Emergency laparotomy for abdominal injuries This must not be delayed unduly, particularly if volume replacement proves difficult, suggesting significant active intra-abdominal bleeding. An adequate reserve of cross- matched blood must be available to cover the procedure. ‘Adequate intravenous lines capable of rapid acceleration of inflow must be in place before the patient is anaes- thetized. Muscle relaxation causes a further fall in blood pressure as the tamponade effect of the abdominal wall is diminished, and this effect is entirely lost as the surgeon opens the abdomen, The operation is usually performed through a mid- line incision, as this cam be readily extended from xiphoid ‘to symphysis. pubis and converted to a thoracoabdo- minal one when necessary. The first priority is control ‘of haemorrhage. ‘The next step concerns the operative treatment of hollow visceral injuries, especially those involving the colon, in order to minimize contamination. The abdominal exploration must be thorough, with a sys tematic inspection of all the quadrants and retroperi- toneum (especially the second part of the duodenum) in order to avoid missed injuries. On completion, the peritoneal cavity is thoroughly lavaged with several litres of warm isotonic saline, especially in the presence of contamination from intestinal damage. Closure of the musculoaponeurotic layer of the abdominal wall is effected by absorbable monofilament material. The skin and subcutaneous tissues are left unsutured and the wound packed with acriflavine gauze if the peritoneal cavity has been contaminated by leakage of intestinal contents,ANATOMY AND PHYSIOLOGY OF ABDOMINAL CAVITY ‘The peritoneum is a smooth, translucent membrane lining the abdominal cavity. Its surface consists of a single layer of flat mesothelial cells that reside on a basement membrane, which in tum overlies a bed of connective tissue. The overall surface area of the peritoneum approximates that of the total cutaneous surface area (~1.7 m*), The peritoneal cavity is normally sterile and contains <50 mL of flu ‘The fluid has a specific gravity <1.016 and a protein concentration <3 g/dL. It con- tains fewer than 3000 cells/mm’, predominantly macrophages and lymphocytes. The peritoneal membrane permits bidirectional diffusion of water and most solutes. In addition, particulate maiter can be cleared through stomata between specialized perito- neal mesothelial cells that overlie lymphatic channels on the diaphragmatic surface of the peritoneal cavity. These intercellular stomata correspond with fenestrations in the ‘basement membrane, and together they serve as channels from the peritoneal cavity to underlying specialized diaphragmatic lymphatics called lacunae (1). In concert with ‘the one-way valves in the thoracic lymphatics, this unit serves as an important clear- ance mechanism of bacteria from the peritoneal cavity. Bacteria pass easily through ‘the large stomata and can be recovered from the thoracic Lymph duct within 6 min and from the blood within 12 min of intraperitoneal inoculation (2). This mechanism is facilitated by an intraperitoneal flow of fluid and particles toward the diaphragm, an effect presumably produced by suction caused by the pull of gravity on the upper abdominal viscera away from the diaphragmatic surface. Management ‘The principles of therapy in patients with sevondary peritonitis are (i) resuscitation, (ii) appropriate antimicrobial therapy, and Gi) surgical intervention. All patients with perito- nitis have some degree of hypovolemia related to third-space fluid loss into the peritoneal cavity. Patients should be resuscitated with crystalloid solution before surgery. The micro- biology of secondary peritonitis is invariably polymicrobial (10) and consists of a mixture of gram-negative enteric bacteria and anaerobes (Box 1). Both experimental and clinical studies suggest that antimicrobial therapy should be directed against both the aerobic and anaerobic components of these infections, typified by Escherichia coli and Bacteroides fragilis (11,12). Single agents or combination regimens that fulfill this requirement are effective for treating secondary peritonitis. Table 2 summarizes the guide- lines proposed by the Surgical Infection Society for the use of anti-infective agents during intra-abdominal infection (13). The need to treat enterococci specifically remains contro- versial, Although experimental studies suggest that this microorganism can act as a sig nificant copathogen with E. coli (14), clinical studies demonstrate that antibiotic coverage directed against coliforms and anaerobes is sufficient treatment for intra-abdominal infection and usually does not result in treatment failure or relapse from enterococci. In contrast, enterococeal bacteremia or the recovery of enterococci from residual or recurrent intra-abdominal infection represents an indication for the treatment with the appropriate antienterococcal therapy (15). Current recommendations from the Surgical InfectionSociety include agents with enterococcal coverage for high-risk patients (13). Similarly, Candida species may be recovered as part of the polymicrobial flora from the peritoneal ‘exudate of patients with secondary peritonitis. As for enterococci, no indication exists for specific therapy directed against Candida species in patients with otherwise uncompli- cated secondary peritonitis. Empiric antifungal therapy may be indicated for patients at high risk for candidiasis (13). ‘The duration of antibiotic therapy following operative management of secondary peritonitis should be based on the clinical status of the patient. If the patient is afebrile, has a normal leukocyte count, and a band count <3%, the chance of recurrent sepsis after discontinuation of antibiotic therapy is virtually zero (16,17). In contrast, if the patient demonstrates a fever or leukocytosis, the probability of recurrent or residual infection ranges from 33% to 50%. With this approach, antibiotics may be discontinued as early as postoperative day 4, However, iff leukocytosis or fever persists alter post- operative days 7-10, the clinician should investigate the patient for the presence of residual infection, rather than simply extending antimicrobial therapy. Several clinical circumstances exist in which the duration of antibiotic therapy may be as short as 1 day. ‘They include simple acute and suppurative appendicitis, small bowel infarction without perforation, and traumatic enteric perforations operated on within 12 h of injury (13). ‘The common feature of these diagnoses is the minimal degree of peritoneal soiling and flammatory response present at the time of laparotomy. A preoperative dose of anti- biotics followed by two doses within 24h of surgery is appropriate therapy for these conditions, ‘The goals of the surgical management of peritonitis are to eliminate the source of contamination, to reduce the bacterial inoculum, and to prevent recurrent or persistent infection. The technique used to control contamination depends on the location and the nature of the pathologic condition. In general, continued peritoneal soiling is controlled by closing, excluding, or resecting the perforated viseus. Colonic pathology is handledmost effectively by resection of the diseased segment with exteriorization of the proximal end as an end colostomy, and by creating a mucous fistula or oversewing the distal end. A primary anastomosis in a patient with diffuse peritonitis is associated with an increased rate of dehiscence and should be avoided (18). Small intestinal pathology should be dealt with similarly by resection of the diseased segment. As the risk of anastomotic dehis- cence is reduced, a primary anastomosis may be considered in this circumstance, ‘However, if peritoneal soiling is particularly extensive or the viability of the intestine is uncertain, the creation of stomas is preferable. A perforated duodenal ulcer caused by peptic ulcer disease is either patched with a piece of omentum or included in the creation of pyloroplasty. In the latter situation, simultaneous vagotomy should be performed. A perforated gastric ulcer is either included in a distal gastric resection with subsequent gas- troduodenal or gastrojejunal anastomosis or excised locally with primary closure. Appen- dicitis is treated by appendectomy. In addition to treating the underlying pathology, gross purulent exudates are aspi- rated, and loculations in the pelvis, paracolic gutters, and subphrenic regions are gently ‘opened and debrided. Adjuvant materials, including fecal matter, barium, necrotic tissue, and blood, should be removed as part of this procedure. Intraoperative peritoneal lavage with saline solution will augment the debridement process. The addition of antibiotics to the lavage solution has not been shown to be of clear benefit. Drains are not generally necessary unless a well-defined abscess cavity is discovered at the time of abdominal exploration, Using either running or interrupted monofilament sutures, abdomi- nal closure is performed in a single fascial layer. In heavily contaminated cases, wound infection is avoided by leaving the skin and subcutaneous tissues open, and closing