Operative measures

There are several contentious issues in the operative management of generalised peritonitis:

• incision: a long midline incision provides ample access to most perforation sites and allows ready toilet.
• source of contamination:
  • appendicectomy for acute appendicitis
  • cholecystectomy for perforation of acute cholecystitis
  • oversew peptic ulcers
  • in perforated diverticular disease and faecal ulceration, one approach is colonic resection, e.g. Hartmann's resection, +/- raising of a stoma, e.g. Paul-Mickulicz double-ended colostomy; when a single perforated diverticulum is found, trimming, suturing and drainage may be adequate steps
  • in perforation secondary to fulminant colitis, the whole colon is usually severely ulcerated and a total colectomy with ileostomy is indicated
• peritoneal lavage
• nasogastric intubation is continued until the return of intestinal function
• closure of the wound with non-absorbable sutures