Open abdominal management for perforative peritonitis with septic shock: a retrospective analysis on usefulness of a standardized treatment protocol

  • Koichi InukaiEmail author
  • Akihiro Usui
  • Motohiko Yamada
  • Koji Amano
  • Nobutaka Mukai
  • Yusuke Tsunetoshi
  • Yasuki Nakata
  • Junichiro Yokota
Original Article



Damage control surgery (DCS) with open abdominal management (OAM) has been increasingly expanded to include critically ill non-trauma patients. However, there is limited data regarding the usefulness of this protocol for the treatment of severe perforative peritonitis (PP), especially with septic shock (SS). Here, we retrospectively evaluated the usefulness of our OAM protocol for PP with SS.


We retrospectively reviewed patients with from June 2015 to September 2018. The proposed protocol was composed of the following steps: (1) rapid control of contamination; (2) temporary abdominal closure; (3) repeated washout of the abdominal cavity; and (4) delayed definitive surgery. For temporary abdominal closure, a negative pressure wound therapy device was used. The end points were the morbidity and 30-day mortality rates. Logistic backward regression was performed to identify factors associated with complications.


The mortality rate was 4% (1/25) and the overall morbidity rate of surviving patients was 58.3% (14/24). The mean duration of the first DCS was 67.36 ± 22.83 min. The median durations of ventilation and intensive care unit stay were 5 and 7 days, respectively. Although not significant, morbidity might be associated with age, diabetes mellitus, initial operative time, and OAM duration.


A standardized protocol for OAM may improve the outcomes of patients with SS due to PP. This damage control approach can be applied for the treatment of severe abdominal sepsis.


Damage control surgery Open abdominal management Perforative peritonitis Secondary peritonitis Septic shock 



Damage control surgery


Negative pressure wound therapy


Open abdominal management


Perforative peritonitis


Septic shock


White blood cell


Body mass index


Chronic obstructive pulmonary disease


Intensive care unit


Author contributions

KI drafted the manuscript. AU, MY, KA, NM, YT, and YN critically revised the article for important intellectual content. JY is the Department Chairperson and supervised the writing of the manuscript. All of the authors approved the final version of the manuscript.


Not applicable.

Compliance with ethical standards

Conflict of interest

The authors have no competing interests to declare.

Ethics approval and consent to participate

Ethical approval was obtained from Institutional Review Board of Sakai City Medical Hospital. Consent to participate was not applicable owing to the retrospective nature of the study.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.


  1. 1.
    Patel NY, Cogbill TH, Kallies KJ, Mathiason MA. Temporary abdominal closure: long-term outcomes. J Trauma. 2011;70:769–74.CrossRefGoogle Scholar
  2. 2.
    Diaz JJ Jr, Cullinane DC, Dutton WD, Jerome R, Bagdonas R, Bilaniuk JW, et al. The management of the open abdomen in trauma and emergency general surgery: part 1-damage control. J Trauma. 2010;68:1425–38.CrossRefGoogle Scholar
  3. 3.
    Aprahamian C, Wittman DH, Bergstein JM, Quebbeman EJ. Temporary abdominal closure (TAC) for planned relaparotomy (Etappenlavage) in trauma. J Trauma. 1990;30:719–23.CrossRefGoogle Scholar
  4. 4.
    van Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, et al. Comparison of on-demand vs. planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA. 2007;298:865–72.CrossRefGoogle Scholar
  5. 5.
    Morris JA Jr, Fildes J, May AK, Diaz J, Britt LD, Meredith JW. A research agenda for emergency general surgery: clinical trials. J Trauma Acute Care Surg. 2013;74:329–33.CrossRefGoogle Scholar
  6. 6.
    Leppäniemi A, Kimball EJ, De Laet I, Malbrain ML, Balogh ZJ, De Waele JJ. Management of abdominal sepsis—a paradigm shift? Anaesthesiol Intensive Ther. 2015;47:400–8.CrossRefGoogle Scholar
  7. 7.
    Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315:801–10.CrossRefGoogle Scholar
  8. 8.
    Lee JC, Peitzman AB. Damage-control laparotomy. Curr Opin Crit Care. 2006;12:346–50.CrossRefGoogle Scholar
  9. 9.
    Coccolini F, Roberts D, Ansaloni L, Ivatury R, Gamberini E, Kluger Y, et al. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg. 2018;13:7.CrossRefGoogle Scholar
  10. 10.
    Wacha H. Mannheim peritonitis index-prediction of risk of death from peritonitis: construction of a statistical and validation of an empirically based index. Theor Surg. 1987;1:169–77.Google Scholar
  11. 11.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–29.CrossRefGoogle Scholar
  12. 12.
    Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36:296–327.CrossRefGoogle Scholar
  13. 13.
    Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med. 2013;369:840–51.CrossRefGoogle Scholar
  14. 14.
    Sartelli M, Catena F, Ansaloni L, Coccolini F, Corbella D, Moore EE, et al. Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW study. World J Emerg Surg. 2014;9:37.CrossRefGoogle Scholar
  15. 15.
    Ivatury RR. Update on open abdomen management: achievements and challenges. World J Surg. 2009;33:1150–3.CrossRefGoogle Scholar
  16. 16.
    Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin N Am. 1997;77:761–77.CrossRefGoogle Scholar
  17. 17.
    Burch JM, Denton JR, Noble RD. Physiologic rationale for abbreviated laparotomy. Surg Clin N Am. 1997;77:779–82.CrossRefGoogle Scholar
  18. 18.
    Bruns BR, Ahmad SA, OʼMeara L, Tesoriero R, Lauerman M, Klyushnenkova E, et al. Nontrauma open abdomens: A prospective observational study. J Trauma Acute Care Surg. 2016;80(4):631–6.CrossRefGoogle Scholar
  19. 19.
    Kritayakirana K, Maggio P, Brundage S, Purtill MA, Staudenmayer K, Spain DA. Outcomes and complications of open abdomen technique for managing non-trauma patients. J Emerg Trauma Shock. 2010;3:118–22.CrossRefGoogle Scholar
  20. 20.
    Wacha H, Linder MM, Feldman U, Wesch G, Gundlach E, Steifensand RA. Mannheim peritonitis index—prediction of risk of death from peritonitis: construction of a statistical and validation of an empirically based index. Theor Surg. 1987;1:169–77.Google Scholar
  21. 21.
    Billing A, Frohlich D. Prediction of outcome using the Mannheim peritonitis index in 2003 patients. Br J Surg. 1994;81:209–13.CrossRefGoogle Scholar
  22. 22.
    Demmel N, Maag K, Osterholzer G. The value of clinical parameters for determining the prognosis of peritonitis-validation of the Mannheim Peritonitis Index. Langenbecks Arch Chir. 1994;379:152–8.CrossRefGoogle Scholar
  23. 23.
    Fugger R, Rogy M, Herbst F, Schemper M, Schulz F. Validation study of the Mannheim peritonitis index. Chirurg. 1988;59:598–601.Google Scholar
  24. 24.
    Chaudhari ND, Nakum A, Mahida H. Mannheim’s peritonitis index validation study in the Indian set-up. Int J Sci Res. 2012;7:43–8.Google Scholar
  25. 25.
    Notash AY, Salimi J, Rahimian H, Fesharaki MS, Abbasi A. Evaluation of Mannheim peritonitis index and multiple organ failure score in patients with peritonitis. Indian J Gastroenterol. 2005;24:197.Google Scholar
  26. 26.
    Baothman AB, Md F, Reddy NV. Study of mannheims peritonitis index in patients with peritonitis. Int Surg J. 2016;3(2):746–50.CrossRefGoogle Scholar
  27. 27.
    Budzyński P, Dworak J, Natkaniec M, Pędziwiatr M, Major P, Migaczewski M, et al. The usefulness of the Mannheim Peritonitis Index score in assessing the condition of patients treated for peritonitis. Pol Przegl Chir. 2015;87:301–6.Google Scholar
  28. 28.
    Sharma R, Ranjan V, Jain S, Joshi T, Tyagi A, Chaphekar R. A prospective study evaluating utility of Mannheim peritonitis index in predicting prognosis of perforation peritonitis. J Nat Sc Biol Med. 2015;6:S49.Google Scholar
  29. 29.
    Kubiak BD, Albert SP, Gatto LA, Snyder KP, Maier KG, Vieau CJ, et al. Peritoneal negative pressure therapy prevents multiple organ injury in a chronic porcine sepsis and ischemia/reperfusion model. Shock. 2010;34:525–34.CrossRefGoogle Scholar
  30. 30.
    Emr B, Sadowsky D, Azhar N, Gatto LA, An G, Nieman GF, et al. Removal of inflammatory ascites is associated with dynamic modification of local and systemic inflammation along with prevention of acute lung injury: in vivo and in silico studies. Shock. 2014;41(4):317–23.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Acute Care SurgerySakai City Medical CenterSakaiJapan

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