The role of minimal access surgery in the acute abdomen.

The improvement in surgical decision-making for patients with abdominal pain but an uncertain diagnosis using DL has now been shown to decrease both negative and nontherapeutic laparotomy rates. Once the diagnosis is established, DL can be taken a step further in many cases, as therapeutic intervention via laparoscopy is possible for a number of these conditions without resorting to a laparotomy. Conditions amenable to therapeutic laparoscopy include appendicitis, perforated peptic ulcer, diverticulitis, small bowel obstruction, acute cholecystitis, diaphragmatic rupture, and splenic or hepatic injuries, to name but a few. However, a number of unanswered questions remain such as: Who should perform emergency laparoscopic procedures? What should the selection criteria be? What are the cost implications? and Is patient outcome actually better with laparoscopy? Only randomized controlled trials can answer these questions. Until such data are available, it is important that common sense prevail. Laparoscopy should be incorporated into the general surgeon's armamentarium for the management of patients with abdominal pain as just another tool to be used selectively when indicated. It is also important that new technologies be carefully evaluated in an unbiased manner under strict protocol so that objective data can be obtained which can be used to devise guidelines for safe and effective use of new devices.