Etappenlavage: Advanced diffuse peritonitis managed by planned multiple laparotomies utilizing zippers, slide fastener, and Velcro^® analogue for temporary abdominal closure

Abstract

Etappenlavage is defined as a series of planned multiple operative procedures performed at a 24-hour interval. It includes a commitment to reexplore the patient's abdomen at the initial corrective operation. This is a report of a prospective study of 117 patients treated by etappenlavage for severe advanced suppurative peritonitis in 2 institutions. Etappenlavage was performed in 15% of all patients with operations for peritonitis. In these patients, the abdominal infection had progressed to an advanced stage of severe functional impairment. A total of 669 laparotomies were performed and the abdomen closed temporarily utilizing retention sutures (n = 45), a simple zipper (n = 26), a slide fastener (n = 29), and Velcro analogue (n = 17). An average of 6.1 procedures were necessary to control the infection. In 57% of the patients, additional complications were recognized and repaired after the initial operation. Patients were artificially ventilated for an average of 17 days. The median duration of therapy was 33 (range, 3-183) days. Twenty-eight patients died between days 3 and 71 (median, 9) after initiation of therapy. In 88%, uncomplicated wound healing was observed after wounds were closed definitely. In the last 17 patients, no complications were attributable to the use of 2 adhesive sheets of polyamide plus nylon or perlon for temporary abdomimal closure (Velcro-like artificial burr). APACHE II scoring predicted a median mortality of 47%. The actual mortality was 25%. Overall, the mortality of advanced diffuse peritonitis was reduced from a predicted 34-93% (APACHE II/SIS scoring) to 24%. Velcro analogue (artificial burr) was the most practical device for temporary abdominal closure.

Management of Peritonitis in the Critically Ill Patient

“…These patients may require several laparotomies to achieve the goals listed above. Therefore the surgeon should decide during the first or "index" laparotomy whether or not the patient may benefit from a reoperation, which could be done either as needed or through a planned/ scheduled reintervention [72][73][74][75][76]. Postoperative peritonitis has a very high mortality, ranging from 30% to 50%.…”

Primary Intra-Abdominal Hypertension and Abdominal Compartment Syndrome: Pathophysiology and Treatment

“…[192][193][194] The sandwich suction dressing is the easiest and cheapest method to employ being a forerunner of the VAC technique with placement of large adhesive drapes into the paracolic gutter under suction drains. 195 This simple dressing is effective, containing the abdominal contents with minimal fluid leakage and is non-contributory either to worsening IAP or the early development of adhesions. It prevents skin maceration or blistering allowing some give with underlying peristalsis (as opposed to fascially fixed techniques) and permitting rapid access for repeat laparotomy.…”

Manejo Del Abdomen Abierto: Desde La Operación Inicial Al Cierre Definitivo

“…Perera y cols., en 1985, recomiendan colocar mallas reabsorbibles en casos de peritonitis generalizadas graves, fístulas intestinales, cierres laparotómicos con tensión e infecciones graves de la pared abdominal 20 . Teichmenn y Wittmann utilizan una cremallera sobre la malla de marlex para lograr un acceso rápido y seguro a la cavidad, en exploraciones posteriores 13 . En 1984 se produce uno de los avances más importantes en este tema: O. Borráez, en Colombia, describe el uso de una lámina de polivinilo (bolsas de irrigación urológica) para cubrir temporalmente las vísceras y dar contención a la pared abdominal 14 .…”

“…En 1983, una nueva táctica de tratamiento para las peritonitis y la sepsis intraabdominal es introducida por la literatura alemana, el llamado "etappen lavage o relaparotomía planificada" 13,79 . Este procedimiento se indicaba cuando en la primera cirugía no se conseguía la resolución completa de la patología causal.…”