1. Abdominal access
& Peritonitis
S A NAQVI
CONSULTANT GENERAL SURGEON
MID WESTERN REGIONAL HOSPITALS, LIMERICK,
IRELAND
2. Abdominal incisions
based on anatomical principles
adequate assess
capable of being extended
Ideally muscle splitting
Nerves preserving
The rectus muscle has a segmental nerve supply
It can be cut transversely without weakening a denervated
segment
Above the umbilicus tendinous intersections prevent
retraction of the muscle
3.
4. Midline incision
Commonest approach
The following structures are divided:
Skin
Linea alba
Transversalis fascia
Extraperitoneal fat
Peritoneum
Can be extended around the umbilicus
5. Falciform ligament should be
avoided
The bladder can be accessed via
an extraperitoneal approach
through the space of Retzius
Mass closure technique
The most popular sutures are
either non-absorbable or
absorbable monofilaments
At least 1 cm bits should be
taken 1 cm apart
Length of sutures, four times
the wound length
6. Paramedian incision
Parallel to and approximately 3 cm from the
midline
The incision Cut
Skin
Anterior rectus sheath
Rectus - retracted laterally
Posterior rectus sheath (above the arcuate line)
Transversalis fascia
Extraperitoneal fat
Peritoneum
7. Paramedian incision Cont…
The potential advantages
1. The rectus muscle is not divided
1. The incisions in the anterior and
posterior rectus sheath are
separated by muscle
2. Closed in layers
3. Had a lower incidence of
incisional hernia (when sutures
were not so good)
The potential Disadvantages
1. Takes longer to make and close
8. Peritonitis
Intra-abdominal infections results in two major
clinical manifestations
Early or diffuse infection results in localised or
generalised peritonitis
Late and localised infections produces an intra-
abdominal abscess
Pathophysiology depend on competing factors of
bacterial virulence and host defences
Bacterial peritonitis is classified as primary or
secondary
9. Primary peritonitis Secondary peritonitis
Diffuse bacterial infection Acute peritoneal infection
without loss of integrity of resulting
GI tract GI perforation
Often occurs in adolescent Anastomotic dehiscence
girls Infected pancreatic necrosis
Streptococcus pneumonia Often involves multiple
commonest organism organisms - both aerobes
involved and anaerobes
Commonest organisms
are E. coli and
Bacteroides fragilis
10. Surgical management
The management of secondary peritonitis involves
Elimination of the source of infection
Reduction of bacterial contamination of the peritoneal cavity
Prevention of persistent or recurrent intra-abdominal infections
Could be combined with fluid resuscitation, antibiotics and ITU / HDU
management
Source control achieved by closure or exteriorisation of perforation
Bacterial contamination reduced by aspiration of faecal matter and pus
Recurrent infection prevented by the used of:
Drains
Planned re-operations
Leaving the wound open / laparostomy
11. Peritoneal lavage
Peritoneal lavage often used but benefit is unproven
Simple swabbing of pus from peritoneal cavity may be of
same value
Has been suggested that lavage may spread infection or
damage peritoneal surface
No benefit of adding antibiotics to lavage fluid
No benefit of adding Chlorhexidine or Betadine to lavage
fluid
If used, lavage with large volume of crystalloid solution
probably has best outcome
12. Intra-abdominal abscesses
An intra-abdominal abscess may arise following:
Localisation of peritonitis
Gastrointestinal perforation
Anastomotic leak
Haematogenous spread
They develop in sites of gravitational drainage
Pelvis
Subhepatic spaces
Subphrenic spaces
Paracolic gutters
13. Clinical features
Postoperative abscesses usually present at between
5 and 10 days after surgery
Suspect if unexplained persistent or swinging
pyrexia
May also cause abdominal pain and diarrhoea
A mass may be present with overlying erythema
and tenderness
A pelvic abscess may be palpable only on rectal
examination
14. Management
Ultrasound scanning may reveal the diagnosis
Contrast-enhanced CT is probably the investigation of
choice
May delineate a gastrointestinal or anastomotic leak
Identifies collection and often allows percutaneous
drainage
Operative drainage may be required if:
Multi-locular abscess
No safe route for per cutaneous drainage
Recollection after percutaneous drainage
Patients should receive antibiotic therapy guided by
organism sensitivities