It is a valuable tool to prevent unnecessary laparotomies when routine investigations fail to identify the cause. It provides a highly important advantage for detecting the degree of bowel

ischemia in AMI following diagnosis with CTA [8]. Although its use in AMI is questioned in a recent review, our experience proved otherwise [14]. After laparoscopy has been successfully introduced and adapted for daily use over the years, its accuracy has been better by improving through technology [9]. Therefore, we utilize laparoscopic exploration in a routine basis in recent years and have shifted our treatment algorithm for AMI in favor of initial laparoscopic exploration. However, if the exploration can not provide enough information regarding the viability of the entire bowel, laparotomy is indicated. Thrombolytic therapy

is an effective and quick treatment modality for AMI Wnt tumor and may obviate surgery and has the potential to resolve the clot completely [15, 16]. If resolution occurs partially, it already serves as an adjunctive to surgery by sparing an amount of near-ischemic bowel segments [6, 7]. We have utilized these diagnostic and treatment modalities for AMI in an algorithm that is presented in this paper. The mortality rate in patients without peritoneal signs was 20% (1/5), whilst it was 62.5% (5/8) in patients with peritoneal signs during admission. It is also worth noting that all patients with peritoneal signs presented 24 h after the find more onset of symptoms. This finding confirms the mafosfamide hypothesis that early diagnosis is extremely important in achieving survival [17, 18]. We prefer to use laparoscopy whenever possible. We believe that this may be a good option both in initial and subsequent evaluations. A previously

placed laparoscopic port enables a second-look even bedside in the intensive care unit (Figure 4). Second look laparoscopy is one of the mainstays of surgical treatment of AMI for the assessment of intestinal viability, motility, absence of a necrotic segment and to look over anastomosis. Due to the advantages of laparoscopic second look procedure including, shorter operative time and making way to third or even more explorations, we prefer to perform laparoscopic second look. Nevertheless, this algorithm can be used in cases, which have salvageable bowel segments and some time needed for LTT to revascularize the mesenteric circulation. Figure 4 Leaving the laparoscopic port in place after laparoscopic evaluation of the abdomen may enable a quick and easy way of second-look after local thrombolytic therapy. In conclusion, acute arterial mesenteric ischemia remains one of the most lethal conditions in patients presenting with an acute abdomen. A high index of suspicion is mandatory for diagnosis. CT-angiography combined with early laparoscopic exploration and thrombolytic treatment may have beneficial effects regarding mortality. References 1. Cokkinis AJ: Intestinal ıschemia.