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

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