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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 intraabdominal 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 taken 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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