Is diagnostic laparoscopy (a surgical procedure using a laparoscope) safe for a patient with peritonitis (inflammation of the peritoneum)?

Diagnostic Laparoscopy in Patients with Peritonitis

Diagnostic laparoscopy is not recommended as the first-line approach for patients with diffuse peritonitis and should be avoided in favor of immediate surgical intervention with open laparotomy. 1

Assessment of Peritonitis

Patients with peritonitis typically present with:

• Abdominal pain
• Elevated temperature
• Tenderness (localized or diffuse)
• Elevated white blood cell count
• Elevated C-reactive protein and procalcitonin levels 1

Diagnostic Considerations

• In patients with obvious signs of diffuse peritonitis, further diagnostic imaging is unnecessary when immediate surgical intervention is planned 1
• CT scan is the imaging modality of choice for patients not undergoing immediate laparotomy 1
• However, CT scans may miss significant intra-abdominal pathology in peritonitis patients, with studies showing negative CT findings despite drainable collections found during surgery 2

Management Approach

Initial Stabilization

• Rapid restoration of intravascular volume
• Immediate fluid resuscitation for patients with septic shock
• Early antimicrobial therapy (in the emergency department for non-septic patients, immediately for septic shock) 1

Surgical Intervention

Timing and Approach

• Patients with diffuse peritonitis should undergo emergency surgical procedure as soon as possible 1
• Open laparotomy is the preferred approach for patients with diffuse peritonitis 1
• Laparoscopic approach should be limited to very selected cases and is not considered first-line treatment 1

Rationale Against Diagnostic Laparoscopy in Peritonitis

1. Patients with diffuse peritonitis require immediate source control that is often better achieved through open surgery 1
2. Laparoscopic peritoneal lavage has shown high failure rates (57-60%) in patients with diffuse peritonitis 1
3. Multiple clinical trials (SCANDIV, Ladies, DILALA) have shown disappointing results with laparoscopic approaches in peritonitis 1

Special Considerations

• For hemodynamically unstable patients, damage control surgery with staged laparotomies is recommended 1
• In critically ill patients with multiple comorbidities, Hartmann's procedure is preferred over primary anastomosis 1
• Laparoscopic sigmoidectomy may only be considered in physiologically stable patients if technical skills and equipment are available 1

Antibiotic Management

• Antimicrobial therapy should be initiated once intra-abdominal infection is diagnosed or considered likely 1
• For septic shock, antibiotics should be administered immediately 1
• Antibiotic selection should cover all likely pathogens including MDR bacteria based on risk factors 3
• In patients with septic shock due to peritonitis, consider one of the following:
  • Meropenem 1g q6h by extended infusion
  • Doripenem 500mg q8h by extended infusion
  • Imipenem/cilastatin 500mg q6h by extended infusion
  • Eravacycline 1mg/kg q12h 1

Outcome Predictors

Poor outcomes are associated with:

• Delay in initial intervention (>24h)
• High severity of illness (APACHE II score >15)
• Advanced age
• Comorbidities and organ dysfunction
• Low albumin levels
• Diffuse peritonitis
• Inability to achieve adequate source control 1

The mortality rate for severe peritonitis remains high (up to 58% in patients with high Mannheim Peritonitis Index scores) despite advances in surgical techniques and intensive care 4, highlighting the importance of prompt and appropriate surgical intervention.