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Journal of Trauma and Acute Care Surgery:
doi: 10.1097/TA.0000000000000288
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

Di Saverio, Salomone MD

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From the Emergency and Trauma Surgery Unit, Department of Surgery, Maggiore Hospital Trauma Centre–Bologna 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 –- 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 (

Address for reprints: Salomone Di Saverio, MD, Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna, Italy; email:,

Surgical practice is continuously evolving mainly because of technologic developments and better-performing instruments. 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 gynecologic 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 painful laparotomy incisions, therefore captivating the patient’s preference.

The laparoscopic approach carries several significant advantages for patients, both in terms of much less postoperative pain (every effort should be undertaken to avoid or at least minimize pain)—including faster and better postoperative recovery, shorter hospital stay, earlier discharge, and earlier return to normal daily activity, such as physical exercise (including sports and sexual life)—and 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 influence 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, while achieving good oncologic results and satisfying good oncologic quality criteria in terms of radical resections and number of lymph nodes removed, modern laparoscopy currently 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 stage–related survival rate but rather improving the postoperative quality of life, reducing pain, and improving aesthetic results.

Further technologic improvements include the development and refinement of laparoscopic techniques, the introduction 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 generation of “minimally invasive surgeons,” who made feasible gastrointestinal anastomoses by using totally intracorporeal techniques (see Video, Supplemental Digital Content [SDC] 1, 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]).

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Compared with oblique incisions in the right hypochondrium 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 anastomosis, 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 are also advocated as an alternative for off-midline extraction site, yielding the lowest rate of incisional hernia development6 (see Video, SDC 2,

In recent years, new concepts are evolving toward even less invasive laparoscopic surgery by total avoidance of performing 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, performed 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 appendectomies (see Video, SDC 3,; Fig. 3B) and cholecystectomies up to colorectal resections (see Video, SDC 4,; 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.

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In the past decades, few pioneering experiences have highlighted the potential advantages of diagnostic and therapeutic 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 invasive 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 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 purulent 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 cholecystitis can harbor technical challenges, but appropriate skills may allow the safe completion of a laparoscopic procedure (see Videos, SDC 5 and 6,, Some cases, commonly defined as “the nasty gallbladder”, may be technically demanding and require a “dome-down” technique (see Video, SDC 25, In case of suspected CBD stones and biliary obstruction, intraoperative cholangiography and transcystic biliary drainage are mandatory (see Video, SDC 7,

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 definite advantages and better outcomes in terms of less postoperative 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,; Fig. 4A); ischemic small bowel strangulated by volvulus on a single band (Video, SDC 9,, Fig. 4B); large-bowel obstructions from obstructing colon carcinoma (Video, SDC 1 and 10,,; Fig. 1C and D, Fig. 5); bowel perforations, mostly perforated peptic ulcers (Video, SDC 11–13,,,; diffuse peritonitis; evacuation and drainage of large intra-abdominal abscesses or collections not percutaneously accessible (Video, SDC 14,; perforated diverticulitis treated by laparoscopic lavage (Video, SDC 15 and 16, and, Fig. 6) or laparoscopic Hartmann sigmoid resection with end stoma (Video, SDC 17,; Fig. 2A and B, Fig. 7); or even laparoscopic sigmoid resection and primary anastomosis (Hinchey Stage I, II, III, and IV) (Video, SDC 18–19, and; gastrointestinal bypasses for unresect able intra-abdominal cancer or laparoscopic gastrojejunostomy for relief of neoplastic gastric outlet obstruction (Video, SDC 20,; and the reduction and eventual repair of incarcerated/strangulated inguinal (Video, SDC 21, and incisional hernias (Fig. 8, Video, SDC 22,

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An example of the best advantages in avoiding a large laparotomy is the laparoscopic approach for small-bowel obstruction 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 contribute to significantly decrease the duration of surgery. In fact within a few minutes the SB obstruction can be relieved (Video, SDC 8 and 9, and; Fig. 4C) without need for 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, In such patients, laparoscopy 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 discharge 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 management of acute perforated diverticulitis (Video, SDC 24,; 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 laparotomy 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 patients with perforated diverticulitis with purulent peritonitis. Laparoscopic treatment by nonresectional lavage and drainage has potential of improving health and reducing costs. A randomized controlled trial (NCT01317485)14 to investigate the safety and efficacy of this minimally invasive approach is ongoing. Single-incision laparoscopic sigmoidectomy is an attractive alternative to either open colectomy or traditional multiport laparoscopy for elective management of diverticular disease. Advantages include better cosmetic results and less pain, even 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 subsequent 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).

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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 anastomosis 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 laparotomy (Fig. 10).

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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 pneumoperitoneum and venous flow return compromise may be easily fatal in such cases. A further relative contraindication to be considered remains a severe respiratory failure with severe hypercapnia, owing to the possible reabsorption of CO2 and development of malignant hypercapnia and toxic shock syndrome.16 However, a wise ventilatory strategy, increasing the minute volume of ventilation, and further measures by decreasing 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 techniques 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 elderly 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 increased risk of atelectasis and pneumonia) as well as circulatory complications (delayed mobilization with consequent increased risk of deep venous thrombosis and possible pulmonary embolism). All these negative consequences will be much more significant 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, requiring limited open surgical incisions (i.e., Mc Burney or Lanz incision or a right subcostal).

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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 disease—in whom substantial cell death takes place—possibly 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 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 systemic 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 demonstrated 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 peritonitis, where open surgery increased the incidence of bacteremia, endotoxemia, and systemic inflammation compared with laparoscopy and caused lower transient immunologic defense, 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 already well-known from animal models that the peritoneal response 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 invasive and laparoscopic techniques in emergency surgery is truly becoming a new discipline and an innovative approach to surgical emergencies with both diagnostic and therapeutic indications. The use of laparoscopy for treating abdominal surgical 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 patients 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 abdominal pathology, such as gangrenous or perforated appendicitis with localized abscess or selected cases of diffuse peritonitis. The patient can benefit from a laparoscopic technique with a single small umbilical incision.

Despite the current worldwide economic crisis leading to a decrease in health care budgets, these laparoscopic procedures 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 invasive techniques may allow one to perform laparoscopic appendectomies 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 peritonitis, 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.

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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 discipline, aiming to join together the difficult issues of emergency surgery with the potential advantages of minimally invasive surgery techniques. This new branch, bridging laparoscopy 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.

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Supplemental Digital Content Legends

Video 1: Laparoscopic left hemicolectomy with intracorporeal anastomosis for partial LBO from obstructing descending colon carcinoma.

Video 2: Laparoscopic right hemicolectomy with intracorporeal anastomosis for perforated caecum and diffuse peritonitis.

Video 3: Surgical glove port SILS for complicated acute appendicitis.

Video 4: SILS right colectomy for cecal perforated diverticulitis with intracorporeal anastomosis.

Video 5: Laparoscopic cholecystectomy for edematous cholecystitis.

Video 6: Laparoscopic cholecystectomy for fibrotic cholecystitis.

Video 7: Laparoscopic cholecystectomy for acute cholecystitis 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 hemostasis of a perforated and actively bleeding peptic ulcer.

Video 14: Laparoscopic lavage and drainage of large pelvic and inter-loop abscesses (Hinchey II acute diverticulitis), 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 anastomosis 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 obstruction 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, adhesiolysys and loop ileostomy.

Video 24: Multi-step minimally invasive approach to perforated acute diverticulitis Hinchey stage II with laparoscopic lavage and elective SILS sigmoidectomy a few months later.

Video 25: The Nasty gallbladder: Dome-down laparoscopic cholecystectomy for largely gangrenous acute cholecystitis. 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.

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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 minimally 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 Saverios 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.

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The author declares no conflict of interest.

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