What is the management for a perforated sigmoid?

Management of Perforated Sigmoid

Perforated sigmoid requires emergency surgical intervention with the specific approach determined by patient hemodynamic stability, extent of peritoneal contamination, and available surgical expertise. 1

Initial Assessment and Resuscitation

• Evaluate hemodynamic stability immediately - unstable patients require aggressive fluid resuscitation and broad-spectrum antibiotics covering gram-negative and anaerobic bacteria before proceeding to urgent surgery 2
• Assess for signs of peritonitis including abdominal tenderness, guarding, and rebound tenderness to determine urgency and surgical approach 2, 3
• Obtain CT imaging with IV contrast when diagnosis is uncertain or to evaluate for ischemia, though this should not delay surgery in unstable patients 1

Surgical Management Algorithm

For Hemodynamically Unstable Patients or Fecal Peritonitis

Hartmann's procedure (sigmoid resection with end colostomy) is the standard approach for patients with hemodynamic instability, significant comorbidities, or feculent peritonitis (Hinchey IV). 1, 2

• This two-stage approach prioritizes source control and patient survival over immediate restoration of bowel continuity 1
• Mortality for emergency surgery ranges 12-20%, with surgical site infections being the most common complication (42.86%) 4
• Important caveat: Approximately 50% of patients never undergo colostomy reversal, and reversal itself carries significant morbidity 5

For Physiologically Stable Patients with Purulent Peritonitis

Primary resection with anastomosis may be considered in carefully selected stable patients with purulent (not fecal) peritonitis, as observational studies demonstrate 40% lower mortality compared to Hartmann's procedure. 1

• This approach avoids permanent stoma in many patients and eliminates need for second operation 1
• However, RCTs have not confirmed mortality benefit, so patient selection is critical 1

For Critically Ill Patients in Physiologic Extremis

Damage control surgery with staged laparotomies should be employed in selected unstable patients who cannot tolerate definitive resection. 1

• Initial surgery focuses solely on source control: primary closure of perforation or limited local resection of diseased bowel 1
• Patient is then transferred to ICU for physiologic optimization before planned second-look surgery 1
• This strategy may improve rates of eventual primary anastomosis by delaying definitive reconstruction until physiologic stability is achieved 1

Role of Laparoscopic Approach

Laparoscopic sigmoidectomy may be performed in physiologically stable patients when technical skills and equipment are available, though evidence remains limited. 1

• Success has been demonstrated in selected patients at experienced centers with purulent and fecal peritonitis 1
• Conversion rates range 0-19%, with mean hospital stay 6-16 days 1
• Critical limitation: This approach is not generalizable to all centers and requires significant laparoscopic expertise in emergency settings 1
• Some series report laparoscopic lavage and drainage as alternative to resection in purulent peritonitis, with lower mortality and avoidance of colostomy 6, 5, 7

Key Clinical Pitfalls

• Never attempt endoscopic closure in patients with peritoneal signs or frank peritonitis - this is absolutely contraindicated and can convert contained perforation to free perforation 2, 3
• Avoid contrast enema when perforation is suspected, as water-soluble contrast can worsen contamination and barium can cause chemical peritonitis 1, 3
• Do not delay surgery for extensive imaging in unstable patients - clinical assessment and plain radiographs showing free air are sufficient to proceed 2
• Assess entire colon intraoperatively for additional areas of ischemia or impending perforation, particularly in obstructive scenarios 2

Postoperative Management

• Close ICU monitoring for sepsis and multiorgan dysfunction is essential given high mortality risk 2
• Continue broad-spectrum antibiotics for minimum 7 days, adjusting based on culture results 2, 6
• Provide early nutritional support to facilitate recovery 2
• Plan for stoma reversal at 3-6 months in Hartmann patients, though counsel patients that reversal may not be feasible in all cases 5