interval greater than 60 hours from the time of
symptom onset to undertaking initial laparotomy.
The presence of two or more risk factors was
associated with a 55% RL rate, and three or more
factors with an 83% RL rate. RL was associated
with a fourfold increase in the rate of hospital
death. 41 In such situations, controversies arise
regarding managing complex abdominal infection
with an open abdomen technique that will allow
re-look and also mitigate concerns of intra-
abdominal hypertension. While the only
randomised controlled trial undertaken under
these circumstances showed that the abdomen
should be closed if it is safe to do so, attempts at
primary closure in all circumstances may be
associated with an increased incidence of
multi-organ failure, resulting in poor survival.
Conversely, the risk of treating abdominal sepsis
with an open abdomen include significant
disruption of respiratory mechanics, loss of
abdominal ‘domain’, exposure to nosocomial
pathogens, challenging wound care and even
enteroatmospheric fistulation.Various temporary
abdominal closure (TAC) techniques have been
described, involving gauze and large,
impermeable, self-adhesive membrane dressings;
mesh (for example, Vicryl™, Dexon™);
nonabsorbable mesh (for example, GORE-TEX™,
polypropylene), negative pressure wound therapy
(NPWT), NPWT with continuous fascial traction,
dynamic retention sutures, Wittmann patch™,
and Bogota bag.
A large systematic review of 74 studies in
over 4300 patients (of which 79% had received
treatment for peritonitis) showed that NPWT
was the most frequent described TAC technique,
and the highest weighted fascial closure rate
was found in series describing NPWT with
continuous mesh or suture mediated fascial
traction and dynamic retention sutures. 42
However, it was not possible to show differences
in mortality, fistula and fascial closure rates,
when comparing NPWT alone and NPWT with
fascial traction. 42
Laparoscopic treatment in abdominal sepsis is
becoming more commonly used. 22,23 However the
most recent NELA report has not shown an
increase in its use over a three-year period, which
remained at 8%. 24 Therapeutic advantages of
laparoscopy are well known in the management
of appendicitis, cholecystitis, and perforated
gastric and duodenal ulcer.
In other situations such as diverticulitis, results
from a multicentre randomised trial have not
shown laparoscopic lavage to be superior to
sigmoid resection for the treatment of purulent
perforated diverticulitis. 43 Great care should be
t aken when laparoscopic treatment is being
considered for use in the septic abdomen, and
should include assessment of the source of
sepsis, the likelihood that adequate source
control can be achieved by laparoscopic means,
patient physiology and habitus, the risks of
injury to other organs in a potentially hostile
environment and, not least, the training and
expertise of the surgical team. However, as
technological advancement extends the potential
range of minimally invasive procedures, it seems
likely that wider adoption of these approaches
will, at least in selected patients, reduce the need
for open surgical treatment for abdominal sepsis.
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