritonitis, who may avoid
a large and painful laparotomy incision. Avoiding a median
laparotomy incision can also significantly decrease the risk of
wound infection and dehiscence. Laparotomy is invariably
associated with significant postoperative pain, which can cause
cardiovascular and respiratory complications (less depth and
effectiveness of breathing as a consequence of attempting to
reduce pain at every movement, ultimately leading to an in-
creased risk of atelectasis and pneumonia) as well as circulatory
complications (delayed mobilization with consequent increased
risk of deep venous thrombosis and possible pulmonary embo-
lism). All these negative consequences will be much more sig-
nificant in an elderly patient compared with a young patient who
undergoes a small open appendectomy for a slightly inflamed
appendix or a simple open cholecystectomy for gallstones, re-
quiring limited open surgical incisions (i.e., Mc Burney or Lanz
incision or a right subcostal).
PATHOPHYSIOLOGIC BASIS OF THE
ADVANTAGES OF LESS INVASIVE SURGERY IN
ABDOMINAL SEPSIS AND ACUTE CARE
SURGICAL PATIENTS
Recent research has focused on the molecular basis of
inflammation of traumatic injuries to human tissues, discovering
that mitochondrial structures released by injured cells possibly
prompt inflammation during heart, kidney, or brain ischemia-
reperfusion injuries, in which local neutrophil activation and
further tissue damage occur when the blood flow is restored.
Finally, the mitochondria are probably released in patients
with infectious diseaseVin whom substantial cell death takes
placeVpossibly contributing to the molecular pathology of sepsis.17
These concepts form the basis for the consideration that
traumatic and surgical tissue injury drives the inflammatory
response through endogenous danger molecules, even more

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 J Trauma Acute Care Surg
Di Saverio Volume 77, Number 2

Figure 8. A, Postoperative results of an obese female patient with bowel obstruction and strangulated incisional hernia, who
underwent laparoscopic adhesiolysis, freeing of strangulated ileal bowel loop, and laparoscopic incisional hernia repair with
intraperitoneal dual mesh placement. All trocars are inserted on the left flank, which is the best position for both exploring the small
bowel distal to proximal starting from the cecum and perform adhesiolysis as well as for reduction of the strangulated incisional
hernia from the anterior abdominal wall and intraperitoneal mesh repair insertion and placement. B, Postoperative results of a male
patient with bowel obstruction and incarcerated incisional hernia, who underwent laparoscopic adhesiolysis and laparoscopic
incisional hernia repair with intraperitoneal dual mesh placement. The incarcerated incisional hernia was on the left side, and the
laparoscopic approach started from the right flank. Trocars are inserted low in the right flank to allow easy exploration and
adhesiolysis on the anterior abdominal wall. The incisional hernia reduction and insertion and fixation of the mesh on the anterior
abdominal wall are also easy from such lateral port sites (see also Video, SDC 22, http://links.lww.com/TA/A449). C, Operative
technique of reducing the incarcerated small bowel. While the first operator is carefully grasping only the mesentery (avoid any
grasping on the distended and edematous bowel wall) and gently pulling down the bowel loop, the assistant surgeon is helping by
attempt of manual reduction of the hernia content from outside the abdominal wall. This technique from both sides is highly effective
in reducing the incarcerated bowel loop, decreasing the risk of traumatizing the bowel and tearing the wall when the reduction is only
attempted from one side. D, After careful assessment of the viability of the reduced bowel and reversal of ischemia, a prolonged
washout is performed, the hernia sac is excised as much as possible, and an infection-resistant dual mesh is opened and fixed
intraperitoneally with tacks and stay transabdominal sutures. The pneumoperitoneum is gradually deflated while holding the
available omentum to avoid leaving the bowel in direct contact with the mesh and tacks.

significantly when hemorrhagic shock or infection is present.
In managing muscoloskeletal injuries, the concept has emerged
that minimally invasive techniques for fixation and insertion of
plates through incisions away from the fractures may decrease
the release of proinflammatory elements with local and sys-
temic effects from the mitochondria, causing or worsening
widespread inflammation and precipitating secondary organ
injury, especially to the lung and kidneys.18 Therefore, it can
easily be assumed that the immune response correlates with
inflammatory markers associated with injury severity and, as a
consequence, the magnitude of surgical interventions may
influence the clinical outcomes through the production of
molecular factors, ultimately inducing systemic inflammatory
response.
Not surprisingly, it is already known that surgical stress
response and postoperative immune function are considerably
better after laparoscopy. In fact, a recent randomized trial
showed that immune function of human leukocyte antigen-DR
in patients undergoing laparoscopic colectomy for cancer with
fast-track care remains highest and promotes an accelerated
recovery.19 Laparoscopic colorectal surgery has been demon-
strated also to inhibit the release of postoperative inflammatory
factors with a reduction in perioperative trauma and stress,
which together plays a protective role on the postoperative
immune system.20
These beneficial effects are even more prominent in the
acute care setting and in emergency surgical patients undergoing
laparoscopic operation for acute cholecystitis complicated by

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J Trauma Acute Care Surg
Volume 77, Number 2 Di Saverio

Figure 9. A and B, Postoperative results of a 72-year-old female underwent laparoscopic Hartmann’s resection for Hinchey Stage IV
perforated diverticulitis with diffuse fecal peritonitis (hemodynamically stable). The ports are in the right flank, and the camera is in
the umbilicus. Double JP drains are left given the diffuse fecal peritonitis, inferior in the Douglas pouch on the rectal stump and
superior in the right hypochondrium. C, The overt colonic perforation is clearly visible. In such condition, resection is mandatory,
and neither primary suture nor laparoscopic lavage is feasible. D, The sigmoid is always exteriorized from the left flank port; the
proximal resection can be completed outside, allowing the assessment of a good margin for the resection (viable colon and free of
diverticula), and the stoma is fashioned in the same site.

peritonitis, where open surgery increased the incidence of bac-
teremia, endotoxemia, and systemic inflammation compared
with laparoscopy and caused lower transient immunologic de-
fense, leading to enhanced sepsis in the patients who underwent
open procedures.21 Similar findings have been recently reported
for perforated peptic ulcer repair22 and perforated appendicitis.23
Several findings support the evidence that, by inflicting less
trauma when using laparoscopy, the healing response is more
efficient, especially in septic patients.24 Nonetheless, it was al-
ready well-known from animal models that the peritoneal re-
sponse to sepsis is better preserved after laparoscopy than after
open surgery.25 CO2 does not seem to influence bacterial growth,
and laparoscopy entails less local trauma and better preserves
intra-abdominal conditions.
Hence, the evolution and popularity of minimally inva-
sive and laparoscopic techniques in emergency surgery is truly
becoming a new discipline and an innovative approach to
surgical emergencies with both diagnostic and therapeutic in-
dications. The use of laparoscopy for treating abdominal sur-
gical emergencies can be defined as emergency laparoscopy.
Emergency laparoscopy, in the presence of appropriate skills, can
carry even greater benefits to the patients needing an emergent/
urgent operation. This kind of acute care surgical patients are
often elderly and with significant comorbidities, they have intra-
abdominal infections, and may harbor diffuse peritonitis or
large intra-abdominal collections. In such acute surgical pa-
tients a less invasive approach can be beneficial, as long as the
operating surgeon is able to laparoscopically perform the same
procedures as he would do in open surgery and therefore
guarantee at least equal or better results in terms of safety and
efficacy.
The rules for an emergency laparoscopic surgeon should
be the same as those for emergency and acute care surgeons:
common sense and a commitment to performing procedures as
safely and as effectively as in open traditional surgery. With
appropriate training, skills, and judicious use, emergency
laparoscopy may easily become an extremely valuable tool for
the modern acute care surgeon.
Even within emergency laparoscopy, techniques such
as SILS and LESS can be viable options, if in experienced
hands and with specific skills, to address complicated ab-
dominal pathology, such as gangrenous or perforated ap-
pendicitis with localized abscess or selected cases of diffuse
peritonitis. The patient can benefit from a laparoscopic tech-
nique with a single small umbilical incision.
Despite the current worldwide economic crisis leading
to a decrease in health care budgets, these laparoscopic pro-
cedures can be offered to all patients, both in urgent and elective
settings, even in rural or peripheral hospitals, thanks to ‘‘low-cost’’
laparoscopic equipment and techniques. Low-cost minimally

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 J Trauma Acute Care Surg
Di Saverio Volume 77, Number 2

Figure 10. A, Functional and aesthetic outcome of laparoscopic Hartmann’s procedure with end colostomy for purulent peritonitis
from diverticular perforation (Hinchey Stage III). The sigmoidectomy is performed using three to four trocars: camera in the umbilicus
and two 12- and 5-mm trocars in the right iliac fossa and right upper quadrant. A fourth trocar on the left flank, just on the site of
the specimen extraction and stoma creation, may be useful for the assistant surgeon and for holding the sigmoid colon up. The specimen
is extracted through an enlargement of the left flank port site and on the same hole the end colostomy is fashioned (see also Video,
SDC 17, http://links.lww.com/TA/A444). B, Laparoscopic Hartmann’s reversal 5 months later on the same patient. The trocars are
inserted in the same position as in the previous laparoscopic Hartmann’s procedure. The colostomy is disconnected from the fascial
edges and the edges debrided. The anvil is inserted in the proximal colon and, after reinduction of the pneumoperitoneum, a transanal
circular laparoscopic anastomosis is performed (see also Video, SDC 17, http://links.lww.com/TA/A444). C, At the time of
Hartmann’s reversal, the beneficial effects of laparoscopic are more evident. Minimal or absent postoperative adhesions are found.
The stoma can be easily isolated and disconnected from the fascial edges. D, The rectal stump is easily found and can be further mobilized
before transanal stapler insertion.

invasive techniques may allow one to perform laparoscopic ap-
pendectomies without compromising the quality of results or
affecting patient safety, even with single-access technique and in
cases of ‘‘difficult’’ appendicitis with localized or diffuse peri-
tonitis, or to perform any other laparoscopic procedure in urgent
settings, with low-cost toolkits and instruments that can be
available also in rural or peripheral hospitals and in areas with
limited resources.26 These low-cost laparoscopic techniques for
emergency and elective surgery may decrease both health care
and operative costs, in experienced hands with laparoscopic
techniques and use of less expensive devices.
THE FUTURE CHALLENGE: DEVELOPMENT OF A
NEW BRANCH BRIDGING BETWEEN
LAPAROSCOPY AND EMERGENCY SURGERY
If the recent concept of emergency surgery has evolved
and merged into the entity of acute care surgery,27 where the
surgeon has specific skills and dedicated education,28 the new
concept of ‘‘acute care laparoscopy’’ is emerging, where the
surgeon should be able to combine the skills and experience of
both acute care emergency surgery with laparoscopic ability
and minimally invasive techniques.
Emergency laparoscopy is now becoming a new dis-
cipline, aiming to join together the difficult issues of emer-
gency surgery with the potential advantages of minimally
invasive surgery techniques. This new branch, bridging lapa-
roscopy and emergency surgery, has the potential to extend the
advantages, traditionally limited to the elective patients, to a
wider population of patients, often older and with comorbidities,
presenting with acute abdomen or acute surgical conditions.
Supplemental Digital Content Legends
Video 1: Laparoscopic left hemicolectomy with intra-
corporeal anastomosis for partial LBO from obstructing de-
scending colon carcinoma.
Video 2: Laparoscopic right hemicolectomy with in-
tracorporeal anastomosis for perforated caecum and diffuse
peritonitis.
Video 3: Surgical glove port SILS for complicated acute
appendicitis.

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J Trauma Acute Care Surg
Volume 77, Number 2
Video 4: SILS right colectomy for cecal perforated di-
verticulitis with intracorporeal anastomosis.
Video 5: Laparoscopic cholecystectomy for edematous
cholecystitis.
Video 6: Laparoscopic cholecystectomy for fibrotic
cholecystitis.
Video 7: Laparoscopic cholecystectomy for acute cho-
lecystitis with intraoperative cholangiography and transcystic
drain.
Video 8: Laparoscopic lysis of a strangulating single
band in a patient with ASBO.
Video 9: Laparoscopic lysis of a strangulating band with
relief of small bowel volvulus and recovering bowel ischemia.
Video 10: Laparoscopic Hartmann’s resection for LBO
from obstructing sigmoid carcinoma and minimally invasive
stoma fashioning.
Video 11: Laparoscopic repair of a large perforated
peptic ulcer.
Video 12: Methylene blue localization of a microscopic,
hardly visible PPU.
Video 13: Laparoscopic technique for repair and he-
mostasis of a perforated and actively bleeding peptic ulcer.
Video 14: Laparoscopic lavage and drainage of large
pelvic and inter-loop abscesses (Hinchey II acute diverticuli-
tis), not amenable to percutaneous drainage.
Video 15: Laparoscopic lavage and drainage for Hinchey
III perforated diverticulitis, with free air and purulent peritonitis.
Video 16: Laparoscopic lavage and drainage for diffuse
peritonitis from Hinchey III perforated diverticulitis and primary
suture of a small probable perforation, without evidence of a
colonic wall disruption, in an 86-year-old male patient.
Video 17: Laparoscopic Hartmann’s sigmoid resection
for Hinchey III perforated diverticulitis in a 51-year-old male
and laparoscopic reversal of the colostomy 6 months later.
Video 18: Laparoscopic sigmoidectomy and primary
anastomosis for diverticulitis Hinchey I with a confined abscess
involving the fallopian and the left ureter.
Video 19: Laparoscopic sigmoidectomy with primary
colorectal transanal anastomosis for perforated diverticulitis
Hinchey III with purulent peritonitis and free air in a 44-year-
old male patient.
Video 20: Laparoscopic gastric intracorporeal anasto-
mosis for the bypass of a complete gastric outlet obstruction in
an elderly patient with locally advanced gallbladder carcinoma.
Video 21: Laparoscopy for relief of small bowel ob-
struction after recent hernioplasty and reduction of SB recurrent
herniation. Depicts avoidance of reopening the inguinal access
and therefore avoidance of the risk of mesh contamination.
Video 22: Laparoscopic reduction and mesh repair of
strangulated or incarcerated incisional hernias in obese
Video 23: Laparoscopy for small bowel obstruction with
finding of peritoneal carcinomatosis, performing biopsy, ad-
hesiolysys and loop ileostomy.
Video 24: Multi-step minimally invasive approach to
perforated acute diverticulitis Hinchey stage II with lapa-
roscopic lavage and elective SILS sigmoidectomy a few
months later.
Video 25: The Nasty gallbladder: Dome-down laparo-
scopic cholecystectomy for largely gangrenous acute cholecystitis.
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Di Saverio
The 63-years old patient had a Severe cholecystitis according to
the definition of TG13 Tokyo Guidelines, presenting with oliguria,
PT of 60%, PLT 71.000/mmc, WCC 1.920/mmc and a CT scan
with signs of gangrenous cholecystitis and free fluid.
ACKNOWLEDGMENT
All intraoperative and postoperative pictures and all movies belong to
Dr. Di Saverio’s library of personal surgical procedures and from his own
patient’s database.
The Author would like to thankfully acknowledge Prof. Elio Jovine, head
of the Department of Surgery, for his commitment in promoting min-
imally invasive procedures in both elective and emergency surgery and
for mentoring his peers as a master of surgery would do. I also thank my
colleagues Dr. Gregorio Tugnoli, MD, head of the Trauma Surgery Unit
in Maggiore Hospital, Dr. Andrea Biscardi, MD and Dr. Fausto Catena,
founder of the World Society of Emergency Surgery, for their constant
support to Dr. Di Saverio s commitment in developing laparoscopy in
the field of acute care and emergency surgery. Finally, I thank Massimo
Annicchiarico, MD, Giovanni Gordini, MD and all members of the Board
of Directors of AUSL Bologna for their continuos efforts in supporting the
commitment of Maggiore Hospital for Acute Care and Trauma Surgery
and for investing in the development of minimally invasive surgery.
Maggiore Hospital has been for more than 30 years the regional referral
center for acute care and trauma surgery.
DISCLOSURE
The author declares no conflict of interest.
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