Damage control surgery for patients with peritonitis. Patient underwent laparotomy candidate with severe illness condition.

1. Evaluation after the
Primary peritoneal drainage in
abdominal emergency
(Damage Control Surgery)
JAY

2. Introduction
 Peritonitis is a serious life threatening and most common
general surgical emergency
 Although phenomenon of self-healing has been claimed to be
efficient in 50% of patients yet a large number of patients
require definitive treatment  Laparotomy has been the
gold standard for the definitive management
 The high risk status of patient  The immediate laparotomy
under general anesthesia is not advisable

3. Pathophysiology of peritonitis
 Localized peritonitis implies either contained or early perforation of a viscus or inflammation of an organ in
contact with anterior parietal peritoneum.
 The inhibition of peritoneal fibrinolysis permits stabilization of fibrinous exudates and limits the spread of
infection  The omentum abdominal policeman is attracted to the inflammatory site and along with the
intraperitoneal viscera, example : the omental plugging of the perforated duodenal ulcer.
 Generalized peritonitis  failure of localization
 A rapid contamination that does not permit localization as in perforated
colon/anastomotic leak;
 persistent or repeated contamination
 a localized abscess that continues to expand and ruptures into the peritoneal cavity
 The peritoneal cavity becomes acutely inflamed with production of an inflammatory exudate, which spreads through the
peritoneum leading to intestinal dilatation and paralytic ileus.

4. Primary peritoneal drainage
 Primary peritoneal drainage as a modality of treatment depended on
same concept of self-healing and expected recovery in patient’s
status if sepsis causing peritoneal collection is drained away.
 The role of primary peritoneal drainage in early and premature
neonates with NEC has been well established by various studies.
 PPD role in adults especially critically ill patients, in whom
anesthesia was detrimental, was proposed and surgeons started
evaluating it only recently

5.  Jaiswal 2020 et al. Perforation peritonitis is a very commonly faced emergency by
every surgeon and sizable number of patients report in a very late stage, when
definitive surgery is not possible, delay increases morbidity and mortality even after
definitive surgery. We, in our study conclude that if a peritoneal drainage is done
under local anaesthesia, fluid is drained out, general condition improves, later
definitive & curative surgery can be done, life can be saved.
Strict monitoring of pulse, BP,
oxygen saturation, urinary output,
conscious level,
respiratory rate, was done and recorded,
patients were
supplemented with IV fluids, antibiotics.
Mini
venesection and central line were used
when required

6. Sepsis (Criteria)
The Third International
Consensus Definitions for
Sepsis and Septic Shock
(Sepsis-3) . JAMA.
2016;315(8):801-810.

7. Damage control surgery
Indications for a damage control include :
• temperature less than 34°C;
• arterial pH less than 7.2;
• an international normalized ratio, prothrombin
time, or partial thromboplastin time greater than
1.5 times normal; or a clinically observed
coagulopathy in the pre- or intraoperative setting.

8. DCS
• Damage control surgery entails the acute resection (stapling-
off) of damaged tissue, drainage and delayed
reconstruction at re-look laparotomy at 48 h.
• Correction of physiology and avoid the lethal triad of death
from hypothermia (temp < 34°C), coagulopathy (PT >16 s)
and acidosis (pH < 7.2)
• The correction of physiology takes precedence over
anatomical correction in the exsanguinating critically ill
patient.

9. Other Indicator
- The lactate cutoffs determining an elevated
level
ranged from 1.6 to 2.5 mmol/L, although
diagnostic characteristics.
- Heart rate, central venous pressure (CVP)
and systolic blood pressure alone are poor
indicators of fluid status.
• Dynamic measures have demonstrated
better diagnostic accuracy at predicting fluid
responsiveness compared with static
techniques.
• Dynamic measures include passive leg
raising combined with cardiac output
(CO) measurement, fluid challenges
against stroke volume (SV), systolic
pressure or pulse pressure (Arterial line),
and increases of SV in response to changes
in intrathoracic pressure

10. Terima kasih