These are investigations of diagnostic values well as prognostic value. Persistent leukocytosis (esp. neutrophilia) in postoperative period or rise in count suggests some infective foci in body. In our study 15 (75%) patients had persistent neutrophilia after first surgery.

Figure 4

Leukocyte counts never come to normal in 8 out of 9 patients who expired even after second surgery & antibiotic treatment. Only 3 patients out of 11 patients (who survived) had neutrophilia after 7 days of second surgery.

Figure 5

Average Hb was just 9.03 gm %. But there was significant hypoalbuminemia (average 2.22 gm %). There was marked anemia & hypoproteinemia among patients who expired.

All patients were resuscitated in form of IV fluids, blood transfusion, oxygenation, etc.. A total of 13 patients required intensive resuscitation with central venous line insertion & 2 patients given ventilatory support.

All patients were given preoperative broad-spectrum antibiotics (cephalosporin + metronidazole). Amino glycosides were added in postoperative period after normal RFT report. Antibiotics were changed according to pus c/s report in 8 patients where as empirical antibiotics were given in rest of the patients.

Figure 8

No significant increase in survival was obtained by administration of anti-biotic according to pus c/s

Figure 9

In 15 patients on re exploration, there was leakage from gut requiring some form of control of the source of infection. In 4 patients, there was spread of residual infection whereas 1 patient expired before any intervention.

There was 70% mortality noted among the patients in whom exteriorization of proximal bowel was done as compared to 20 % mortality among the patients in whom primary closure was done.

All patients were given peritoneal lavage with combination of normal saline, betadine and metronidazole of about 3 - 4 litres. In all the patients, pelvic drain was put. In two patients with duodenal perforation and in 1 patient with spread of residual peritonitis following appedicectomy, drain was put in Morrison pouch.

In all the patients, decompression of the bowel was done

In 3 patients, abdomen was kept open (laparostomy) out of which 2 expired whereas in rest of the patients conventional surgical procedure was done. Mortality was 66% among patients with laparostomy as compared to 47.05 % mortality in-patients who underwent conventional surgical procedures.

Figure 10

Abdominal pain, usually generalized, is a most common complain. Sometimes it may be not significant as good analgesic is administered in postoperative period. It is very difficult to differentiate it from simple postoperative pain without presence of other findings, which point towards peritonitis. Such patients avoid movement due to pain.

Progressively increasing abdominal distention is the next most important finding. It leads to difficulty in respiration and decreased abdominal movement with respiration. It requires differentiation from paralytic ileus due to other causes of peritonitis

High-grade fever with rigors is a sign of infection in body. Thus, new appearance of fever in post operatively period after laparotomy always points toward peritonitis.

As peritonitis causes paralytic ileus; high RT output, nausea, vomiting, constipation or watery diarrhea may develop.

Open wound, wound discharge, per drain discharge, etc. all suggest failure of primary surgery.

Raised temperature, tachycardia, tachypnoea with hypotension suggest systemic inflammatory response syndrome and in post laparotomy patient mostly due to peritonitis

Poor nourishment, pallor, dehydration may be contributing factors for development of peritonitis due to poor immune response or it may be consequence of septicemia.

Icterus, cyanosis, edema may be indicators of MODS.

In terminal stage Hippocratic faces is characteristic.

On inspection, generalized abdominal distension with decreased abdominal movement with respiration is characteristic

On palpation, evidence of peritonitis in form of generalized tenderness with rebound tenderness, guarding and / or rigidity are evident.

Scar of previous surgery with purulent / fecal discharge or similar kind of discharge in drains may be present

On percussion, free fluid in abdomen and on auscultation, absent bowel sounds are usual findings.

Per rectal examination may suggest bulging in anterior rectal wall with tenderness and raised temperature.

For diagnostic purpose total and differentiated WBC count done. It shows Leucocytosis with predominant neutrophils and premature cells.

Rests of the investigations are important from etiological and prognostic view

X-ray abdomen may reveal obliteration of peritoneal fat planes and the psoas shadow, indicating peritoneal edema. Air filled loops of bowel, with thickened, opaque walls may be found when bowel edema and paralytic ileus is present.

Ultrasonography may show free fluid in abdomen with echogenic material, absent peristalsis or thickened peritoneum, mesentery or bowel wall. Diagnostic aspiration of fluid under USG guidance if possible is more reliable

CT and MRI are not indicated routinely. According to Hiyama & Bennion ₈ as written in Maingot's abdominal operations, in general USG, CT and especially MRI should not be routinely used in patients with acute peritonitis.

Supportive measures and Resuscitation

1. To combat hypovolumia and shock and maintain adequate tissue oxygenation.

2. To treat bacteria, not eliminated by surgery, with antibiotics.

3. To support failing organ system

Operative treatment

1. Repair: -control the source of infection

2. Purge: - evacuate bacterial inoculums, pus and adjuvant (Peritoneal toilet)

3. Decompress: - treat abdominal compartment syndrome

4. Control: - prevent or treat persistent and recurrent infection

The sine qua non of success is timely surgical intervention to stop delivery of bacteria and adjuvant into peritoneal cavity. All other measures are of little use, if the operation does not successfully abort the infective source and quantitatively reduce the inoculum of microorganism and adjuvants of infection so that they can be effectively handled by the patient's defense.

Generally, the choice of the procedure and whether the ends of resected bowel are anastomosed, exteriorized, or simply closed depends on anastomic source of infection, the degree of peritoneal inflammation and generalized septic response, and the patient's premorbid reserves.

The prevailing trend has been to minimize the immediate risk of complication by avoiding any intestinal suture lines in presence of severe peritonitis.₂

In the present study mortality was more in the group of patients who undergone extereiorisation, because their general condition were very poor as compared to rest of the patients.

That means to evacuate bacterial inoculum, pus and adjuvants [peritoneal toilet]

Any dead or foreign material, including haemoglobin, in the peritoneum potentiates the action of bacteria and for fewer are required to cause serious infection if foreign material is present ₆. So, all infectious fluids should be aspirated and particulate matter should be removed ₁₄.

Three different approaches have been suggested ₁₄

• Mechanical cleansing

• Peritoneal lavage

• Aggressive debridement

Cleansing the peritoneal cavity with swab especially the local part was thought to reduce spread of bacteria and localize the process. But now it is evident that bacterial contamination is rapidly disseminated throughout the peritoneal cavity by so called intraperitoneal circulation.₁₃

What could be more natural, then, that surgeons since the time of Lister and Halsted have attempted to "wash" wound and peritoneum clean by using copious quantities of saline, solution of antiseptics or solutions of antibiotics.

The problem is that bacteria rapidly become attached to tissues, often by reaction between bacterial surface ligands and cell receptors.15 These bacteria cant be removed by gentle washing, although they can be removed by "pulsating jet lavage" at pressure upto 70 psi. ₁₆

Experimental studies on rat suggested that antimicrobial lavage produced an immediate decrease in mesothelial microbial recovery. The results were transitory and the microbial populations achieved or exceeded pre lavage levels at 24 hr post lavage. ₁₅

Lavages with antiseptic solutions like povideone-iodine, chlorhexidine, etc., have not established safetly or efficacy in experimental or clinical trials. ₁₇

Lavage with solutions of antibiotics during operation for bacterial peritonitis is a little better established. In Britain, audit from Aberdum on use of peritoneal and wound lavage with several liters of 0.1% tetracycline had reduced rate of wound infection to 8% and intraabdominal infection to 4% in 187 patients. ₆ in USA, Noon and associates had observed the same results. It might be assumed that the concentration in the peritoneal exudates of antibiotics given systemically parallels the concentration in serum while local application results in an unequal distribution within peritoneal cavity. Local therapy may be advantageous because penetration to the infected spaces during systemic therapy is markedly reduced. ₁₄

In my study all patients were given through peritoneal lavage.

Recently, this modality of treatment reopened by Hydspeth. ₁₈ He felt that main benefit attained from lavage was its debridement effect. He used to open all peritoneal cavities and meticulous dissection of firbinous exudates and debris was done. He found promising results.

There are several objections to this method, the most serious being that bleeding from damaged surfaces results in hemoglobin and fibrin deposition, both known to be potent adjuvants to infection.

In a prospective randomized trial, Polk & Fry ₁₉ found no differences in terms of hospital mortality or the frequency of reoperation.

It seems, therefore, that a general recommendation of aggressive debridement in all cases of peritonitis cannot be given.₁₄

According to Kisschner " The early cleansing fanaticism to eliminate fibrin deposits by barbaric procedures of wiping and ripping is to be condemned"₁₄

At the termination of intra abdominal procedure, the question remains whether a drain or several drains should be left behind. Nobody would object to the statement that it is better to allow dead and live bacteria to be drained out continuously instead of being absorbed.

But there are still several objections to drainage of peritoneal cavity₂₀

• Fibrous tract will develop within a short period, which do not communicate with abdominal cavity as such.

• Contamination from the outside might occur.

• Visceral erosion with fistulization and bleeding has been reported.

• Drains may interfere with proper sealing of anastomoses.

Drains will be effective in evacuating absusses, establishing a controlled fistula, or offering a pathway for visceral secretions ₂,₁₄

It is an attempt to continue peritoneal toilet post operatively. 3 major approaches have emerged. ₁₄

• Continuous postoperative peritoneal lavage.

• Planned relaparotomies

• Laparotomy (the lift open abdomen)

This may be performed by different means. Two inflow catheters in the subphrenic spaces and two outflow catheters in the pelvis are the most prevalent arrangements.

The time period of either intermittent or continuous lavage usually ranges from 1 to 5 days. Most authors add antibiotics to the lavage fluids.

The basic question in all lavage procedure is whether it is possible to irrigate the abdomen properly or whether drainage tracts develop. So that only the drains communicate and one irrigated continuously.

Hallerback & Andersson 21 had evaluated continuous peritoneal lavage in the treatment of purulent peritonitis in a prospective randomized study and found no clinical benefit of it.

Indications for staged abdominal repair₂

1. critical patient's condition

2. excessive peritoneal edema preventing abdominal closure without undue tension, intra abdominal pressure > 15mmHg

3. massive abdominal wall loss

4. impossibility to eliminate or to control source of infection

5. incomplete debridement of necrotic tissue.

6. uncertainty of viability of remaining bowel

7. uncontrolled bleeding (the need for 'packing')

It has been suggested for patients with diffuse peritonitis being at high risk of developing MODS.

Planned relaparotomies or also known as "Etappenlavage" is defined as a series of planned multiple operative procedures performed at a 24 hrs interval ₂₂. It includes a commitment to reexplore the patient's abdomen at the initial corrective operation.

The abdomen can be closed temporarily utilizing extension suture, a simple zipper, a slide fastener and Velcro analogues.

The advocates of an absorbable mesh claims that it reduces intra abdominal pressure, prevents evisceration, and allows for effective drainage of the abdominal cavity; however, the development of diffuse, patchy necrosis of the bowel wall resulting in fistula formation has been described. ₁₄

Wittman₂₂ found Velcro analogue as the most practical device for temporary abdominal closure. In the same study he found reduction of overall mortality due to diffuse peritonitis from between 34.93% to 24%. Penninekx et al 1983 ₂₅ also found planned relaparotomies beneficial in patients with severe peritonitis and reduction of mortality from 73% to 29%.

Whereas Anderws ₂₃ compared planned reoperation with the policy of observation following the primary operation when indicated by signs of continuing infection and he found no difference in mortality. Similarly Christou et al 1993 ₂₄ had not found any significant difference in mortality between patients treated with a " closed abdomen technique" (31% mortality) and those treated with variation of the " open abdomen technique" (44% mortality).

Also, with this approach patients need to ventilate mechanically for longer period post operatively. As in series of Wittman the average period of mechanical ventilation was 17 days. So, turely, there are, as yet, no standards in this field.₁₄

Technique:

Open packing of the peritoneal cavity with delayed closure had been advocated as useful technique in operative management of patients with diffuse peritonitis. This method treats the entire abdominal cavity as if it was on abscess cavity and theoretically establishes optimum drainage.

Steinberg 1979 ₂₅ had attempted this technique & had found dramatic improvement in outcome. Duff & Moffat 1981 ₂₇ confirmed that findings and conclude that leaving the abdomen completely open facilitates the widest possible drainage, uncompromising debridement of abdominal wall, and is compatible with good recovery. Mortality was 34%. Anderson et al 1983 ₂₈ found no advantage of keeping abdomen open in-patient with severe peritonitis. Contrary he reported 60% mortality as compare to 33% in control group and increased post operative complications.Like ettapenlavage in this technique patients need mechanical ventilatory support post relaparotomies. Average period of ventilatory support in series of Duff and Moffat was 44 days.

We also tried this modality in our three patients but did not found any more advantage.

Much remains to be done in this field in order to develop standards of management that can be generally accepted.

Figure 11

• As there is very high mortality and morbidity associated with postoperative peritonitis, prevention should be the main goal.

• The main etiological factor for postoperative peritonitis is disruption of anastomotic site, that to be prevented.

• The prevention of anatomic disruption and following post operative peritonitis starts from pre operative period that includes:

• good bowel preparation that may not be possible pre operatively in emergency condition, in that circumstances one may go for intraoperative mechanical lavage and avoidance of soilage.

• • Systemic antibiotic pre operatively and throughout procedure.

  • Improve patient's nutrition. Parameters showing poor nutritional status are

  • weight loss of 10 15% of total body weight over

  • 3 - 4 months or shorter period

  • S. Albumin < 3 gm %

  • S.Trasferrin < 220mg %

  • energy to injected recall antigen

  • inability to perform usual tasks because of weakness

  • or easy fatigability

• intra operative measures

• • sound surgical procedure

  • anastomosis to be done in healthy bowel with adequate blood supply

  • meticulous haemostasis

• if there is severe peritonitis on first operation than avoidence of anastomosis and exteriorization of bowel.

• Post operative measures:

• • prevent hypotension

  • maintain good nutrition status

  • adequate antibiotic coverage