O.O. Bohomolets National Medical University CHAIR OF GENERAL SURGERY No. 1 Approved by methodical meeting of the chair "__"___2007, minutes No.___ Prof., MD, PhD. O.I. Dronov METHODICAL GUIDES FOR PRACTICAL LESSONS Materials for teachers and students Subject:Peritonitis: Inflammation of the peritoneal cavity. Classifications, clinics, diagnosis, prophylaxis Course 3 Faculties 2 and 3, faculty for educating the doctors for Ukrainian Army, faculty of medical psychology Duration: 4 academic hours Prepared by assistant M.D. S.V. Zemskov Kyiv 2007
2I. Priorities of the subject: The concept of the relative and absolute indications for a surgery exists in the surgicalpractice. The absolute indication is the patients condition which could not be corrected by theconservative means. Peritonitis or he threat of peritonitis is the most prevalent absoluteindication for the urgent abdominal surgery. Therefore, the knowledge of the clinical features ofperitonitis and the major principles of its treatment is of vital importance for the clinicians.II. The aims of training:А-1. Scope of the knowledge:- Anatomy and histology of the peritoneum and the greater omentum;- Resorptive and exudative properties of the peritoneum;- Biological and chemical characteristics of the secretions of the glands comprising the digestive system and other biological fluids of the body capable of contacting the peritoneum;- Features of the local and general inflammatory response of the peritoneum;- Clinical symptoms and syndromes peculiar to peritonitisА-2. Student should be acquainted with the following subjects:- Mechanisms of the development of localized and general peritonitis;- Extent of clinical manifestations depending on the etiology of peritonitis;- Pathogenesis of complications due to peritonitis;- Hazards of peritonitis and importance of the timely adequate treatment. А-3. Scope for practical skills: - Competent anamnesis for the assessment of the causes of peritonitis; - Use of physical examination techniques and assessment of pathognomonic symptoms of peritonitis; - Timely recognition of peritonitis and use of the require complex of the diagnostic procedures for confirmation / refusal of peritonitis diagnosis. А-4. List of practical technique to be trained: - Detection of Schotkin-Blumberg symptom; - Interpretation of the survey X-ray film of peritoneal cavity - Interpretation of the ultrasonographic data.III. Training and educational objectives:1. To demonstrate the importance of the subject for the timely and adequate treatment of peritonitis.2. To demand the adherence to the principles of the medical ethics and deontology.3. To demonstrate the importance of the knowledge and skills in the field employing the practical examples.
3IV. Interdisciplinary integration:Subject for study and Scope of knowledge Scope of skillscorresponding chair Pathological states resulting in Detection and interpretation ofGeneral surgery with care complications manifesting as pathognomonic symptoms offor patients peritonitis peritonitis Interpretation of peritonitis Anatomical structure and probability in case of injury ofHuman anatomy relation of the peritoneal the specified organ located in organs to the peritoneum peritoneal cavity Structure and embryogenesisHistology and embryology of peritoneum Differential prescription of Microflora of the specificMicrobiology antibacterial agents according to divisions of the intestines the etiology of peritonitis Exudative and resorptive Indications for drainage / lavagePhysiology functions of peritoneum of the peritoneal cavityV. Content of training INTRODUCTION The peritoneum is a two-layered serous membrane that lines the abdominal cavitycovering the inside walls of the abdomen (parietal peritoneum) and the abdominal organs(visceral peritoneum). Passing from the abdominal walls to the intra-abdominal organs and fromone organ to another one, the peritoneum generated the folds and the mesenteries bordering thespaces, the sinuses, and the recesses. The peritoneal cavity is limited by the diaphragm from above, the pelvic diaphragm andthe ilia from below, then backbone and the muscles of the back posteriorly, the rectus muscles ofabdomen anteriorly, and the internal oblique and transverse muscles of abdomen anteriorly andlaterally. The peritoneum is a semipermeable actively functioning membrane possessing severalfunctions such as exudative-and-resorptive function and the barrier function (due to migratingand resident macrophages, immunoglobulins, and non-specific factors. Histologically, the peritoneum comprises six layers: mesothelium, basal membrane andfour layers of elastic and collagenous fibers. On average, the thickness of the serous membrane isabout 0.2 mm. The total area of the peritoneal cover amounts to 17000-20400 square centimeters, whichpractically equals to the area of the skin surface.
4 The exudative areas of the peritoneum are represented for the most part by the serouscover of the intestines. The most intensive exudation is in the duodenal area with the gradualdecrease in caudal direction. The most intensive resorption is inherent to the peritoneum of the diaphragm, the greateromentum, the ileum, and the cecum. The amount of the fluid absorbed by peritoneum within onehour makes up to 8% of body mass. The greater omentum represents the duplicature of the peritoneum containing the fat withwell-developed blood and lymphatic vessels providing for the protective function circumscribingthe foci of the inflammation by means of the fibrin. The peritoneum is supplied by the blood from the basins of the vessels feeding thecorresponding organs. The outflow of the venous blood is provided mainly through the portalsystem and partly through the caval system. The most intensive outflow of the lymph occursfrom the surface of the greater omentum and the diaphragm. The visceral peritoneum has the vegetative innervation (parasympathetic andsympathetic) and practically is devoid of the somatic innervation. This is the reason why thevisceral pains due to the irritation of the visceral peritoneum are not localized. The mostsensitive are so called reflex areas of the root of mesentery, the areas of the celiac trunk, thepancreas, the ileocecal angle, and Douglas pouch. The parietal peritoneum is devoid of thesomatic innervation. This fact explains the absence of the protective tension of the muscles of theanterior abdominal wall in the case of the inflammations in the small pelvis. PERITONITIS CLASSIFICATION (after Yu.M. Lopukhin and V.S. Saveliev)І. According to the clinical course: acute and chronic.ІІ. According to the route of penetration of bacteria into the peritoneal cavity:А. Primary peritonitis when the infection spreads by hematogenic or lymphogenic route or viathe fallopian tubes.B. Secondary peritonitis when the infection penetrates due to the acute surgical conditions or theinjury of the peritoneal organs. 1. Infectious and inflammatory peritonitis results from the following diseases of theperitoneal organs: - acute appendicitis, - acute cholecystitis, - acute ileus,
5 - acute pancreatitis, - thromboembolia of the mesenterial blood vessels, - diverticulitis, - intestinal tumors, - gynecological conditions. 2. Perforative peritonitis results from the perforations due to: - duodenal and gastric ulcers; - intestinal ulcerations associated with typhus, dysentery, tuberculosis, cancer, stress, etc.) - decubitus ulcer in the obturation ileus; - strangulation groove in strangulated intestinal obstruction in the foreign bodies of gastrointestinal tract; - intestinal necrosis in the strangulated hernia or thromboembolia of the mesenterial blood vessels. 3. Traumatic peritonitis develops in the open and closed abdominal traumas both withaccompanying damage of the abdominal organs and without such damage. 4. Postoperative peritonitis results from: - the failure of the sutures of anastomosis after the abdominal surgery; - the infection of the peritoneal cavity in the course of the surgery; - the defects of the ligatures applied to the large areas of the omentum and the mesentery followed by the necrosis of the tissues distal to the ligature - the mechanical damage of the peritoneum: drying or the hemorrhage into the free abdominal cavity without the reliable hemostasis.ІІІ. According to the microbiological features1. Bacterial peritonitis: non-specific caused by microflora of the gastrointestinal tract andspecific caused by microflora, which is not associated with the gastrointestinal tract such asgonococci (Neіsserіa gonorrhoeae), pneumococci (Streptococcus pneumonіaе), hemolyticstreptococci (Streptococcus pyogenes, Streptococcus vіrіdans), micobacteria of tuberculosis(Mycobacterіum tuberculosіs).2. Aseptical peritonitis develops because of the exposure of peritoneum to the toxic andenzymatic agents of non-infectious origin (the blood, the bile, the gastric juice, the chylous fluid,the pancreatic juice, the urine, the aseptic necrosis if the internal organs).3. Specific forms of peritonitis:Carcinomatous.Parasitic.
6Rheumatoid.Granulomatous.ІV. According to the character of the peritoneal exudate." Serous" Fibrinous" Purulent" HemorrhagicV. According to the character of the lesions of the peritoneal surface1. Depending on the circumscription, the following forms of peritonitis may be delineated:The circumscribed peritonitis may be represented as an abscess or infiltrate (for example,paravesical abscess or pericholecystitis as the complication of the gangrenous cholecystitis)Non-circumscribed peritonitis lacks the strict boundaries and the tendencies towards thecircumscription.2. Depending on the extent of the spread, the following forms of peritonitis may bedelineated :Localized: confined only to one anatomical division of the abdominal cavity.Diffuse: extended to 2-5 anatomical divisions of the abdominal cavity.Generalized: total involvement of the peritoneum (6 and more divisions of the abdominal cavity.VІ. According to the phases of the development.1. Reactive phase (first 24 h, 12 h for perforative peritonitis)2. Toxic (24-72 h, 12-24 h for perforative peritonitis)3. Terminal (more than 72 h, more than 24 h for perforative peritonitis). Definition of peritonitis as the surgical pathologyPeritonitis is defined as the acute inflammation of the peritoneum. Peritonitis represents one ofthe most severe complication accompanying the diseases and the injuries of the intra-abdominalorgans and may be delineated as the separate nosology with the characteristic clinical pattern andthe complex of the severe pathophysiological reactions with the impairment of the wholehomeostasis systems. Referring to the peritonitis and its surgical treatment, one bears in mindacute, secondary, non-specific peritonitis being the cause of complications of about 15-20 % ofall the acute pathologies of the abdominal organs. Among the forms of the acute peritonitis, the acute appendicitis with the incidence of30-65% ranks the first followed by the perforated ulcer (7-15 %), the acute cholecystitis (10-12%), the gynecological pathologies (3-12 %), the ileus (3-5 %), the pancreatitis (1 %), andpostoperative peritonitis (1 %).
7The chronic peritonitis may develop in tuberculosis, mycosis, carcinomatosis, also in asciticconditions and in the presence of the numerous syphilitic gummas.The aseptic peritonitis develops - Upon irritation of the peritoneum with various chemical agents (iodine, ethanol, non- isotonic solutions, some antiseptics, enzymes); - Upon irritation of the peritoneum with the aggressive biological fluids (urine, bile, pancreatic or gastric juice, the content of the hydatid cyst), - Upon the extensive ligation of the tissues.All the forms indicated above make up to less than 1 % of all peritonitis cases, the rest beingattributed to the acute secondary peritonitis. CLASSIFICATION OF SURGICAL PERITONITIS The general classification is rather bulky for everyday use. That is why in so calledworking classifications the cause of the peritonitis is given (the perforated ulcer or acutegangrenous perforated appendicitis) with accompanying morphological description (diffuse,fibrinous-purulent peritonitis). The words such as "secondary" and "infectious non-specific" areusually being avoided). In final diagnosis, the complications resulting from the infectious (septic) processes andpostoperative complications are referred to (if any). Circumscription and extent of spreading: The redundant terms (circumscribed – local ornon-circumscribed – diffuse) should not be used together. The area of the lesion should bestrictly indicated. Phases of the development: We use the pathogenetic classification after K. Simonian: Reactive phase: The manifestations of the peritonitis are caused by the activated defensesystems such as the massive release of the kinins in the response to the primary infectiousaggression. Therefore, when the source of infection is eliminated, in reactive phase the radicalsurgery is possible with anastomoses being applied to the abdominal organs. In the inflammatoryprocess, the reactive phase lasts up to 24 hours (in perforative peritonitis up to 12 hours). Uponthe source of the peritonitis is eliminated (the perforated ulcer, for example) in the early(reactive) phase, the peritonitis does not progress as usual and the lethality is rather low. Toxic phase is characterized by the alterations in the functions of all systems of the bodybecause of the syndrome of the systemic inflammatory response. The toxic phase is evident in12-24 hours after the onset of the disease in perforative processes and 24-48 hours in theinflammatory processes. The lethality is 20% and higher.
8 Terminal phase is characterized by the development of the polyorgan insufficiencysyndrome representing the depletion of the functional reserves of the major systems of the body.The toxic phase is evident in 24-36 hours in the perforative peritonitis and in 48-72 hours in theinflammatory processes. The lethality in the patients with polyorgan insufficiency syndrome is about 90%.Complications The local and general complications may be delineated. The local complications comprise pylephlebitis, the multiple abscesses of the liver. The general complications comprise the liver insufficiency, the toxic encephalopathy, therenal failure, the cardiovascular failure. The predominant part of the peritoneum covers the intestines. It is naturally, therefore,that the toxic products flowing out with blood or lymph impair microcirculation in the intestinalwall and neuromuscular transmission resulting in decreasing and arresting the peristalsis(intestinal paresis). The intestinal content is a good milieu for the development of bacteriaincluding the anaerobic ones since the aerobic bacteria realize the available oxygen. The arrest ofthe intestinal passage results in the increasing microbial content in the middle and upper thirds ofthe small intestine where the bacteria are normally absent. The serous edema extends to the whole intestinal wall. The mucosa loses the barrierfunction. Ads a result, the bacteria and their metabolites are absorbed into the lymph and theblood circulation not only from the peritoneal cavity but from the intestine as well. Therefore,since the onset of the intestinal paresis in peritonitis, the intoxication and dehydration of thebody progress rapidly. The increase in the toxic load to the liver results in then rapid depletion of its detoxifyingfunction and other metabolic functions as well. The penetration of the bacteria and toxins intothe caval system results in extra loading to the lungs resulting in the development of theinflammation in the lung tissue. As a consequence, the respiratory function is impaired with thedevelopment of the respiratory distress syndrome resulting finally in the pneumonia.Microbiological features of peritonitis As a rule, the exudate is infected with variety of bacterial species inhabiting the cavitiesand the surfaces of the human body. The most prevalent batteries are the Escherichia coli, Enterococcus, and Proteus sp. Theputrefactive odor and the sordid of the exudate suggest that the predominant microflora relates tothe facultative anaerobic bacteria (so-called non-clostridial anaerobic microflora).
9 Earlier, gas chromatography was used as the express method for detecting the bacteriacomprising the exudates based on the analysis of the specific bacterial metabolites – volatilefatty acids (propionic, butyric, valeric). The up-to-date techniques of detection and identificationare based on the immunocytochemistry and polymerase chain reaction. Upon the prolonged treatment, the nosocomial infection caused by penicillinase-producing cocci or Pseudomonas aerugіnosa may be evident. The results of the commonly used bacteriologic techniques are evident in three days.Therefore, the initial antibiotic therapy should be based on the previous experience in the field.The following findings should be taken into account: – Gram-positive cocci are the major bacterial species in the case of the localization of theprimary focus in the upper division of the gastrointestinal tract (the stomach, the duodenum, thebile ducts, the pancreas, upper third of the small intestine). The probability of the involvement ofthe anaerobic bacteria is rather low (10-15%) and depends entirely on the duration of theprocess. – Gram-negative bacilli and non-clostridial anaerobic bacteria prevail in the perforationof the small intestine and the appendix as well as in the cases of peritonitis with theaccompanying ileus. – Escherichia coli ranks among the first in the development of the peritonitis when theperforation is not available. SYMPTOMATICS AND DIAGNOSIS OF PERITONITIS The diagnosis of the peritonitis is based on the complex assessment of the anamnesis, thelocal symptoms, the presence of the inflammation and intoxication, and the specificcomplications. Complaints: The steady blunt pain throughout the abdomen increasing upon themovements and the breathing. The irradiation into the shoulder is possible upon the irritation ofthe diaphragm. The general sickness is evident with frequent nausea and stool retention. Anamnesis The time passed since the onset of the symptoms should be clarified. The dynamics of thecharacter and the localization of the pain, the dynamics of the toxic manifestations are followed.In most cases, the signs of the previous disease (appendicitis, cholecystitis, acute condition of theulcer) resulting in peritonitis are evident. Frequently, in the setting of some improvement of thegeneral state and decreasing of the abdominal pains, the sudden increase of the pain occurs
10which becomes more extensive. Since this moment, the general state of the patient deteriorates,the dryness in mouth and the thirst appear, the palpitation increases. General examination As usual, the patient lies in supine position with the knees bent. The attempts to changethe pose or to rise fail due to the increasing pain. When the patient sits, the attempt to lie downresults in increasing abdominal pain and the pain irradiating to the shoulders due to the irritationof the diaphragmatic nerve. The patient is forced to take up the previous sitting position (thetumbler toy symptom). The patient speaks quietly and does not shout claiming the attention. Such a behavior ofthe patient especially the breathing accompanied by the quiet moaning is a sign of particularconcern for the doctor. All the components of the infectious process and the intoxication such as the temperature,the tachycardia, the rate, and the deepness of breathing, the changes in blood pressure, thedryness of the tongue and the internal buccal surface should be taken into account. The loss ofconsciousness should be of special concern signifying the severe intoxication. The tachycardia with heart rate of 100-120 beats per minutes is evident with normal ordecreased blood pressure and the increased respiration rate (20-24 breathings per minute). The toxic encephalopathy may be manifested both as the inhibition and the excitation inthe form of delirium. The paleness of the skin and cutis marmorata reflects the deep disorder ofmicrocirculation. Specific examination The abdomen is usually symmetrical, somehow distended, is not involved in breathingmovements. By palpation, the diffuse pain, the tension of the abdomen, and Mendel andSchotkin-Blumberg symptoms are revealed. The peristalsis sounds are usually weakened orabsent. The presence of the free gas should be checked by the disappearance of the liver dullness.The presence of the free liquid is proved by the dullness of the percussion sound in the lateraldivisions disappearing upon turning the patient to the side. In rectal and vaginal examination, the overhang of the fornices and the tenderness due tothe accumulation of the inflammatory exudates are frequently evident. In general blood analysis, the pronounced leukocytosis and the shift towards theimmature forms are present.
11 Biochemically, normo- or hyperglycemia, the moderate increase of urea, creatinine, thealanine aminotransferase, aspartate aminotransferase, alkaline phosphatase activities aredetected; the syndrome of the disseminated intravascular blood coagulation may develop. Laboratory examination The moderate leukocytosis (14-20 х 109/L) with the shift of the formula to the left,lympho- and monopenia, aeosinophilia, thrombocytopenia are evident. For the objectiveassessment of the intoxication extent, Calf-Calif leukocytic index of intoxication is calciulatedwith its value of 4 characteristic of the reactive phase, the value of 8 characteristic of the toxicphase, and the value of 12-18 characteristic of the terminal phase. The increase of the hematocrit, the increased content of urea and creatinin, the increasedactivity of transaminases, the elevation of bilirubin, glucose, lactate, the alteration of theparameters of coagulation system, the changes of acid-alkaline state, the increase in the bloodpartial pressure of CO2 and the decrease in the blood partial pressure of O2 are the signs of theimpaired functions of various organs and systems. Additional examinations The presence of the free fluid in the abdominal cavity may be confirmed sonographically.X-ray examination may be useful for detecting free gases, the signs of ileus (Kloiber bowls), thehigh position of the diaphragmatic cupolas and the limitation of their mobility due to the tensionof the abdominal muscles (the muscular defense). In the severe cases, the respiratory distresssyndrome develops. In doubtful cases, laparoscopy may be performed for clarifying the source and theextent of the source of the peritonitis. The diagnosis of peritonitis may be confirmed bylaparocentesis by the presence of the specific exudate. The manifestations of the peritonitis in reactive and terminal phases are quite different. Inthe reactive phase, the pain syndrome prevails. The area of the utmost tenderness corresponds tothe primary inflammatory focus. The rigidity of the abdomen, due to contraction of the musclesof the abdominal wall is a characteristic feature. The tense abdomen looks somehow tucked andboat-like. This sigh is of peculiar importance for the peritonitis with perforation of the holloworgans. Mendel and Schotkin-Blumberg symptoms are revealed. The peristalsis sounds areusually weakened or absent. The overt signs of dehydration are absent. The tachycardia mayreach 90-100 beats per minute. The respiration rate is not increased. Several elements of theexcitation phase of the shock such as the elevated blood pressure may also be evident. The
12neutrophilic leukocytosis 12-18 х 109/L, lympho- and monopenia, aeosinophilia, may be present.The biochemical parameters are usually within the normal limits. In the terminal phase the diagnosis of the peritonitis may be rather difficult if theanamnestic details are not available. The vomiting with the congestive content takes placeseveral times a day. The stool is scarce, frequently only after the enema. The stool has theputrefactive odor. The objective state: Adynamia, the general inhibition, the acute dehydration, the holloweyes, the sharpened features of the face, the superficial frequent respiration, frequently with thequiet moaning. The tongue is dry and difficult to hang out; the internal buccal surfaces are alsodry. The abdomen is inflated, weakly painful. Mendel and Schotkin-Blumberg symptoms arerather dubious. The percutory sound is not uniform. The symptoms of the deathly silence may beevident when the respiratory and the vascular noises are heard instead of the intestinalmovements. The splash sound may be detected when the abdominal wall is stroke by the hand. The multiple Kloiber bowls are evident in survey X-ray pictures. The tachycardia isabove 120 beats per minute. The blood pressure is decreased, especially after the transportationof the patient. The maintenance of the normal blood pressure requires the intensive infusion. Thebreathing rate is about 30 per minute. The oxygen saturation of the blood is diminished. Theshadows of various sides in the lungs are characteristic of the respiratory distress syndrome.Hydrothorax may be developed. In blood, normocytosis, sometimes leukopenia are detected withthe sharp shift to the left (towards the immature elements), sometimes plasma cells are detected. GENERAL PRINCIPLES OF TREATMENT1. The early elimination of the infection source.2. The decrease of the possible intraoperative contamination.3. The treatment of the residual infection and the prevention of further infection of theabdominal cavity.4. The maintenance of vitally important functions prior to and after the surgery, incudingthe techniques requiring the artificial organs. METHOD OF TREATMENTА. SurgicalLaparotomy, early elimination or isolation of the peritonitis source.Intra- and postoperative sanitization of the abdominal cavity.Decompression of the small intestine.
13B. GeneralMassive antibioticotherapy.Medicamentous correction of hemostasis shifts.Stimulation or temporary substitution of the major detoxifying systems of the body by means ofextracorporeal hemocorrection. PREOPERATIVE PREPARATION. It is impossible to correct the hemostasisimpairment prior to the surgery. Nevertheless, it is advantageous to delay the surgery for 2-3hours for directed preparation. It is sufficient to stabilize arterial pressure and central venouspressure and to reach the diuresis at 25 mL/h. The total preoperative infusion volume is 1.5-2.0 Lwithin two hours. In advanced cases when the hemodynamic imbalance is pronounced (the lossof fluid exceeding 10% of body mass), the infusion volume increases up to 3-4 L within 2-3hours. The catheterization of the central (for example subclavian) vein is always performedproviding for high infusion flow rate and the control of the central venous pressure. Thecatheterization of the urinary bladder is expedient providing for measuring the diuresis as theobjective criterion of the infusion therapy efficacy. PREPARATION OF GASTROINTESTINAL TRACT. The stomach is emptied with theaid of the probe. In the advanced cases, the permanent presence of the probe in the stomach isexpedient pre-operatively, intraoperatively and postoperatively for specified time until therecovery of gastric motor activity. ANESTHESIA. The multicomponent anesthesia with the artificial lung ventilation isused in surgery due to peritonitis. MAJOR OPERATIVE STAGES IN PERITONITIS1. Surgical access.2. Possible Novocain blockade of the reflexogenic areas.3. Elimination or reliable isolation of septic focus.4. Sanitization of the abdominal cavity.5. Decompression of the intestine.6. Draining of the abdominal cavity.7. Suturing of the laparotomic wound. 1. Surgical access. The optimal access to all divisions of the abdominal cavity is providedby the midline laparotomy. Depending on the localization of the septic focus, the wound may be
14extended in superior or inferior direction. When the diffuse peritonitis is revealed in the courseof the surgery started from another access, it is worth to perform the midline laparotomy. 2. Novocain blockade of the reflexogenic areas is performed by administering 0.5%solution of Novocain (up to 100.0 mL) into the area of the celiac trunk, the root of themesocolon, transverse mesocolon, the mesentery of the small intestine, and sigmoid mesocolon.Such blockade eliminates the reflex vascular spasm providing for earlier recovery of peristalsis.In addition, such blockade allows diminishing the amount of the narcotic substances used as theanalgesics. 3. Elimination or reliable isolation of septic focus. In the reactive phase, the radicaloperations (resection of the stomach, hemicolectomy) are possible since the risk of theanastomosis failure is rather low. In the toxic and terminal phases the scope of the surgery shouldbe minimal (appendectomy, the suturing of the perforative hole, the resection of the necrotic areaof the gastrointestinal tract with entero- or colostoma, the isolation of the septic focus from thefree abdominal cavity. The reconstructive surgery should be postponed until more favorableconditions. 4. Sanitization of the abdominal cavity. The washing of the abdominal cavity allows fordecreasing the bacterial count in the exudates below the critical level (105 in 1 mL) facilitatingthe elimination of the infection. The dense deposits of fibrin are not removed because of the riskof deserozation. The removal of exudate by means of the wiping with the gauze pieces isunacceptable due to the risk of the injury of the serous membrane. The washing fluid must beisotonic. The use of antibiotics is meaningless because the short-term contact with theperitoneum is not sufficient for their effects. Most antiseptics are cytotoxic; this fact restrictstheir use in the cases under consideration. With this aim, one may use sodium chloride solutionupon electrochemical activation (0.05% sodium hypochlorate) containing activated chlorine andoxygen. This solution is particularly indicated in then cases when anaerobic bacteria are present.Several clinics also use the ozonized solutions. 5. Decompression of the intestine. In the toxic and terminal phases when the intestinalparesis is of particular clinical importance, nasogastrointestinal intubation is performed. Thepolyvinylchloride tube is used with this aim. The intubation is extended distally from Treitzligament. When necessary, the colon is intubated through the anus. Rarely, gastro-, jejuno- orappendicostoma is required for passing the probe. Postoperatively, the probe-assisted correctionof the enteral content is performed comprising the decompression, the intestinal lavage, theenterosorption, and early enteral feeding. All these measures are useful for decreasing thepermeability of the intestinal walls for the bacteria and the toxins facilitating early recovery ofthe functional activity of the gastrointestinal tract.
15 6. Draining of the abdominal cavity is performed by the tubes made of polyvinylchlorideor rubber. Multichanneled polyvinylchloride drainages are the good choice for this procedure.One channel is used for supplying the antiseptic, while another one is used for the aspiration ofthe exudate. 7. Suturing of the laparotomic wound may be performed with the draining of thesubcutaneous fat. The treatment of the residual infection, namely the techniques of the draining and theexudate removal, depends on the techniques used for the final stages of the surgery. Methods of suturing laparotomic wound: 1. The tight suturing without the drainage may be employed only in the case of the local,non-circumscribed peritonitis serous peritonitis with the low level of the bacterial load and lowrisk of abscesses and infiltrates. In these cases, the self-defense of the body and the use ofantibiotics may be sufficient for curbing the infection. 2. The suturing with the passive drainages. The drainages are also used for the localadministration of antibiotics. 3. The suturing with the drainages for the flow and fractional lavage. The technique is notemployed in wide scale due to the difficulties in correcting the shifts in protein and electrolyticbalance. Moreover, the efficacy of the technique lowers in 12-24 hours since the beginning of thelavage. 4. Semi-closed technique with approaching of the wound edges provides for thedrainages being installed in the posterior abdominal wall for the dorsoventral washing with theaspiration of the outflowing fluid via the midline wound. 5. The approaching of the wound edges with the specific appliances used for the repeatedrevisions and sanitizations. We use the term "scheduled laparosanitization". The indication forsuch technique is the pronounced adhesion process in the severe forms of the fibrinopurulentperitonitis with sub- and decompensation of the vitally important functions. The number of therevisions is from 2-3 to 7-8 with 1248-hours interval. 6. The open technique (laparostomy after N. Macokh or Steinberg-Miculich) with theexudate outflow through the wound covered by the tampons with the ointment is used in the caseof the multiple non-shaped intestinal fistulas. The doctor may observe the condition of theintestinal loops adjacent to the wound in every change of the tampons.
16 GENERAL TREATMENTAntibacterial therapyThe most adequate schedule of the empirical antibacterial therapy before the microbiologicalverification of the causative agent and the assessment of its sensitivity to antibiotics is acombination of the synthetic penicillins (Ampicillin) or cephalosporins with aminoglycosid(Gentamicin or Vancomicin) and Metronidasol. Such a combination seems to be effectiveagainst the broad spectrum of the possible causative agents of the peritonitis. When the data of bacteriological analysis are obtained, the corresponding antibiotics ortheir combination are prescribed. The routes of the administration: 1) Local (intraperitoneal) through irrigators and drainages (the double function ofdraining) 2) General a) intravenous (systemic) b) intramuscular (only after the recovery of microcirculation) c) intra-arterial (into aorta, celiac trunk, mesenteric or omental artery) d) intraportal (through the recanalized umbilical vein of the round ligament of the liver(regional way) e) endolymphatic – antegradely: through microsurgically catheterized peripheral lymphastic vesselin the back of the foot, the depulpated inguinal lymph node – retrogradely: through thoracic lymphatic duct – lymphotropically: through the lymphatic net of the shin or retroperitoneal space. Immunotherapy The following preparations improving the immune reactivity of the body may be used:immunoglobulins (antistaphylococcus gamma-globulin), the leukocytic mass, antistaphylococcusplasma. Interleukin-2, α- and γ-interferons, interferon inducers (cycloferon) also may beemployed as the modern drugs improving the immune reactivity. Meanwhile, the use ofPyrogenal, Decaris (Levamisol), Prodigiosan, Thymalin and other agents "stimulating thereduced immunity" seems to de contraindicated.
17 Postoperative correction therapy For the adequate anesthetization, besides the narcotic analgesics, the prolonged epiduralanalgesia with the local analgesics, acupuncture analgesia, and electroanalgesia are employed. The balanced infusion therapy is performed. The total daily volume of the infused fluidcomprises the physiological daily requirement (1500 mL/m2), the deficit of the liquid, and thephysiological expenses (vomiting, drainage, increased sweating, and hyperventilation). The preventing and the treatment of multiple organ failure syndrome: The pathogenetic bases of the multiple organ failure syndrome is hypoxia and cellhypotrophy due to the impaired respiration and hemodynamics. The following measures should be undertaken to prevent and to treat multiple organfailure syndrome: – Elimination of the infectious and toxic focus. – Elimination of the toxins by the techniques of the efferent therapy. – Maintenance of the adequate lung ventilation and gas exchange (sometimes long=-termartificial lung ventilation). – Stabilization of blood circulation with restoration of the blood circulation volume, thesupport of heart function. Normalization of microcirculation in organs and tissues. – Correction of protein, electrolyte, and acid-base balance of the blood. – Parenteral feeding Recovery of functions of gastrointestinal tract The most effective means for recovering the functions of gastrointestinal tract consists inthe intestinal decompression by transnasal probe followed by the intestinal lavage. For the normalization of the nervous regulation and the recovery of the tonus of intestinalmusculature, the correction of the protein and electrolyte balance is performed. Thenanticholinesterase drugs (Proserin, Ubretid), Metaclopramide and ganglioblockers (Dimecolin,Benzohexonium) may be used. The forced diuresis, hemodialysis, plasmapheresis, hemofiltration through the porcineorgans, the artificial lung ventilation, hyperbaric oxygenation are indicated in case of themultiple organ failure syndrome. The hyperbaric oxygenation is capable for arresting all types ofhypoxia in peritonitis, facilitates the decrease in the bacterial load of the peritoneum, stimulatesmotor and evacuatory function of the intestine. For preventing endotoxicemia, the surgical methods and antibacterial therapy are to beused for eliminating the residual infection. Hemosorption, lymphosorption, plasmapheresis and other detoxifying techniques are tobe regarded only as the supplementary methods in the complex therapy of peritonitis.
18 VI. Plan and arrangement of training 6.1 Duration of classes: 4 academic hours 6.2. Stages of classes:N Content and program of Educa- Methods of Supporting Time teaching tional teaching and materials in objectives control min within learning levels1 2 3 4 5 6І Preparatory step Log-book for1 Organization of classes entering the 52 Formulation of the teaching learning progress goals of students3 Preparatory stage (control of the initial level of knowledge Tables, slides 20 and skills): α-ІІ Tests α-ІІ Tables, slides а) major concepts on the 20 anatomy and physiology of α-ІІ Tests α-ІІ Tables, slides peritoneum; α-ІІ Tests α-ІІ 15 б) infectious process; Typical check в) approaches for the surgical situations treatment;ІІ Principal step Equipment and 1201. Training the professional facilities skills and knowledge Training2. Examination of the patients α-ІІІ with peritonitis Non-typical3. Differential; diagnosis of check peritonitis. Diagnostical and situations clinical features. α-ІІІІІІ Final step Individual Control questions ,1. Control and correction of the control of tasks. 50 attained level of professional α-ІІ students Advice for skills knowledge homework with the 52. Summary of classes literature (theoretical, practical, α-ІІІ organizational) 53. Home tasksVII Supporting materials required for teaching Materials for the control of initial level of knowledge and skills: А. Control questions: 1. Anatomical relations between the peritoneum and the organs of the abdominal cavity 2. Histological structure and innervation of the peritoneum.
19 3. Physiology of the peritoneum: resorptive and exudative functions. 4. Definition of peritonitis. 5. Classification of peritonitis according to the clinical course. 6. Classification of peritonitis according to the character of penetration of bacteria into the abdominal cavity. 7. Infectious inflammatory peritonitis. 8. Perforative peritonitis. 9. Traumatic peritonitis. 10. Postoperative peritonitis. 11. Classification of peritonitis according to the microbiological features. 12. Bacterial peritonitis. 13. Aseptic peritonitis. 14. Specific forms of peritonitis. 15. Classification of peritonitis according to the character of the peritoneal exudate. 16. Classification of peritonitis according to the character of lesions on the surface of the peritoneum. 17. Circumscribed peritonitis. 18. Non-circumscribed peritonitis. 19. Classification of peritonitis according to the extent of spreading. 20. Localized peritonitis. 21. Generalized (diffuse) peritonitis. 22. General (total) peritonitis. 23. Phases of the development of peritonitis. 24. Reactive phase of peritonitis. 25. Toxic phase of peritonitis. 26. Terminal phase of peritonitis. 27. Complications of peritonitis. 28. Microbiological features of peritonitis. 29. Patients complaints and the anamnestic data in peritonitis. 30. General and specialized examination of the patients with peritonitis. 31. Laboratory examinations 32. Supplementary examinations. 33. General principles of treating peritonitis. 34. Method for treating peritonitis. 35. Preoperative preparation. 36. Preparation of gastrointestinal tract. 37. Anesthesia. 38. The major steps of the surgical treatment of peritonitis. 39. Draining of the abdominal cavity and suturing of the laparotomic wound in peritonitis. 40. The general treatment of peritonitis. TESTSІ. The most pronounced exudative activity is peculiar to: A. peritoneum of ileum; B. peritoneum of duodenum; C. peritoneum is devoid of exudative activity; D. peritoneum of diaphragm; E. peritoneum of sigmoid colon.
20ІІ. The most pronounced resorptive activity is peculiar to: A. peritoneum of jejunum; B. peritoneum of duodenum; C. peritoneum is devoid of resorptive activity; D. peritoneum of diaphragm and greater omentum; E. peritoneum of sigmoid colon.ІІІ. The peritoneum covers (completely or partially) all the organs of the abdominal cavity exceptfor: A. pancreas; B. kidneys; C. urinary bladder; D. omentum; E. in the abdominal cavity all the organs without exception are covered by the peritoneum. IV. Select the wrong statement – peritonitis may be: A. primary; B. secondary; C. perforative; D. traumatic; E. all the statements are correct. V. Infectious and inflammatory peritonitis is not a consequence of: A. acute appendicitis; B. acute cholecystitis; C. acute ileus; D. traumatic injuries of parenchymatous organs; E. gynecological pathology. VI. Which of the form in the list below is not regarded as the specific form of peritonitis: A. infectious; B. parasitic; C. rheumatoid; D. granulomatous; E. carcinomatous. VII. Which of the pathologies from the list below do not belong to the systemic complications of peritonitis: A. pylephlebitis; B. syndrome of the disseminated intravascular blood coagulation; C. toxic encephalopathy; D. renal failure; E. cardiovascular failure. VIII. Select the wrong statement – the following symptom does not belong to the pathognomonic symptoms of peritonitis: A. Mussi-Heorhievskyi symptom; B. Ortner symptom; C. Karavaiev symptom; D. Schotkin-Blumberg symptom; E. Pasternatsky symptom.
21 IX. The stage which does not comprises the major stages of the surgical treatment of peritonitis: A. operative access; B. elimination or reliable isolation of the septic focus; C. sanitization of the abdominal cavity; D. draining of the abdominal cavity; E. antibioticotherapy. Х. Select the wrong statement: Paresis of the intestine… A. ...accompanies the development of peritonitis; B. …is a pathogenetic factor contributing to the severity of the clinical course in peritonitis; C. …in peritonitis is subjected to the conservative correction; D. … is not observed in all cases of the local form of peritonitis; E. …is in most cases an indication for intestinal intubation. The correct answers: 1–A 4–E 7–A 10 – C 2–D 5–E 8–A 3–E 6–D 9–DREFERENCES1. S.V. Petrov. «General surgery». Peter. 2005 (in Russian).4. Yu.M. Lopukhin, V.S. Saveliev «Surgery» Moscow. 1997 (in Russian).5. C.M. Townsend. Textbook of Surgery. The biological basis of modern surgical practice. 2001.