Surgical treatment of peritonitis

Severity assessment and preoperative preparation

Although purulent peritonitis requires emergency surgery, the intervention is always preceded by intensive preoperative preparation. Its duration should not exceed 2 hours. The main goals of this stage are the restoration of circulating blood volume (CBV), correction of water-electrolyte balance, and maintenance of circulation. Special attention is paid to elderly and senile patients: due to severe intoxication, they have a critically high risk of rapid cardiovascular decompensation.

To assess the severity of the patient's condition and predict the outcome, the Mannheim Peritonitis Index (MPI) is used. The sum of points determines the degree of risk.

The nature of the exudate is also assessed (only one option is selected): clear gives 0 points, turbid-purulent — 6 points, and fecal-putrid — 12 points.

Surgical access and source elimination

In widespread peritoneal inflammation, midline laparotomy is considered the optimal surgical access. It provides the surgeon with a full view for the revision of all abdominal compartments.

The primary task in the wound is the elimination of the source of inflammation. Depending on the cause of the disease, tactics may include:

• Organ removal: performance of appendectomy, cholecystectomy, tubectomy, or resection of the affected intestinal segment.
• Organ-preserving surgery: closure of a perforation (e.g., in perforated gastric or duodenal ulcer).

Sanitation and drainage of the abdominal cavity

After eliminating the source, the abdominal cavity must be cleared of pathological contents. Sanitation implies the removal of spilled exudate, pus, and GI tract contents. Fluid is removed with an electric suction device (aspiration), and the abdominal cavity is dried with gauze sponges. If complete sanitation cannot be achieved intraoperatively, special methods such as continuous peritoneal lavage can be used.

The final stage is drainage. For this purpose, silicone-vinyl chloride tubes with a diameter of 0.2–0.8 cm are used. They are brought out not through the main incision, but through separate punctures of the abdominal wall — counter-incisions. The surgical wound itself is most often tightly closed. In generalized peritonitis, drains allow for fractional irrigation of the abdominal cavity with antiseptics in the postoperative period.

Management of gastrointestinal paresis: intestinal decompression

The development of peritonitis is always accompanied by intestinal paresis, so GI tract decompression is strictly mandatory. The choice of technique depends on the nature of the performed intervention:

1. In case of intestinal resection: decompression is carried out through the open ends of the intestine before applying the anastomosis. The ends are brought out beyond the surgical wound, clamps are removed, and gases and liquid contents are evacuated by squeezing movements. If an intestinal stoma (enterostomy or colostomy) is formed, decompression is continued through it.
2. Without opening the intestinal lumen (appendectomy, ulcer closure): long, soft small-bowel tubes with multiple side holes are used. The tube is placed nasogastrointestinally (through the nose, esophagus, and stomach) or retrogradely (through the rectum). The instrument is passed during laparotomy and left for long-term intestinal decompression.

Additional measure: after decompression, 150 ml of 0.25% procaine solution is injected into the mesentery of the small intestine.

Goals of postoperative decompression

The indwelling tube performs three critically important functions in the postoperative period:

• Detoxification: removal of contents prevents the absorption of intestinal toxins into the blood.
• Improvement of trophism: elimination of intestinal wall distension by gases restores normal blood circulation and nutrition in it.
• Normalization of cardiorespiratory function: elimination of abdominal distension restores normal excursion of the diaphragm and eliminates displacement of the heart and lungs.

> Important: even ideal source elimination, thorough sanitation, and intestinal intubation cannot instantly stop the inflammatory process in the peritoneum.

Class and exam questions

What else to study on this topic

• Clinical examples of Mannheim Peritonitis Index calculation
• Technique of nasogastrointestinal and retrograde intestinal intubation
• Indications and methodology for continuous peritoneal lavage
• Management of patients with intestinal stomas (colostomy and enterostomy) in the postoperative period

Other topics from the section "CHAPTER 11. SURGICAL INFECTION (PURULENT-INFLAMMATORY DISEASES)"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.