Emergency Surgical Intervention for Diffuse Peritonitis

Rationale and Timing

Patients with diffuse peritonitis should undergo an emergency surgical procedure as soon as possible, even if ongoing measures to restore physiologic stability need to be continued during the procedure, as delayed source control is associated with increased morbidity and mortality, according to the Clinical Infectious Diseases guidelines 1
Emergency surgery should not be delayed for complete physiologic stabilization - resuscitative measures should continue concurrently with surgical intervention, as recommended by the Clinical Infectious Diseases guidelines 1
Patients with diffuse peritonitis are typically critically ill and require prompt fluid resuscitation, antibiotic administration, and definitive surgical management, as stated by the World Journal of Emergency Surgery guidelines 2, 3

Initiate fluid resuscitation immediately to address volume depletion, which is common in patients with peritonitis, as recommended by the Clinical Infectious Diseases guidelines 1
Start appropriate antimicrobial therapy as soon as possible, ideally within 1 hour for patients with septic shock, according to the Clinical Infectious Diseases guidelines 1
Ensure antimicrobial drug levels are maintained during source control intervention, which may require additional administration just before the procedure, as stated by the Clinical Infectious Diseases guidelines 1

The primary goals of surgery are to drain infected foci, control ongoing peritoneal contamination, and restore anatomic and physiological function, as recommended by the Clinical Infectious Diseases guidelines 1
For perforated diverticulitis with diffuse peritonitis, Hartmann's procedure remains useful in critically ill patients, according to the World Journal of Emergency Surgery guidelines 3, 4, 5
For other causes (perforated peptic ulcer, small bowel perforation), surgery is the treatment of choice, with options including simple closure with or without omental patch for small perforations, and resection with primary anastomosis when appropriate, as stated by the World Journal of Emergency Surgery guidelines 5

Mandatory or scheduled relaparotomy is not recommended in the absence of intestinal discontinuity, abdominal fascial loss preventing abdominal wall closure, or intra-abdominal hypertension, as recommended by the Clinical Infectious Diseases guidelines 1
Failure to maintain adequate antimicrobial coverage during the perioperative period should be avoided, according to the Clinical Infectious Diseases guidelines 1

Delaying surgical intervention while attempting complete physiologic stabilization increases mortality, as stated by the Clinical Infectious Diseases guidelines 1
Inappropriate selection of surgical approach based on patient condition, such as not using more conservative approaches (Hartmann's procedure) for unstable patients, should be avoided, according to the World Journal of Emergency Surgery guidelines 3