SURGICAL-MANAGEMENT OF PERITONITIS

The surgical management of secondary peritonitis is based on the follo wing principles : control of the pathologic process causing the bacter ial contamination, peritoneal toilet and prevention of recurrent infec tion. Gastric and small bowel perforations are generally treated by si mple suture or resection with primary anastomosis. Peritonitis seconda ry to large bowel perforation results in 15 to 60% mortality depending on the etiology of the perforation. Some studies have questioned the surgical dogma which forbids primary anastomosis after perforated sigm oid diverticulitis or traumatic colonic perforation. The interest for laparoscopy in peritonitis is based on the theorical advantage of redu cing the morbidity of midline incisions of the contaminated abdomen. L aparoscopy seems to be admitted as treatment for biliary peritonitis ( acute cholecystitis). The indication for laparoscopic treatment of app endicular peritonitis or duodenal ulcer perforation however has still to be validated. Peroperative peritoneal lavage with isotonic solution s, with or without antiseptics or antibiotics, as well as the systemat ic and complete peritoneal debridment have not shown any advantage in terms of reduction of intra peritoneal abscesses or reduction of morta lity. In advanced peritonitis, the utility of postoperative peritoneal lavage, planned relaparotomies as well as laparostomy has yet to be e stablished. Future 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.