SURGICAL-MANAGEMENT OF PERITONITIS

The surgical management of secondary peritonitis is based on the follo wing control of the pathologic process causing the bacterial contamina tion, peritoneal toilet and prevention of recurrent infection. Gastric and small bowel perforations are generally treated by simple suture o r resection with primary anastomosis. Peritonitis secondary to large b owel perforation results in 15 to 60% mortality depending on the etiol ogy of the perforation. Some studies have questioned the surgical dogm a which forbids primary anastomosis after perforated sigmoid diverticu litis or traumatic colonic perforation. The interest for laparoscopy i n peritonitis is based on the theorical advantage of reducing the morb idity of midline incisions of the contaminated abdomen. Laparoscopy se ems to be admitted as treatment for biliary peritonitis (acute cholecy stitis). The indication for laparoscopic treatment of appendicular per itonitis or duodenal ulcer perforation however has still to be validat ed. Peroperative peritoneal lavage with isotonic solutions, with or wi thout antiseptics or antibiotics, as well as the systematic and comple te peritoneal debridment have not shown any advantage in terms of redu ction of intra peritoneal abscesses or reduction of mortality. In adva nced peritonitis, the utility of postoperative peritoneal lavage, plan ned relaparotomies as well as laparostomy has yet to be established. F uture prospective evaluations of surgical techniques for the treatment of secondary peritonitis should include a severity score, preferably based on the preoperative APACHE II score, rather than on peroperative findings.