Operative management addresses the need to control the infectious source and to purge bacteria and toxins. The type and extent of surgery depends on the underlying disease process and the severity of intra-abdominal infection. Definitive interventions to restore functional anatomy involve removing the source of the antimicrobial contamination and repairing the anatomic or functional disorder causing the infection. This is accomplished by surgical intervention. Occasionally, this can be achieved during a single operation; however, in certain situations, a second or a third procedure may be required. In some patients, definitive intervention is delayed until the condition of the patient improves and tissue healing is adequate to allow for a (sometimes) lengthy procedure.
Damage control surgery
Alternatively, over the past decade, in the setting of extensive abdominal inflammatory disease and septic shock, surgeons have used damage control operations (DCS) to temporarily drain the infection, quickly control the visceral leak, and defer any definitive repair until the patient has stabilized. DCS appears to be feasible for perforated diverticulitis and peritonitis or septic shock, whether or not patients are hemodynamically stable. [22, 23, 24]
See Surgical Approach to Peritonitis and Abdominal Sepsis for more information.
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Peritonitis and abdominal sepsis. Diagnostic and therapeutic approach to peritonitis and peritoneal abscess.
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Peritonitis and abdominal sepsis. A 48-year-old man underwent suprapubic laparotomy, right hemicolectomy, and gastroduodenal resection for right colon cancer invading the first portion of the duodenum. After surgery, the patient developed abdominal pain and distention. Computed tomography (CT) scanning was used to confirm an anastomotic dehiscence. Figure A shows a contrast-enhanced scan of the abdomen and pelvis that reveals multiple fluid collections, perihepatic ascites, and mild periportal edema. A collection of fluid containing an air-fluid level is visible anterior to the left lobe of the liver. A second collection is anterior to the splenic flexure of the colon. In figure B, a third fluid collection is present in the inferior aspect of the lesser space and in the transverse mesocolon. Figure C shows the pelvis with a collection of free fluid in the rectovesical pouch.
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Peritonitis and abdominal sepsis. A 78-year-old man was admitted with a history of prior surgery for small bowel obstruction and worsening abdominal pain, distended abdomen, nausea, and obstipation. In figure A, a marked amount of portal venous gas within the liver, mesenteric venous gas, and pneumatosis intestinalis are consistent with ischemic small intestine. The superior mesenteric artery appears patent. The liver has a nodular contour consistent with cirrhosis. In figures B and C, markedly distended loops of small intestine containing fluid and air-fluid levels are consistent with a small bowel obstruction. No focal fluid collections are identified.
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Peritonitis and abdominal sepsis. A 35-year-old man with a history of Crohn disease presented with pain and swelling in the right abdomen. In figure A, a thickened loop of terminal ileum is evident adherent to the right anterior abdominal wall. In figure B, the right anterior abdominal wall is markedly thickened and edematous, with adjacent inflamed terminal ileum. In figure C, a right lower quadrant abdominal wall abscess and enteric fistula are observed and confirmed by the presence of enteral contrast in the abdominal wall.
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Peritonitis and abdominal sepsis. Gram-negative Escherichia coli.
