What is the treatment for pneumoperitoneum?

Treatment of Pneumoperitoneum

Patients with pneumoperitoneum and signs of peritonitis should undergo immediate surgical intervention, as every hour of delay from admission to surgery is associated with a 2.4% decreased probability of survival. 1

Initial Assessment and Management

The approach to pneumoperitoneum depends on the clinical presentation and underlying cause:

• Operative treatment is strongly recommended for patients with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis 2, 1
• In patients with pneumoperitoneum and clinical peritonitis, operative intervention is associated with significantly reduced mortality (odds ratio 0.17) 3
• Approximately 10% of pneumoperitoneum cases have non-surgical causes that can be managed conservatively 4

Surgical Management

When surgery is indicated, the approach should be determined by:

• Patient stability
• Source of perforation
• Surgical expertise

Surgical Options:

• For perforated peptic ulcer:

  • Laparoscopic approach is preferred for stable patients 2, 1
  • Open approach should be considered for unstable patients or when laparoscopic expertise is unavailable 1
  • Primary repair with omentopexy is standard for perforations smaller than 2 cm 1

• For diverticular disease with pneumoperitoneum:

  • Hartmann's procedure for managing diffuse peritonitis in critically ill patients and those with multiple comorbidities 2
  • Primary resection with anastomosis (with or without diverting stoma) in clinically stable patients without major comorbidities 2
  • Emergency laparoscopic sigmoidectomy should be avoided, especially if long operative duration is expected 2

• For colonic obstruction or perforation:

  • Loop colostomy (shorter operative time) or Hartmann's procedure 2
  • Hartmann's procedure is preferred over simple colostomy to avoid longer hospital stay and multiple operations 2

Non-Operative Management

Non-operative management may be appropriate in select cases:

• Patients without signs of peritonitis 3
• Cases of sealed perforated peptic ulcer confirmed on water-soluble contrast study 2
• Non-surgical causes of pneumoperitoneum (approximately 10% of cases) 4

In the absence of peritonitis, operative treatment is associated with increased morbidity and non-home discharge 3. However, careful monitoring is essential as clinical deterioration should prompt immediate surgical intervention.

Special Considerations

• Timing is critical: Every hour of delay in surgical intervention for perforated viscus increases mortality by 2.4% 1
• Laparoscopy vs. open approach: Both approaches carry risk of viral dissemination during the COVID-19 pandemic; appropriate PPE is essential regardless of approach 2
• Negative laparotomy risk: Up to 10% of pneumoperitoneum cases have non-surgical causes, and unnecessary laparotomies can lead to significant morbidity 4, 5

Common Pitfalls to Avoid

• Delaying surgery in patients with peritonitis 1
• Performing unnecessary laparotomy in patients with non-surgical pneumoperitoneum 4, 5
• Underestimating the severity of peritonitis, which may require a more aggressive surgical approach 1
• Attempting complex resections in hemodynamically unstable patients 1