MINIMALLY INVASIVE SURGERY IN ABDOMINAL EMERGENCIES: TECHNICAL EVOLUTION AND CURRENT CHALLENGES

Abstract

Minimally invasive surgery (MIS) has become the standard for various abdominal emergencies in recent decades, with consistent benefits in terms of postoperative pain, length of hospital stay, wound complications, and functional recovery. The incorporation of technologies such as high-definition/3D optics, energy sealers, indocyanine green (ICG) fluorescence, and robotic platforms has expanded indications in acute scenarios (appendicitis, cholecystitis, selected digestive perforations, complicated diverticular disease), while maintaining however, dilemmas of case selection, 24/7 logistics, and cost-effectiveness. The present objective seeks to analyze the technical evolution of MIS applied to abdominal emergencies and discuss current challenges related to patient selection, safety, clinical outcomes, and systemic implementation. This is a qualitative, descriptive, and analytical literature review of national and international publications (2019–2025), including guidelines, observational studies, randomized trials, and systematic reviews in the PubMed, SciELO, LILACS, Scopus, and Web of Science databases. Evidence with clinical applicability in emergency rooms and general hospitals was prioritized. Laparoscopy is widely validated for acute appendicitis (less surgical site infection, better recovery), including complicated cases with abscesses when there is expertise and imaging/intervention support. In acute cholecystitis, early laparoscopic cholecystectomy (first 72 hours) reduces readmissions and costs; ICG aids in identifying the cystic duct and may reduce biliary injuries in difficult anatomies. In diverticular disease, laparoscopy is an option in selected Hinchey II/III cases for lavage or resection with primary anastomosis depending on hemodynamic stability and degree of contamination. Minor gastroduodenal perforations can be treated by laparoscopy with raffia and omentoplasty when there is early diagnosis and no prolonged diffuse peritonitis. In intestinal obstruction, the laparoscopic approach is feasible in subgroups (single adhesions, without massive distension); it requires low pneumoperitoneum pressure and high technical proficiency to avoid enterotomies. Diagnostic laparoscopy continues to play a role in the evaluation of indeterminate acute abdomen and selected penetrating trauma, reducing non-therapeutic laparotomies. Technical advances include 4K/3D optics, advanced hemostatic energy, assisted intracorporeal suturing, and ICG fluorescence for anastomotic perfusion and biliary anatomy. Robotics offers ergonomics and dexterity in the pelvis and intense inflammation, but its use in emergencies is limited by cost, availability, and docking times. ERAS strategies adapted to the acute setting (multimodal analgesia, early mobilization, fluid optimization) enhance the benefits of MIS. Challenges remain: (i) case selection (hemodynamic instability, refractory sepsis, extensive peritonitis, and resuscitation failure indicate laparotomy); (ii) logistics and 24/7 access to trained staff and equipment; (iii) learning curve and variation in results by institutional volume; (iv) management of special patients (frail elderly, obesity, pregnancy, use of anticoagulants); (v) specific risks (biliary injury, energy burns, complications related to pneumoperitoneum in cardiorespiratory dysfunction). From a public health perspective, there are disparities in access between urban centers and smaller hospitals; training programs, teleproctoring, and telerobotics and telementoring protocols emerge as alternatives for safe dissemination. It is concluded that MIS in abdominal emergencies is safe and effective when integrated with strict selection criteria, prior volume replacement and septic control, an experienced team, and adequate infrastructure. The adoption of technologies (ICG, advanced energy, 3D/robotics) must be judicious and cost-effective, combined with ERAS protocols and results auditing. Current priorities include: expanding simulation-based training, ensuring 24/7 availability, standardizing care flows, and reducing inequalities in access. Thus, an approach that combines quality, safety, and efficiency in the care of patients with acute abdomen is consolidated.