Treatment of Perforated Viscus
Immediate surgical source control should be performed as soon as possible, ideally within 5-8 hours of diagnosis, as delays beyond this threshold significantly increase mortality and septic complications. 1
Immediate Surgical Indications
Emergency laparotomy without delay is mandatory when any of the following are present 1, 2:
- Hemodynamic instability or septic shock
- Signs of diffuse peritonitis on physical examination
- Evisceration or impalement
- Free intraperitoneal air with peritoneal signs
The mortality risk escalates dramatically with surgical delay: 2% if operated within 8 hours, 9% at 8-16 hours, 17% at 16-24 hours, and 31% beyond 24 hours 1. Mortality increases fourfold when surgery is delayed beyond 24 hours 1.
Surgical Source Control Components
The primary objectives of surgical intervention include 2:
- Determining the cause of peritonitis
- Draining fluid collections and controlling ongoing contamination
- Resection or suture of the perforated viscus (e.g., gastroduodenal perforation, diverticular perforation) 2
- Removal of infected organs (appendix, gallbladder) when indicated 2
- Debridement of necrotic tissue and resection of ischemic bowel 2
- Primary anastomosis or exteriorization of bowel depending on patient stability and contamination 2
Laparoscopic vs. Open Approach
Exploratory laparoscopy is safe and should be considered the first-line approach in hemodynamically stable patients to assess perforation-related damage 2. Laparoscopy allows simultaneous diagnosis and treatment with less invasive access 2. However, conversion to laparotomy occurs in 8.5-40% of cases when definitive repair is needed 1.
Open surgery is preferred when 2:
- Very delayed presentation with diffuse peritonitis
- Hemodynamic instability
- Previous multiple abdominal surgeries
- Very large defects
Highly Selected Exceptions to Immediate Surgery
Only highly selected patients may be managed non-operatively if ALL of the following criteria are met 2:
- Hemodynamic stability without signs of sepsis
- Localized peritoneal signs (not diffuse peritonitis)
- Small, sealed-off perforation detected early
- Adequate bowel preparation (for colonic perforations)
- Absence of fever and improving symptoms
Specific conditions where non-operative management may be attempted include 2:
- Perforated diverticulitis with abscess <4 cm diameter
- Peri-appendiceal mass
- Perforated peptic ulcer in stable patients
- Pericolic free air only (not distant intraperitoneal air)
Conservative Management Protocol
When non-operative management is attempted, it requires 2:
- Serial clinical and imaging monitoring every 3-6 hours 2
- Absolute bowel rest for 2-6 days 2
- Intravenous hydration 2
- Broad-spectrum intravenous antibiotics for 3-5 days 2
- Multidisciplinary team follow-up 2
Critical caveat: Early improvement with conservative treatment does not rule out the need for surgery 2. If clinical deterioration, progression to sepsis, or peritonitis develops, surgical treatment must not be delayed 2. Complication rates and hospital stays are significantly higher in patients who undergo surgery after failed conservative management than in those initially treated surgically 2.
Percutaneous Drainage
Percutaneous drainage is appropriate for well-localized abscesses with appropriate density and consistency (lack of extensive loculations) 2. Ultrasound- and CT-guided drainage is safe and effective in selected patients 2. The maximum abscess diameter for treatment with antimicrobial therapy alone without drainage is generally 3-6 cm 2.
Damage Control Surgery and Open Abdomen
For critically ill or unstable patients, damage control surgery with abbreviated laparotomy is preferred over delaying definitive source control 1.
Open abdomen (OA) should be considered when 2:
- Abdominal compartment syndrome is expected
- Bowel viability must be reassessed after resection
- Excessive contamination in unstable patients
OA should be closed within 7 days 2. Early fascial closure within 4-7 days is associated with reduced mortality (12.3% vs 24.8%) and complications compared to delayed closure 2.
Re-laparotomy Strategies
Following initial emergency laparotomy, two approaches exist 2:
- On-demand re-laparotomy: Performed only when required by clinical deterioration 2
- Planned re-laparotomy: Performed every 36-48 hours for inspection, drainage, and peritoneal lavage until the abdomen is free of ongoing peritonitis 2
On-demand re-laparotomy is generally preferred as it is associated with shorter ICU and hospital stays 2, though planned re-laparotomy may reduce the need for additional re-operations 2.
Common Pitfalls to Avoid
- Never delay surgery based solely on negative initial imaging, as CT sensitivity for hollow viscus injury is imperfect 1
- Do not pursue prolonged non-operative management in equivocal cases, as missed injury with catastrophic septic complications outweighs the morbidity of a potentially non-therapeutic laparotomy 1
- Avoid time-consuming procedures like anastomosis in unstable patients; Hartmann's procedure is rapid and eliminates anastomotic failure risk 2
- Do not use peritoneal contamination alone as indication for open abdomen; aggressive source control with abdomen closure should be attempted first 2