A 68-year-old previously fit woman was admitted with left lower abdominal pain and signs of cardiovascular shock. She had had a 2 day history of crampy left lower abdominal pain and altered bowel habit. Clinically she had a diagnosis of bowel perforation with generalised peritonitis. She was exhibiting signs of shock with a pronounced tachycardia and a reduced systolic blood pressure.

She was started on fluid resuscitation and intravenous antibiotics. After her cardiovascular system stabilised she was taken to the operating theatre where she had a laparotomy. A sigmoid perforation was found with four quadrant faecal contamination. A Hartmann’s procedure was performed. A laparostomy was decided upon at the first instance, and was covered with a VAC dressing.

She was transferred to the intensive care unit (ICU) still intubated and ventilated.

Her condition rapidly worsened on the ICU. She required vasopressor support intra-operatively and her requirements rapidly escalated. She seemed to stabilse over the next 36 hours. Her condition then worsened and she was taken back to theatre for a washout of her peritoneal cavity. A number of collections were found and further soiling of her abdomen was evident. Her condition remained the same for the next 12 hours but then started to show an improvement again. She continued to make a good response to treatment over the next 3-4 days. She had another washout at 4 days. She was extubated on day 5 and invasive monitoring and cardiovascular support was no longer needed.

What is the role of laparotomy in the management of faecal peritonitis?

James Day

Laparostomy is the surgical technique of leaving the peritoneal cavity open anteriorly through a midline laparotomy incision. Often termed the “open abdomen”. The abdominal contents are exposed and covered with a temporary covering. The role of laparostomy in intra-abdominal hypertension (IAH) and abdominal compartment syndrome is well proven. Its preventative use in secondary peritonitis is not as clear cut. In a small randomised study of 40 patients comparing open treatment with a mesh vs closed treatment there was no statistically significant difference in mortality although the study was terminated at first analysis as there was a clear tendency to improved outcome in the closed group (1).

The benefits of laparostomy in intra-abdominal sepsis are linked to the presumed need for re-look laparotomies. The decision to be made is to do this in a scheduled or expectant manner. A randomised study in 2007 with 232 patients with severe peritonitis looked at planned re-look laparotomy vs expectant laparotomy. The on demand group had a reduction in relaparotomy, medical costs and healthcare utilisation. There was no significant difference in mortality or peritonitis related morbidity (2). It seems that the current consensus is to favour a policy of on demand re- laparotomy rather than laparostomy and scheduled re-look (3).

The morbidity associated with an open abdomen is an important consideration. In one study there was a 25% incidence of abscesses, enteric fistulas, and wound infections (4). In another study 55% of patients required further surgery related to complications associated with a laparostomy; these were for infection, hernia and enteric fistulas (5).

The indications for laparostomy are inability to close the laparotomy wound due to tissue loss or extreme swelling. There is evidence of improved physiological recovery which is reflected in improved mortality in damage control surgery and those with abdominal compartment syndrome. Open abdomen treatment of secondary peritonitis or infected pancreatic necrosis seems unwarranted.

References

1. Robledo FA, Luque-de-Leon E, Suarez R, et al. Open versus closed management of the abdomen in the surgical treatment of severe secondary peritonitis: a randomised clinical trial. Surg Infect 2007 8:63-71.
2. van Ruler O, Mahler CW, Boer KR, et al.: Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis. JAMA 2007, 298:865–873.
3. Pieracci FM, Barie PS: Management of severe sepsis of abdominal origin. Scand J Surg 2007, 96:184–196.
4. Miller RS, Morris JA Jr, Diaz JJ Jr, Herring MB, May AK: Complications after 344 damage-control open celiotomies. J Trauma 2005, 59:1365–1374.
5. Sutton E, Bochicchio GV, Bochicchio K, et al.: Long term impact of damage control surgery: a preliminary prospective study. J Trauma 2006, 61:831–836.