Minimally invasive approach to peritonitis from left colonic perforation: a retrospective multicenter observational study

Background: Laparoscopic procedures have nowadays become the gold standard in multiple abdominal diseases, but in the emergency setting, especially in major surgery, laparoscopy still represents an obstacle for most surgeons. This multicentric study aims to define the surgical approach for emergency resective surgery in left colonic perforation peritonitis, determine the factors influencing the choice between MIS and open surgery, and identify factors associated with laparotomic conversion. Methods: Retrospective data from 516 patients treated for left colonic perforation between January 2019 and December 2023 across six Italian centers was collected. Variables analyzed included patient demographics, disease and surgical characteristics, post-operative complications, and long-term outcomes. Univariate and multivariate regression models were performed to identify factors associated with surgical choice and likelihood of conversion. Results: Only 24.5% of patients underwent laparoscopic approach, with a conversion rate of 52.8%. MIS was associated to lower CCI and MPI and less severe septic status at arrival. MIS was mostly performed by colorectal surgeons, compared to acute care surgeons. The post-operative outcome, considering LOS, ICU admission, post-operative complications and mortality rate, was better in the MIS group. The multivariate regression model revealed that CCI, MPI, and night-time surgery were negatively associated with MIS while colorectal surgeons had a positive association. Laparotomic conversion more commonly occurred in older patients with a higher MPI and CCI and more severe septic status; these patients had a worse post-operative outcome. MPI was the only factor with statistical significance in the univariate analysis, associated with conversion. Conclusion: Although MIS is associated with better post-operative outcomes, it is underutilized in the emergency setting. Patients requiring laparotomic conversion had higher morbidity and mortality compared to those who underwent successful laparoscopy. Limiting factors for MIS include logistic factors, patient severity, and surgical skills, therefore careful patient selection and surgical training is crucial.