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