Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma
Authors: Sermonesi Giacomo , Tian Brian W. C. A. , Vallicelli Carlo , Abu‑Zidan Fikri M. , Damaskos Dimitris , Kelly Michael Denis , Leppäniemi Ari , Galante Joseph M. , Tan Edward , Kirkpatrick Andrew W. , Khokha Vladimir , Romeo Oreste Marco , Chirica Mircea , Pikoulis Manos , Litvin Andrey , Shelat Vishal Girishchandra , Sakakushev Boris , Wani Imtiaz , Sall Ibrahima , Fugazzola Paola , Cicuttin Enrico , Toro Adriana , Amico Francesco , Mas Francesca Dal , De Simone Belinda , Sugrue Michael , Bonavina Luigi , Campanelli Giampiero , Carcoforo Paolo , Cobianchi Lorenzo , Coccolini Federico , Chiarugi Massimo , Di Carlo Isidoro , Di Saverio Salomone , Podda Mauro , Pisano Michele , Sartelli Massimo , Testini Mario , Fette Andreas , Rizoli Sandro , Picetti Edoardo , Weber Dieter , Latifi Rifat , Kluger Yoram , Balogh Zsolt Janos , Biffl Walter , Jeekel Hans , Civil Ian , Hecker Andreas , Ansaloni Luca , Bravi Francesca , Agnoletti Vanni , Beka Solomon Gurmu , Moore Ernest Eugene , Catena Fausto 
Published: December 2023

Abstract
Background
Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

Methods
This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

Results
A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

Conclusions
The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.