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Editor
Vincenzo Mandalà
Surgical and Emergencies Department
“Villa Sofia – Cervello” Hospital Trust
Palermo, Italy

In collaboration with
Antonino Mirabella
Massimo Lupo

The publication and the distribution of this volume have been supported by the Italian
Society of Surgery

The Editor acknowledges the educational contribution offered by Johnson & Johnson
Medical S.p.A.

ISBN 978-88-470-2326-0 ISBN 978-88-470-2327-7 (eBook)

DOI 10.1007/978-88-470-2327-7
Springer Milan Dordrecht Heidelberg London New York

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 This book is dedicated to all Italian Surgeons,
a group to which I proudly belong.

To Elisabetta, Giuliana and Stefano,

and the whole family,
in particular to my father,
my greatest supporter during the beginning of my career.
Foreword

It is my great honor and pleasure to write a preface for this new book from
Springer focusing on the role of laparoscopy in emergency surgery.
The work has been edited and supervised by Vincenzo Mandalà, an undis-
puted expert in modern emergency and trauma surgery, and it presents an
excellent overview of the methodologies practiced by the major Italian surgery
schools, which have elevated the mini-invasive approach to a principle govern-
ing their work and, one might add, their overall approach as clinicians.
The book provides an effective summary of many of the already well-estab-
lished techniques as well as other, more innovative ones, all of which are
employed in compliance with the emergency and safety criteria required by
this particular surgical field.
Emergency surgery is one of the most demanding branches of general sur-
gery: time is crucial and any decision must be immediate but nonetheless
agreed upon by a multidisciplinary team of surgeons and anesthesiologists
able to recognize the benefits of mini-invasive surgery not just during the pro-
cedure itself but, above all, during the postoperative period. This is particular-
ly true for the most complex cases. Furthermore, surgeons working in an
increasingly technological setting need to be supported by nursing and med-
ical teams familiar with the sophisticated and constantly changing equipmentt
and materials.
In this setting, continuing education plays a crucial role, and books like this
one, which summarize techniques, protocols, and evidence, can support sur-
geons in their decision-making when they are dealing with the various clinical
and organizational problems common to both small and large hospitals.
The work–one could even say, the mission–that Vincenzo Mandalà has
been carrying out in the most important Italian and international scientific
societies makes him an ideal advocate of the approaches underlying this spe-
cific surgical field and so well-presented in this volume.

vii
viii Foreword

What is certain is that emergency laparoscopy has made the transition and
is no longer the last diagnostic step but the first–and, in many cases, the
only–therapeutic step.
Thank you Vincenzo for this very fine job!

Rome, October 2011 Gianluigi Melotti

President, Italian Society of Surgery
Preface

Over the last ten years of my professional activity and particularly since 1999 I
have been working as head of department at “Villa Sofia-CTO Hospital Trust”
in Palermo. The mission of the Hospital Trust is emergency (it has been recog-
nized as a level III leading regional center and a DEA level II, a Department off
Emergency and Admission of a high level) and since there was no mini-invasive
surgery unit, I decided to make every effort in my daily professional and organi-
zational life towards this new surgical approach. I wanted not only to improve
elective laparoscopic advanced surgery, but also to raise the level of emergency
surgery by introducing standardized emergency surgery protocols.
Since 1992 I have devoted my professional life to laparoscopic surgery.
During a previous experience as the Director of an operative surgery unit in a
suburban Hospital (Cefalù Hospital), we had to enhance the use of diagnostic
laparoscopy extensively, because of the structural problems and the lack off
radiologic imaging modalities such as CT and MR. The laparoscopic approach
was, therefore, used for abdominal emergencies, particularly appendicularr
peritonitis caused by acute appendicitis and perforated ulcers, acute cholecys-
titis and emergencies of the abdominal wall.
In that period I realized how important diagnostic laparoscopy was not only
for neoplastic problems but also for intra-abdominal peritonitis and for non-
specific abdominal pains that mostly affected young women. I found myselff
being a pioneer of laparoscopic surgery, a technique which can sometimes
ensure therapeutic resolutions with all the benefits that we know.
In 1999, I found in the Villa Sofia hospital the structural strength of a large
hospital equipped with spiral CT scanning, MR, angiography (although limit-
ed), the possibility of intraoperative blood recuperation and intensive care
units. For this reason my main aim was to increase emergency laparoscopic
surgery, although I have to admit I encountered strong resistance from seniorr
doctors and inexperience but enthusiasm in younger colleagues.
Peritonitis and other nontraumatic emergencies using a laparoscopic
approach were the first to be carried out, but as my older colleagues opposed
the use of mini-invasive surgery, especially for hemoperitoneum, I had to ded-
icate myself to tackling abdominal traumas.
ix
x Preface

Going through the literature concerning abdominal trauma, I realized thatt

laparoscopy had started to be used much earlier than when it actually emerged
as a preferred surgical technique, especially for the most dangerous and neg-
lected field of trauma. Estes, Gazzaniga, Cuschieri and Bercy’s experiences inn
fact go back to the 1970s and 1980s.
The problem was not only the doubts regarding the possible benefits of the
laparoscopic approach, but - as several trauma surgeons have highlighted - also
the dilemma to decide when and if a laparotomy has to be carried out. This
was underlined by many authors who stressed that missed injuries and there-
fore an unacceptable delay in treatment should be considered extremely dan-
gerous for patients. They referred to an axiom: the first rule for emergency
abdominal surgery in general, and in particular for trauma abdominal sur-
gery, is the final treatment of all lesions.
A more recent analysis, although it is not easy to find and elaborate
prospective randomized studies, has highlighted that laparotomy is associated
with mortality, morbidity and a series of complications which become unac-
ceptable especially when exploration proves negative or nontherapeutic; there-
fore, all diagnostic procedures, both invasive and noninvasive, become
unavoidable if they can reduce explorations which are uncomfortable and use-
less. Laparoscopy has, recently, shown that when it is carried out by capable
hands it can, indisputably, reduce useless explorative laparotomies in at leastt
40-60% of trauma cases, in particular, for the peritoneal evaluation of the tra-
jectory in penetrating injuries, for diaphragmatic ruptures both in open or
blunt trauma and also for the evaluation of non-active bleeding.
Furthermore, laparoscopy allows the surgeon to wait and provides the pos-
sibility of using interventional complementary therapies. It must also be
stressed that the percentage rate of missed injuries and delayed treatment has
dropped 5-10% in the latest evaluations.
Laparoscopy has reached a wider use also thanks to its therapeutic poten-
tial, which in the past only concerned some treatment for hemoperitoneum
caused by liver and splenic lesions after blunt trauma and for the identification
of peritoneal penetration in penetrating trauma. Recently laparoscopy has been
widely used for minor lesions (moderate bleeding of the mesentery or moder-
ate lesions of hollow viscous) especially when the surgeon is expert att
advanced laparoscopy surgery.
The therapeutic potential of laparoscopy is even more important for emer-
gency nontraumatic surgery. At the beginning of the 1980s Philippe Mourett
also demonstrated the real advantages of laparoscopy in acute appendicitis,
adhesiolysis and also in peritonitis caused by perforated ulcers.
In the last ten years, as the methodology has undergone increasing
improvement it has been possible to carry out laparoscopy in perforated diver-
ticulitis and small bowel obstruction by adhesion and nonadhesion and the
approach to nonspecific abdominal pain. Acute pancreatitis and mesenteric
ischemia are still to be taken into consideration.
Preface xi

Of course in very many situations laparoscopy cannot be resolutive, butt

laparoscopic assisted surgery (tailored minilaparotomy) or hand assisted tech-
niques can prove beneficial. Findings in the literature demonstrate that these
two different laparoscopic procedures offer the same advantages as pure
laparoscopy.
This book about laparoscopy in abdominal emergencies which we believe
is the first of its kind has the purpose of underlining the meaning and the
potential of minimally invasive surgery in abdominal emergency in trauma and
nontraumatic fields.
I am convinced that this study, which is meant to be a guide for specialists
and dedicated surgeons, is principally addressed to young internal and trainee
surgeons who are faced with emergencies on a daily basis and may also come
up against medicolegal problems when they have to take rapid and effective
decisions.
Besides being an easy text for consultation, I hope it can stimulate all col-
leagues with an interest in these problems. I am strongly convinced that we can
meet the challenge of putting together guidelines, protocols and records, in
order to standardize topics that are currently only in the planning stage.
Finally, I am sure that the ever growing technological innovations togetherr
with the technical experience of surgical teams will ensure that today’s role off
laparoscopy in emergency abdominal surgery will maintain its continual and
exponential growth. This will make it a diagnostic and therapeutic strong pointt
in so many decisional algorithms of emergency surgery.
Lastly, I would like to make some acknowledgments: to the board of the
governors of the Italian Society of Surgery and its President Professor Melotti,
an experienced surgeon in this area, for giving me the opportunity to submitt
this manuscript on behalf of the Association; to Professor Enrico De Antoni forr
considering my request years ago; and to all the professors, colleagues and my
dear assistants who have actively collaborated in the writing of this book and
to the publisher Springer Verlag Italia for the effective book layout, the assis-
tance and the patience during the production of this book.

Palermo, October 2011 Vincenzo Mandalà

Contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XV

1 Diagnostic Laparoscopy in Abdominal Emergencies . . . . . . . . . . . . . . 1

Ferdinando Agresta, Antonello Mirabella, Natalino Bedin
and Vincenzo Mandalà

2 Gastroduodenal Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Antonino Mirabella, Massimo Lupo, Fausto Di Marco
and Vincenzo Mandalà

3 Acute Cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Fabio Cesare Campanile, Paolo Colobraro, Nicola Foti,
Massimo Lupo and Vincenzo Mandalà

4 Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Carlo Staudacher, Gianpaolo Balzano, Nicolò Pecorelli
and Vincenzo Mandalà

5 Acute Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Antonino Mirabella, Nereo Vettoretto, Massimo Lupo,
Fausto Di Marco and Vincenzo Mandalà

6 Role of Laparoscopy in the Treatment of Acute Diverticulitis:

an Evidence-Based Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Boris Franzato, Stefano Mandalà, Grazia Fusco and Carlo Sartori

7 Adhesive Small Bowel Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Fausto Catena, Salomone Di Saverio, Luca Ansaloni,
Antonio Pinna, Massimo Lupo, Antonino Mirabella
and Vincenzo Mandalà

xiii
xiv Contents

8 Incarcerated Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Micaela Piccoli, Grazia M. Attinà, Domenico Marchi,
Vincenzo Trapani and Gianluigi Melotti

9 Laparoscopy in Acute Mesenteric Ischemia . . . . . . . . . . . . . . . . . . . . . 117

Gianfranco Cocorullo, Antonino Mirabella, Gaspare Gulotta
and Vincenzo Mandalà

10 Laparoscopic Approach in Gynecologic Emergencies . . . . . . . . . . . . 129

Luciano Casciola, Graziano Ceccarelli and Alberto Patriti

11 Nonspecific Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Mario Morino and Federico Famiglietti

12 Intestinal Bleeding and Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Annunziato Tricarico, Gabriele Salvatore, Gianluca Lanni,
Raffaele Landi and Vincenzo Mandalà

13 The Role of Laparoscopy in Emergency Treatment

of Complications after Laparoscopic and Endoscopic
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Francesco Corcione, Diego Cuccurullo, Felice Pirozzi,
Antonio Sciuto, Camillo La Barbera and Stefano Mandalà

14 Abdominal Trauma and Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Vincenzo Mandalà, Massimo Lupo, Antonino Mirabella
and Benedetto La Motta

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Contributors

Ferdinando Agresta Azienda ULSS 19 di Adria, UOC di Chirurgia Generale,

Presidio Ospedaliero di Adria, Adria (RO), Italy

Luca Ansaloni General Surgery, Ospedali Riuniti di Bergamo, Bergamo, Italy

Grazia M. Attinà Department of Surgery, “S. Agostino-Estense” New Hospital

Modena, Italy

Gianpaolo Balzano Pancreas Unit, Department of Surgical Sciences,

San Raffaele Scientific Institute, Milan, Italy

Natalino Bedin Department of General Surgery, Presidio Ospedaliero di Vittorio

Veneto, Vittorio Veneto (TV), Italy

Fabio Cesare Campanile General Surgery, Andosilla Hospital,

Civita Castellana (VT), Italy

Luciano Casciola Department of Surgery, Division of General, Minimally

Invasive and Robotic Surgery, ASL 3 Umbria, “San Matteo degli Infermi”
Hospital, Spoleto (PG), Italy

Fausto Catena Department of General Emergency and Transplant Surgery,

“S. Orsola-Malpighi” University Hospital, Bologna, Italy

Graziano Ceccarelli Department of Surgery, Division of General, Minimally

Invasive and Robotic Surgery, ASL 3 Umbria, “San Matteo degli Infermi”
Hospital, Spoleto (PG), Italy

Gianfranco Cocorullo General and Emergency Surgery, University of Palermo,

Palermo, Italy

xv
xvi Contributors

Paolo Colobraro General Surgery, Andosilla Hospital,

Civita Castellana (VT), Italy

Francesco Corcione Department of General, Laparoscopic and Robotic Surgery,

Azienda Ospedaliera dei Colli Monaldi-Cotugno-CTO, Naples, Italy

Diego Cuccurullo Department of General, Laparoscopic and Robotic Surgery,

Azienda Ospedaliera dei Colli Monaldi-Cotugno-CTO, Naples, Italy

Fausto Di Marco Department of General and Emergency Surgery, “Villa Sofia –

Cervello” Hospital Trust, Palermo, Italy

Salomone Di Saverio General Emergency and Laparoscopic Surgery, Trauma

Surgery Unit, Maggiore Hospital, Bologna, Italy

Federico Famiglietti Digestive and Colorectal Surgery, Centre for Minimally

Invasive Surgery, University of Turin, Turin, Italy

Nicola Foti General Surgery, Andosilla Hospital, Civita Castellana (VT), Italy

Boris Franzato General Surgery, “San Giacomo Apostolo” Hospital,

Castelfranco Veneto (TV), Italy

Grazia Fusco General Surgery, “San Giacomo Apostolo” Hospital,

Castelfranco Veneto (TV), Italy

Gaspare Gulotta General and Emergency Surgery, University of Palermo,

Palermo, Italy

Camillo La Barbera Department of Oncologic Sciences Policlinico,

Palermo, Italy

Benedetto La Motta Department of General and Emergency Surgery,

“Villa Sofia – Cervello” Hospital Trust, Palermo, Italy

Raffaele Landi General Surgery and Laparoscopic Unit, “San Giuliano”

Hospital, ASL Na2 Nord, Giugliano (NA), Italy

Gianluca Lanni General Surgery and Laparoscopic Unit, “San Giuliano”

Hospital, ASL Na2 Nord, Giugliano (NA), Italy

Massimo Lupo Department of General and Emergency Surgery,

“Villa Sofia – Cervello” Hospital Trust, Palermo, Italy
Contributors xvii

Stefano Mandalà Service de Chirurgie Digestive et Endocrinienne, NHC

Hôpitaux Universitaires, Strasbourg, France

Vincenzo Mandalà Department of General and Emergency Surgery,

“Villa Sofia – Cervello” Hospital Trust, Palermo, Italy

Domenico Marchi Department of Surgery, “S. Agostino-Estense” New Hospital,

Modena, Italy

Gianluigi Melotti Department of Surgery, “S. Agostino-Estense” New Hospital,

Modena, Italy

Antonino Mirabella Department of General and Emergency Surgery,

“Villa Sofia – Cervello” Hospital Trust, Palermo, Italy

Mario Morino Digestive and Colorectal Surgery, Centre for Minimally Invasive
Surgery, University of Turin, Turin, Italy

Alberto Patriti Department of Surgery, Division of General, Minimally Invasive

and Robotic Surgery, ASL 3 Umbria, “San Matteo degli Infermi” Hospital,
Spoleto (PG), Italy

Nicolò Pecorelli Pancreas Unit, Department of Surgical Sciences,

San Raffaele Scientific Institute, Milan, Italy

Micaela Piccoli Department of Surgery, “S. Agostino-Estense” New Hospital,

Modena, Italy

Antonio Pinna Head of General Emergency and Transplant Surgery Department,

“S. Orsola-Malpighi” University Hospital, Bologna, Italy

Felice Pirozzi Department of General, Laparoscopic and Robotic Surgery,

Azienda Ospedaliera dei Colli Monaldi-Cotugno-CTO, Naples, Italy

Gabriele Salvatore General Surgery and Laparoscopic Unit,

“San Giuliano” Hospital, ASL Na2 Nord, Giugliano (NA), Italy

Carlo A. Sartori General Surgery, “San Giacomo” Hospital, Castelfranco Veneto,

(TV), Italy

Antonio Sciuto Department of General, Laparoscopic and Robotic Surgery,

Azienda Ospedaliera dei Colli Monaldi-Cotugno-CTO, Naples, Italy
xviii Contributors

Carlo Staudacher Head of Department of Surgical Sciences, San Raffaele

Scientific Institute, Milan, Italy

Vincenzo Trapani Department of Surgery, “S. Agostino-Estense” New Hospital,

Modena, Italy

Annunziato Tricarico Head of General Surgery and Laparoscopic Unit,

“San Giuliano” Hospital, ASL Na2 Nord, Giugliano (NA), Italy

Nereo Vettoretto Laparoscopic Surgery Unit, “M. Mellini” Hospital,

Chiari (BS), Italy
Diagnostic Laparoscopy
in Abdominal Emergencies 1
Ferdinando Agresta, Antonello Mirabella, Natalino Bedin
and Vincenzo Mandalà

1.1 Introduction
Acute emergency situations often pose a diagnostic challenge to the general
surgeon. The diagnosis is important due to the different pathologic conditions
that might be responsible for the acute situation and therefore important for
planning the correct abdominal incision or avoiding an unnecessary laparoto-
my. There are several noninvasive diagnostic procedures – such as ultrasono-
graphy and CT scanning − which can be performed along with plain film radi-
ography on patients with an acute abdomen to aid the surgeon in establishing
a preoperative diagnosis [1−12]. In experienced hands, which are not always
available around the clock in every hospital setting, the results of these meth-
ods are quite good, but in general practice they are not completely accurate
and conclusive (partly due to the patients’ physical limitations, e.g. obesity or
massive bowel distension, and partly because, as already stated, they are
dependent on operator skills) and they might be time-consuming and expen-
sive (such as CT scanning) [13−15]. Another factor to keep in mind is that
nowadays the mean patient age is increasing and, as a consequence, there is
an increasing possibility of being confronted with emergency abdominal situ-
ations in the elderly with many co-morbidities which complicate not only the
therapeutic strategy but the diagnostic approach as well. In the imaginary
equilateral triangle which represents the danger signal for every kind of acute
abdomen, the diagnostic side of the triangle and the therapeutic side are
increasingly tied together by the technique which for over twenty years has
been calling the attention of the surgical world: laparoscopy. Once the diag-
nosis is established, laparoscopy in fact can take a further step in many cases,

F. Agresta ()
Azienda ULSS 19 di Adria
UOC di Chirurgia Generale, Presidio Ospedaliero di Adria,
Adria (RO), Italy

V. Mandalà, The Role of Laparoscopy in Emergency Abdominal Surgery, 1

© Springer-Verlag Italia 2012