Editing Peritonitis laparotomy


Finding the source of perforation

* Long midline incision
* Consider Alexis early if likely to be contamination
* Clean the abdomen systematically
** Infracolic
*** Transverse pulled upwards
*** Small bowel eviscerated and covered with moist packs
*** Female reproductive organs
*** Rectosigmoid
*** Left, transverse, right colon, including mesocolon
*** Small bowel from ICV to ligament of Treitz, including mesentery
** Supracolic
*** Liver
*** GB
*** Stomach (NGT placement)
*** Spleen
*** Lesser sac (enter through gastrocolic omentum on left)
** Retroperitoneal 
*** Kocher's manoeuvre
*** Mattox manoeuvre/left-sided Kocher/medial visceral rotation
* Think about the colour/texture/smell of peritoneal fluid for clues (bile proximal, faeces distally)
* Adhesions often densest near the perforation
* Irrigate copiously, pack in four quadrants
* If nothing obvious found:
** Open lesser sac and inspect posterior stomach
** Fill abdomen with saline and inject air into stomach via NGT, looking for bubbles
** Carefully look at sigmoid for a potential diverticular perforation
** Send cultures
** Potentially place a drain and close the abdomen
* Consider abthera if patient is unwell

[[Category:Operating theatre]]