Treatment of purulent peritonitis

Surgical tactics in the postoperative period

The general management tactics for patients with peritoneal inflammation involve a comprehensive approach. As a rule, the inflammatory process gradually subsides under the influence of well-selected therapy. The key elements of basic postoperative care are adequate drainage, peritoneal dialysis (peritoneal lavage), and potent detoxification therapy.

However, the clinical picture may change. In severe cases of diffuse peritonitis and clear progression of the purulent process, standard measures may not be enough. In such situations, there is an urgent need for a re-operation — relaparotomy, the main purpose of which is a repeated thorough debridement of the abdominal cavity.

Laparostomy and the algorithm of scheduled debridements

To ensure regular and safe repeated planned debridements in modern surgery, the technique of laparostomy is used. The direct indication for its use is diagnosed diffuse purulent peritonitis.

The technique for completing the primary surgery using this method has its own specific features:

1. A special surgical "zipper" is sutured into the edges of the laparotomy wound.
2. Alternatively, the surgeon can place sparse sutures that are not tied tightly, but rather tied in a "bow" to facilitate subsequent access.

Algorithm for scheduled debridement:

• Anesthesia: The procedure is performed strictly under general anesthesia or epidural anesthesia.
• Access: Achieved by opening the sutured zipper or untying the previously placed sutures.
• Debridement steps: A thorough visual inspection of all abdominal compartments is performed. Accumulated purulent exudate is removed using suction aspiration. Then the cavity is thoroughly washed with antiseptic solutions, after which the surgeon removes any identified necrosis.
• Completion: The wound is temporarily re-closed until the next procedure.

Peritoneal lavage

Peritoneal dialysis (lavage) is an important tool for the mechanical cleansing of the abdominal cavity in the postoperative period. The main factor determining the success of this procedure is dialysate hydrodynamics.

Effective lavage is possible only if a balance is maintained: an adequate inflow of irrigation fluid and an equally free, unimpeded outflow must be ensured. A decrease in the effectiveness of the procedure most often occurs precisely due to a reduction or blockage of dialysate outflow, which leads to the retention of toxins in the body.

Conservative treatment: 5 main areas

Comprehensive treatment of purulent peritonitis in the postoperative period is based on five critical areas implemented in parallel:

1. Abdominal cavity debridement (surgical and local phase).
2. Antibiotic therapy. Broad-spectrum antibiotics are prescribed. A combined route of administration is used: drugs are administered intravenously as well as locally — intraperitoneally through placed drains. Therapy requires mandatory consideration of the sensitivity of the identified microflora and adherence to general rules of antibiotic prescribing.
3. Detoxification therapy. Based on the intravenous administration of plasma substitute fluids with detoxification effects. Additionally, the method of forced diuresis is used along with extracorporeal detoxification modalities.
4. Correction of metabolic disorders. The physician must strictly monitor and restore the water-electrolyte balance, acid-base status (ABS), blood protein profile, and normal circulating blood volume (CBV).
5. Restoration of gastrointestinal motility and evacuation function.

Nutritional support: Until gastrointestinal functions are fully restored, the patient is indicated for total parenteral nutrition. As peristalsis begins to recover, a smooth and gradual transition to enteral nutrition is carried out.

Prevention of purulent peritonitis

Preventing the development of severe intra-abdominal infections requires a systematic approach at all stages of medical care:

• Ensuring early patient admission: It is necessary to improve health education work among the population (educating about early symptoms of acute pathology and the importance of emergency hospitalization). It is also required to improve the qualifications of outpatient service physicians (polyclinics, emergency medical services) for the rapid diagnosis of acute surgical diseases.
• Sanitary and epidemiological regimen: It is important to strictly observe sanitary standards upon hospitalization and reliably isolate patients with purulent processes from other patients in surgical wards.
• Preoperative preparation: Includes improving the patient's immunological defense and carrying out preliminary antibiotic prophylaxis, especially if the risk of purulent complications is high.
• Intraoperative measures: The surgeon is required to strictly adhere to the principle of delicate surgical technique (careful handling of tissues), as well as rigorous compliance with the rules of asepsis and antisepsis throughout the entire surgery.

Class and exam questions

What else to study on this topic

• Criteria for transitioning from parenteral to enteral nutrition
• Methods of extracorporeal detoxification in surgery
• Assessment of blood acid-base status (ABS)
• Drugs for stimulating gastrointestinal motility and evacuation function
• Specifics of epidural anesthesia in peritonitis

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.