What is the recommended treatment approach for patients with diffuse peritonitis?

Emergency Surgical Intervention for Diffuse Peritonitis

Patients with diffuse peritonitis should undergo an emergency surgical procedure as soon as possible, even if ongoing measures to restore physiologic stability need to be continued during the procedure. 1

Rationale and Timing

• Diffuse peritonitis represents a critical condition requiring prompt intervention, as delayed source control is associated with increased morbidity and mortality 1, 2
• Emergency surgery should not be delayed for complete physiologic stabilization - resuscitative measures should continue concurrently with surgical intervention 1
• Patients with diffuse peritonitis are typically critically ill and require prompt fluid resuscitation, antibiotic administration, and definitive surgical management 1

Preoperative Management

• Initiate fluid resuscitation immediately to address volume depletion, which is common in patients with peritonitis 1
• Start appropriate antimicrobial therapy as soon as possible, ideally within 1 hour for patients with septic shock 1
• Ensure antimicrobial drug levels are maintained during source control intervention, which may require additional administration just before the procedure 1
• Meropenem is FDA-approved for treatment of complicated intra-abdominal infections including peritonitis 3

Surgical Approach

• The primary goals of surgery are to:

  • Drain infected foci
  • Control ongoing peritoneal contamination
  • Restore anatomic and physiological function 1

• Specific surgical options depend on the cause of peritonitis:

  • For perforated diverticulitis with diffuse peritonitis:

    • Hartmann's procedure remains useful in critically ill patients 1
    • Primary resection with anastomosis (with or without diverting stoma) may be performed in clinically stable patients 1, 4

  • For other causes (perforated peptic ulcer, small bowel perforation):

    • Surgery is the treatment of choice 1
    • Simple closure with or without omental patch for small perforations 1
    • Resection with primary anastomosis when appropriate 1

• Laparoscopic peritoneal lavage and drainage is not considered the first-line treatment in patients with diffuse peritonitis 1

Postoperative Considerations

• Mandatory or scheduled relaparotomy is not recommended in the absence of:

  • Intestinal discontinuity
  • Abdominal fascial loss preventing abdominal wall closure
  • Intra-abdominal hypertension 1

• On-demand reoperations should be performed when clinically indicated rather than as scheduled procedures 5

Special Considerations

• Source control at the initial operation is achievable in approximately 89% of patients with diffuse peritonitis 6
• The most common complications following surgery for peritonitis include dehydration (18.8%), septicemia (11.3%), and paralytic ileus (6.4%) 7
• For patients with perforated diverticulitis, the choice between Hartmann's procedure and primary anastomosis should consider hemodynamic stability and comorbidities 4

Common Pitfalls to Avoid

• Delaying surgical intervention while attempting complete physiologic stabilization - this increases mortality 1, 2
• Inadequate source control during initial operation - thorough exploration and definitive management are essential 6
• Inappropriate selection of surgical approach based on patient condition - more conservative approaches (Hartmann's procedure) may be necessary for unstable patients 1, 4
• Failure to maintain adequate antimicrobial coverage during the perioperative period 1