The role of peritoneal lavage in benign gynecologic laparoscopic surgery

OBJECTIVE

Laparoscopic surgery offers many advantages compared to invasive surgery but one of the main problems is postoperative pain, partially resulting from the peritoneal inflammatory process mediated by inflammatory cytokines. The rationale of this study is that intraperitoneal washing could remove inflammatory mediators that are the cause of postoperative pain and could help in the removal of CO2 from the abdominal cavity. This article aims to analyze the effects of peritoneal lavage in the reduction of postoperative shoulder pain.

PATIENTS AND METHODS

277 patients enrolled to undergo laparoscopic gynecologic surgery were included in the study. Women are randomized into two groups, according to the use or non-use of peritoneal lavage with saline solution at the end of laparoscopic gynecological major procedures.

RESULTS

Data show that the peritoneal lavage can significantly reduce postoperative pain in the first 36 hours after surgery, as well as patients' requests for analgesics: during the first 3 postoperative days, requests for paracetamol were lower in the YW (Yes Washing) group than the NW (No Washing) group (77 vs. 101; p<0.05); similar results are obtained considering ketorolac administration (62 vs. 71; p<0.05).

CONCLUSIONS

Peritoneal lavage after gynecological laparoscopic procedures may be effective in the reduction of postoperative pain and use of analgesics.

Laparoscopic lavage for Hinchey III perforated diverticulitis: factors for treatment failure in two randomized clinical trials

BACKGROUND

The Scandinavian Diverticulitis (SCANDIV) trial and the LOLA arm of the LADIES trial randomized patients with Hinchey III perforated diverticulitis to laparoscopic peritoneal lavage or sigmoid resection. The aim of this analysis was to identify risk factors for treatment failure in patients with Hinchey III perforated diverticulitis.

METHODS

This was a post hoc analysis of the SCANDIV trial and LOLA arm. Treatment failure was defined as morbidity requiring general anaesthesia (Clavien-Dindo grade IIIb or higher) within 90 days. Age, sex, BMI, ASA fitness grade, smoking status, previous episodes of diverticulitis, previous abdominal surgery, time to surgery, and surgical competence were all tested in univariable and multivariable logistic regression analyses using an interaction variable.

RESULTS

The pooled analysis included 222 patients randomized to laparoscopic lavage and primary resection (116 and 106 patients respectively). Univariable analysis found ASA grade to be associated with advanced morbidity in both groups, and the following factors in the laparoscopic lavage group: smoking, corticosteroid use, and BMI. Significant factors for laparoscopic lavage morbidity in multivariable analysis were smoking (OR 7.05, 95 per cent c.i. 2.07 to 23.98; P = 0.002) and corticosteroid use (OR 6.02, 1.54 to 23.51; P = 0.010).

CONCLUSION

Active smoking status and corticosteroid use were risk factors for laparoscopic lavage treatment failure (advanced morbidity) in patients with perforated diverticulitis.

Long-term outcomes and risk factors for diverticulitis recurrence after a successful laparoscopic peritoneal lavage in Hinchey III peritonitis

PURPOSE

Recently, treatment of Hinchey III diverticulitis by laparoscopic peritoneal lavage has been questioned. Moreover, long-term outcomes have been scarcely reported. Primary outcome was to determine the recurrence rate of diverticulitis after a successful laparoscopic peritoneal lavage in Hinchey III diverticulitis. Secondary outcomes were identification of associated risk factors for recurrence and elective sigmoidectomy rate.

METHODS

A retrospective cohort study in a tertiary referral center was performed. Patients with Hinchey III diverticulitis who underwent a successful laparoscopic peritoneal lavage between June 2006 and December 2019 were eligible. Diverticulitis recurrence was analyzed according to the Kaplan-Meier and log-rank test, censoring for death, loss of follow-up, or elective sigmoid resection in the absence of recurrence. Risk factors for recurrence were identified using Cox regression analysis.

RESULTS

Sixty-nine patients had a successful laparoscopic peritoneal lavage (mean age: 63 years; 53.6% women). Four patients had an elective sigmoid resection without recurrences. Recurrence rate was 42% (n = 29) after a median follow-up of 63 months. The cumulative global recurrence at 1, 3, and 5 years was 30% (95% CI, 20-43%), 37.5% (95% CI, 27-51%), and 48.9% (95% CI, 36-64%), respectively. Smoking (HR, 2.87; 95% CI, 1.22-6.5; p = 0.016) and episodes of diverticulitis prior to laparoscopic peritoneal lavage (HR, 5.2; 95% CI, 2.11-12.81; p < 0.001) were independently associated with an increased risk of recurrence.

CONCLUSIONS

Diverticulitis recurrence after a successful laparoscopic peritoneal lavage is high, decreasing after the first year of follow-up. Smoking and previous episodes of acute diverticulitis independently increase the risk of new episodes of diverticulitis.

Monitoring of Acid-base and Regulating Variables during Abdominal Lavage

This prospective clinical study was performed to determine acid-base regulating variables during abdominal lavage treatment for patients with severe peritonitis or after abdominal surgery. Arterial blood was sampled from twelve patients with secondary peritonitis and nine patients after abdominal surgery without peritonitis at three time points: immediately before, immediately after and 15 minutes after abdominal lavage with normal saline solution. The total++ – amount of irrigant fluid, the strong ion difference [(Na+ +K+)-(Cl- +lactate-)], and total protein concentrations were determined and standard bicarbonate, standard base excess were calculated from pH and PaCO2. Peritonitis patients developed a moderate alkalaemia (pH 7.440-7.485). The alkalaemia was unmasked after optimization of mild hypoventilation, but was supported by a decrease in protein concentration of about 3.4 mEql/l in the first 15 minutes after the lavage. There was no marked increase in chloride concentration in either the peritonitis or the control group. The data indirectly exclude major fluid absorption during abdominal lavage with 3000 to 6000 ml normal saline, given that we found no clinically relevant electrolyte and acid-base changes that might be expected after rapid fluid absorption. The factors of major influence in acid-base regulation were ventilation and protein loss in the course of abdominal lavage. Monitoring of the Stewart variables is an easily applicable method of monitoring acid-base regulating variables in the perioperative course of patients undergoing abdominal lavage therapy.

[Opportunities of intraoperative hyperthermic perfusion application in treatment of peritoneal carcinomatosis]

Normothermic intraperitoneal perfusion (IPEP) and hyperthermic intraperitoneal perfusion (HIPEP) were performed in 44 Wistar female rats with transplanted ascites tumor of the ovary. Opportunities of intraoperative hyperthermic perfusion application in treatment of peritoneal carcinomatosis. Antineoplastic affects were evaluated according to increase of animals' survival. IPEP and HIPEP increase median survival time by 78% (p=0.307) and 150% (p=0.005) respectively in comparison with conventional intraperitoneal introduction of physiological solution. Thus HIPEP has statistically more significant antineoplastic affect in vase of peritoneal carcinomatosis.

[Influence of immobilized forms of sodium hypochlorite on the immediate and long-term results of treatment of the patients with diffuse peritonitis]

An analysis of complex examination and results of treatment was made in 290 patients with diffuse peritonitis. The patients were divided into two groups according to way of sanation of the abdominal cavity. The sanation with 0.03% aqueous solution of sodium hypochlorite was used for the first group of 155 patients. The immobilized forms of sodium hypochlorite in carboxymethyl cellulose gel were applied in the second group. The rate of postoperative complications was decreased on 15.4%, the lethality--on 8.2% in the case of application of the immobilized forms of sodium hypochlorite. The developed technology allowed increasing of physical component of life quality of the patients in 1.3 times, though it didn't influence on psychical component.

[Intraperitoneal irrigation for pseudomyxoma peritonei-a case of critical metabolic alkalosis precipitated by irrigation with 101 of sodium bicarbonate--]

Pseudomyxoma peritonei causes marked accumulation of jelly-like ascites in the peritoneal cavity. Removal of much mucinous ascites by irrigating the cavity appears to be an effective treatment. We describe a patient who underwent the irrigation with sodium bicarbonate solution and developed critical alkalemia. A 68-year-old woman with normal renal function was operated on for recurrent pseudomyxoma peritonei. Fol- lowing the excision of primary lesion, her intraperitoneal cavity was irrigated with 10 1 of 7% sodium bicarbonate in about 45 minutes. Thirty minutes after irrigation, blood gas analysis revealed severe metabolic alkalosis (pH 7.714, BE 25.6 mmol x l-1 ) with electrolyte disorder (Na 157.8 mmol x l-1 K 2.31mmol x l-1, Ca 0.73 mmol x l-1). Hypotension (<60 mmHg) and sinus tachycardia (>130 beats x min -1) supervened 75 minutes later. Transferring to the ICU, she was given KC1 solution intravenously based on serial blood analysis while on mechanical ventilation. The next day acid-base disturbance returned spontaneously to normal (pH 7.45, BE 8.0mmol x l-1), leading to endotracheal extubation. Electrolyte imbalance was gradually resolved on 2nd POD and she was discharged from the ICU. Intraperitoneal irrigation with sodium bicarbonate requires special perioperative considerations for lifethreatening alkalemia, especially in a patient with renal impairment.

[Patient with pseudomyxoma peritonei in whom, hyperglycemia and hyponatremia were induced by massive intraperitoneal lavage with 5% glucose]

A 74-year-old woman was admitted to our hospital with weight loss and sense of abdominal distension. She was diagnosed to have pseudomyxoma peritonei based on careful examinations in the surgical department of our hospital. She therefore underwent elective surgery consisting of an ileocecal resection under general anesthesia. The induction of anesthesia was very smooth, but the patient's blood pressure became unstable during the operation. As a result, we inserted an arterial catheter into the radial artery, and the blood gas analysis showed severe hyperglycemia and hyponatremia. We determined that a massive amount of intraperitoneal lavage fluid with 5% glucose had been absorbed into the blood vessels. We administered regular insulin to manage the hyperglycemia and also mannitol and furosemide to treat the hyponatremia that had been caused by water intoxication. Thereafter, both the hyperglycemia and hyponatremia improved quickly, and the patient was extubated safely. We had little prior knowledge about pseudomyxoma peritonei, and therefore had not expected such an occurrence. Moreover we did not sufficiently provide the surgical team with all of the patient's information. In the future, we will maintain close cooperation with the surgical team and establish an appropriate anesthesia plan when we encounter patients presenting with pseudomyxoma peritonei.

[The videoendoscopic sanation of the abdominal cavity by the diffuse septic peritonitis]

The 1st group consisted of 68 patients with the diffuse peritonitis, who were treated with the use of traditional approach, i.e., laparotomy, elimination of the peritonitis source, nasointestinal intubation, abdominal cavity sanation and drainage. Within 24--48 hours all these patients had videoendoscopic abdominal sanation with the injection of 200 ml 0.03% water solution of sodium hypochlorite. The 2nd group, consisted of 41 patients. The first treatment stage was the same, but during the videoendoscopic stage the pulsing stream of the antiseptic was used and the procedure ended with intraabdominal injection of 200 ml 0.03% water solution of sodium hypochlorite immobilized in gel. All patients of the 2nd group showed better recovery results.

[Sodium intoxication with fatal outcome caused by peritoneal lavage with hypertonic solution of NaCl]

We report a case of fatal sodium poisoning due to the unintentional use of 20% hypertonic saline serum during peritoneal lavage after intestinal resection. The patient presented with unconsciousness, metabolic acidosis, and plasma sodium concentration of 193 mE/l. After 3 hours, he developed paroxysmal supraventricular tachycardia, hyperthermia, generalized tonic-clonic convulsions, disseminated intravascular coagulation, and adult respiratory distress syndrome. The patient died 15 hours after the operation. Pathological examination revealed cerebral and lung oedema, pericentral hepatic necrosis, and fibrin thrombi in the lungs, stomach, and kidneys. We review, in addition, other reported cases of sodium poisoning.

[Transient hyperglycemia following intra-peritoneal irrigation with 5% glucose in a patient with pseudomyxoma peritonei]

Pseudomyxoma peritonei is a condition characterized by the production of a large amount of mucopolysaccharide by a neoplastic epithelium. Although surgical removal of the mucinous ascites may be attempted, complete removal of the material is difficult. Thus, intra-peritoneal lavage with the liquid containing glucose or dextrose has been advocated to prevent reaccumulation of the mucus and complications such as bowel obstruction requiring repeated surgery. We report a case showing transient hyperglycemia following intra-peritoneal irrigation with 5% glucose in a patient with psudomyxoma peritonei. The patient was a 72-year-old woman. Preoperatively, she had hypertension and angina pectoris; but no history of glucose intolerance. Serum glucose was 92 mg x dl(-1). General anesthesia was induced with propofol (100 mg), vecuronium (6 mg), and fentanyl, and maintained with oxygen (33%), nitrous oxide and sevoflurane (1-2%). A mucinous tumor was found with a great deal of mucinous ascites. To remove the mucus and prevent subsequent re-accumulation, intra-peritoneal irrigation with 5% glucose in water was performed. Shortly after this procedure, the patient was found to be hyperglycemic (serum glucose 266 mg x dl(-1)) with normal oxygenation and hemodynamic data. The patient recovered uneventfully and could be extubated soon after surgery. Serum glucose level returned to 154 mg x dl(-1) one hour after surgery. Therefore, we think that this acute hyperglycemic condition, presumable due to intra-peritoneal irrigation, was transient. It is important to be aware of this dangerous complication associated with intra-peritoneal glucose instillation. Glucose monitoring during and after irrigation with glucose or dextrose is recommended.

Infectious complications following laparoscopic appendectomy

INTRODUCTION

A meta-analysis of the literature suggests there is an increased rate of intra-abdominal abscess after laparoscopic appendectomy (LA) compared with open appendectomy (OA).

METHODS

To analyze the infectious complications of LA at one tertiary care centre, we completed a retrospective chart review for all patients undergoing LA for acute appendicitis from 1995 to 2002.

RESULTS

We used established exclusion criteria to identify 175 patients with a mean age of 37.6 (standard deviation [SD] 14.5) years (95 male, 80 female). The mean operating time was 61.9 (SD 22.5) minutes. Excluding conversions to OA (14/175, 8%), operating time was 59.9 (SD 20.5) minutes. On surgical assessment, 143 patients had acute nonperforated appendicitis (17 perforated, 15 gangrenous). However, on histopathology assessment, 13 cases of normal appendix were identified (13/175, 7.4%). The overall median length of stay was 2.0 days. Three patients had significant postoperative infectious complications, including 1 wound infection and 2 cases of intra-abdominal abscesses. All abscesses were managed successfully with percutaneous drainage. An analysis of perioperative factors that might have contributed to the infectious complications revealed that each case of postoperative intra-abdominal abscess occurred in patients with gangrenous appendicitis and when extensive irrigation was used during LA.

CONCLUSIONS

An institutional review demonstrates outcomes comparable with the Cochrane systematic review of the published literature. Technical issues that may impact on intra-abdominal abscess formation after LA include aggressive manipulation of the infected appendix and increased use of irrigation fluid, possibly producing greater contamination of the peritoneal cavity.

Postoperative Ascites Associated With Intraperitoneal Antiseptic Lavage

BACKGROUND

Peritonitis is the established term for infective inflammation of the peritoneum, whereas serositis generally refers to aseptic inflammation of a serous cavity, including the peritoneum. Serositis may be metabolic, viral, autoimmune, drug induced, genetic, allergic or granulomatous, or due to chemical antiseptics.

CASES

In our gynecological department, 4 patients had peritonitis and ascites after laparotomy.

CONCLUSION

Based on the investigation, we think that the solution used for peritoneal lavage (0.1% octenidine dihydrochloride and 2% phenoxyethanol) played a role in the tissue toxicity that caused chemical serositis with effusion.

[Indications for and efficiency of peritoneal lavage in severe acute pancreatitis]

Peritoneal lavage was developed as a simple method to evacuate the ascitic fluid associated with pancreatitis. Although a number of studies demonstrated its efficacy in improvement of clinical manifestations, a meta-analysis of randomized control studies could not reveal its effectiveness on mortality or morbidity in severe acute pancreatitis. However, it has been well established that the ascitic fluid with pancreatitis is extremely toxic and to induce organ damage due to apoptotic cell death. Particularly, we have recently found that the ascitic fluid with pancreatitis can induce bacterial translocation due to the increase of gut permeability. Therapeutic strategy of peritoneal lavage, i.e. evacuation of toxic substances from peritoneal cavity, should be reevaluated to achieve further improvement of treatment result of severe acute pancreatitis.

Increased postoperative peritoneal adhesion formation after the treatment of experimental peritonitis with chlorhexidine

BACKGROUND AND AIMS

Chlorhexidine is known as a substance that produces adhesions. However, in an experimental model of peritoneal injury, lavage with chlorhexidine and saline solutions produced a similar number of adhesions. This study was designed to test the hypothesis that chlorhexidine gluconate 0.05% solution used for the treatment of peritonitis increases formation of postoperative peritoneal adhesions as compared to standard lavage with saline solution.

MATERIAL AND METHODS

Forty Wistar rats were randomly allocated to gastric or faecal peritonitis groups. In each group rats were further randomly subdivided into saline or chlorhexidine peritoneal lavage groups. After 30 days the rats were killed and intraperitoneal adhesions were evaluated by adhesion score and grading.

RESULTS

Adhesion scores were statistically significantly different between saline and chlorhexidine groups in both gastric and faecal peritonitis models. In the faecal peritonitis chlorhexidine group a 20% small bowel intussusception rate was observed, while there were no such complications in the other study groups. The conglomerate of organs formed by dense adhesions was present in 60% of cases when gastric peritonitis was lavaged by chlorhexidine and in only 10% when saline solution was used ( P<0.05). Neither chlorhexidine nor saline solutions have caused such dense adhesions in faecal peritonitis.

CONCLUSION

Peritoneal lavage with chlorhexidine gluconate 0.05% solution in the treatment of experimental peritonitis results in increased adhesion formation.

The effect of lavage on intraabdominal cell burden

BACKGROUND

Abdominal lavage is a common surgical practice, but few studies have been conducted to assess its efficacy at removing cells from the abdominal cavity, particularly during laparoscopic surgery.

METHODS

After three 12-mm trocars were inserted into six female 30-kg pigs at the umbilicus left and right iliac fossae, the abdomen was insufflated with carbon dioxide. The pelvis of each pigs was injected with 6 million radiolabeled LIM 1215 cells. Then the abdominal cavity was irrigated with either 500 ml 0.9% saline, 500 ml 10% betadine solution, or 1 L 0.9% saline. A maximum of 5 L of solution was used for each animal. The lavage fluid was suctioned into separate containers after each aliquot, and each container was measured for radioactivity.

RESULTS

Significantly greater numbers of cells were removed by lavage by the first to third lavage cycle; however, after four lavage cycles, relatively few cells were removed by each further cycle. No difference was observed between 500-ml and 1-L aliquots. Additionally, the mechanical efficacy of 0.9% saline and 10% betadine solution appeared similar.

CONCLUSION

These findings suggest that optimal lavage consists of four irrigation/suction cycles utilizing 500-ml aliquots.

Reduced neutrophil sequestration in lung tissue after laparoscopic lavage in a rat peritonitis model

Laparoscopy to treat abdominal infections is becoming more and more popular. The effects of the CO(2) pneumoperitoneum have not yet been completely clarified. In a rat peritonitis model, therefore, we investigated the influence of laparoscopic lavage in comparison with the conventional technique. A defined multibacterial fecal specimen was installed in the abdominal cavities of 80 rats. These animals were randomized to three groups: group 1 (n = 32), no intervention; group 2 (n = 24), conventional; group 3 (n = 24), laparoscopic lavage. At 1, 2, and 8 hours after the surgical intervention, animals were killed and autopsied. The main outcome measures were bacteremia, interleukin-6 (IL-6) in plasma and ascites, changes in the blood count, and myeloperoxidase (MPO) activity in lung, liver, kidney, and pancreas. Differences of bacteremia were not found. In the ascites a marked increase in IL-6 was observed after 8 hours, which was lower in the treatment groups than in the controls (p <0.025). MPO activity as a measure of the granulocytes present in the tissue showed significant changes only in lung tissue. Two hours after the surgical intervention, the MPO in the lung in the laparoscopy group was significantly lower than that in the controls and the laparotomy group. In conclusion, conventional and laparoscopic lavage reduce inflammation. In this model, laparoscopic lavage with a CO(2) pneumoperitoneum appeared to have no negative influence on the inflammatory reaction during the early postoperative phase. Reduced neutrophil sequestration in lung tissue following laparoscopic lavage reflects the lower level of trauma caused by laparoscopy.

[Extrapontine myelinolyses caused by iatrogenic hypernatremia following rupture of a hydatid cyst of the liver with an amnesic syndrome as sequela]

INTRODUCTION

Extrapontine myelinolisis is a rare condition caused by severe hydroelectrolytic disorders. Following an initial stage of diffuse encephalopathy, the neurological sequelae are usually of diffuse cognitive deficits and extrapyramidal or cortico-bulbo-spinal disorders. We report a case of extrapontine myelinolisis following hypertonic peritoneal lavage due to rupture of a hydatid cyst of the liver (HCL), which was followed by a syndrome of isolated amnesia due to bilateral hippocampal lesions.

CLINICAL CASE

Following rupture of a HCL a 37 year old man was treated by peritoneal lavage with hypertonic saline solution. In the immediate postoperative period he had a prolonged confusion state associated with natremia of 176 mg/dl, which was corrected in less than 24 hours. Seven days later the patient had an apathy-inattention frontal syndrome. Six weeks later, and lasting until three months after operation, he had a selective memory deficit in learning tests (of the Barcelona-PIENC series of tests) with normality (29/30) in the MMST. On magnetic resonance there were hyperintense images in T2 in both hippocampus, insulas and corpus callosum.

CONCLUSIONS

Generally caused by rapidly corrected hyponatremia, isolated hyponatremia or hypernatremia may also lead to extrapontine myelinolisis. However, we have found no report of extrapontine myelinolisis due to rupture of HCL and treatment with hypertonic peritoneal lavage. The neurological sequelae of extrapontine myelinolisis are usually global cognitive deficits, extra-pyramidal or cortico-bulbo-spinal disorders. Lesions seen on MR are usually found in the basal ganglia, thalamus or corpus callosum (with or without involvement of the pons). We have found no descriptions of bilateral hippocampal lesions causing selective memory deficits in this condition. Treatment by hypertonic peritoneal lavage for ruptured HCL may cause severe hydro-electrolytic alterations which may lead to myelinolisis of the CNS. We report of a case with bilateral hippocampal lesions and selective memory deficit, not previously described within the clinical spectrum of extrapontine myelinolisis.

Local and systemic effects of peritoneal lavage with high concentrations of adenosine in rats

BACKGROUND

Adenosine exerts actions which may be beneficial in treating diseases of the gastrointestinal tract. However, administered systemically, adenosine causes a 'stress reaction' and may adversely affect blood pressure and cardiac and renal function.

AIM

To determine whether peritoneal lavage with adenosine provides pharmacological levels of adenosine in the intestines without elevating adenosine levels in the systemic circulation.

METHODS

Rats received an intramesenteric artery infusion of angiotensin II (30 ng/min) plus methoxamine (3 microg/min) to reduce mesenteric blood flow by approximately 60%, and adenosine solutions were instilled into the abdominal cavity. In a second study, microdialysis probes were placed in the mesenteric vein and aortic arch of rats, and the peritoneal cavity was continuously lavaged with adenosine solutions.

RESULTS

High concentrations (10(-3)M) of adenosine normalized the mesenteric blood flow without affecting blood pressure or heart rate. High concentrations of adenosine (10(-3)M) induced micromolar levels of adenosine and inosine in the mesenteric vein, without affecting adenosine or inosine levels in the aorta.

CONCLUSIONS

Peritoneal lavage with high concentrations of adenosine provides pharmacological levels of adenosine in the gastrointestinal tract without systemic side-effects. Peritoneal lavage with high concentrations of adenosine may be useful for the treatment of a number of diseases of the gastrointestinal tract.

Experience with over 2500 diagnostic peritoneal lavages

This study was undertaken to confirm the safety and efficacy of diagnostic peritoneal lavage (DPL) for trauma patients. A prospectively maintained database of all DPLs performed in the past 75 months was analyzed. A red blood cell count of 100,000/mm(3) was considered positive for injury in blunt trauma; 10,000/mm(3) was considered positive for peritoneal penetration in penetrating trauma. Information relative to type of injury, DPL result, laparotomy result and complications, was analysed to determine if DPL was more or less suited to any specific indication or type of patient. Over a 75 month period, 2501 DPLs were performed at our urban level I trauma center. The overall sensitivity, specificity and accuracy for the above thresholds were 95, 99 and 98%. The majority (2409, 96%) were performed using percutaneous or "closed" seldinger technique. Ninety-two (4%) were performed using open technique because of pelvic fractures, previous scars and pregnancy. Open DPL was less sensitive than closed DPL in patients who sustained blunt trauma (90 vs 95%) but slightly more sensitive in determining penetration (100 vs 96%). Overall, there were 21 complications (0.8%). There was no difference in complication rate between open and closed DPL. In conclusion, DPL remains a highly accurate, sensitive and specific test with an extremely low complication rate. It can be performed either open or closed with comparable results. We recommend its use in the evaluation of both blunt and penetrating trauma.

Perioperative lavage promotes intraperitoneal adhesion in the rat

This study was designed to study the effect of peritoneal lavage solutions on postsurgical adhesion formation in rats undergoing laparotomy and standardized ischemic injury to the lateral peritoneum with sutures. This reproducible model enabled semiquantitative scoring of adhesion formation. Adhesions were induced in 33 adult female Wistar rats. The solutions RPMI medium, NaCl (0.9%), Viaspan(R) and both povidone-iodine (1%) and chlorhexidine (0.02%) in dilution were evaluated. In the control group that was operated upon (without peritoneal lavage), a mean adhesion percentage of 22.5% was scored. All solutions used for abdominal lavage in this rat model induced significantly (p = 0. 0001) more adhesions (40.6-70.8%). Not all solutions induced an equal effect. The results found in the present in vivo study correlate with observations in previous in vitro experiments i.e. exposure of peritoneal areas to lavage solutions enhances peritoneal activation and thus promotes intra-abdominal adhesion formation.

Does hysteroscopy facilitate tumor cell dissemination? Incidence of peritoneal cytology from patients with early stage endometrial carcinoma following dilatation and curettage (D & C) versus hysteroscopy and D & C

BACKGROUND

In several case reports, distension and irrigation of the uterine cavity during fluid hysteroscopy was suspected to cause tumor cell dissemination into the abdominal cavity in patients with endometrial carcinoma. It was the aim of this study to compare the incidence of positive peritoneal cytology in patients who underwent dilatation and curettage (D & C) with or without previous hysteroscopy.

METHODS

The authors conducted a multicentric, retrospective cohort analysis. One hundred thirteen consecutive patients with endometrial carcinoma treated between 1996 and 1997 were included. Endometrial carcinoma had to be limited to the inner half or less than the inner half of the myometrium (pathologic Stage IA,B). Positive peritoneal cytology was obtained during staging laparotomy. Patients underwent D & C either with or without prior diagnostic fluid hysteroscopy. No selection or randomization was applied to the two groups. Positive peritoneal cytology, defined as malignant or suspicious, was considered the primary statistical endpoint.

RESULTS

Peritoneal cytology was suspicious or positive in 10 of 113 patients (9%). The presence of suspicious or positive peritoneal cytology was associated with a history of hysteroscopy (P = 0.04) but not with myometrial invasion (P = 0.57), histologic subtype (P = 1.00) or grade (r = 0.16, P = 0.10), or the time between D & C and staging laparotomy (r = 0.04, P = 0.66).

CONCLUSIONS

Based on the limited extent of endometrial carcinoma in the current analysis, our data strongly suggest dissemination of endometrial carcinoma cells after fluid hysteroscopy. Determining whether a positive peritoneal cytology affects the prognoses of patients without further evidence of extrauterine disease will require longer follow-up.

Bedside diagnostic laparoscopy and peritoneal lavage in the intensive care unit

BACKGROUND

Early diagnosis and treatment of intra-abdominal pathology in critically ill intensive care unit (ICU) patients remains a clinical challenge. The objective of this study is to assess the feasibility of portable, bedside diagnostic laparoscopy (DL) in the ICU for patients suspected of intra-abdominal pathology, and to contrast its accuracy with diagnostic peritoneal lavage (DPL).

METHODS

All adult ICU patients for whom a general surgery consultation was requested were eligible. Patients with a recent laparotomy or obvious peritonitis were excluded. All procedures were performed in the ICU.

RESULTS

Over a consecutive 16-month period, 12 patients underwent DPL/DL. Ages ranged from 28 to 88 (mean, 72) years. Causative findings were disclosed by DL in five patients, (42%) including intestinal ischemia in two. Perforated diverticulitis, thickened terminal ileum, and nonpurulent peritonitis were found in one patient each. All patients with findings by DL had a positive DPL (WBC > 200 cells/mm3), and one negative laparoscopy was positive by lavage. The average length of time to perform DPL was 14 min, and to complete DL 19 min. One patient underwent laparotomy based on DPL/DL and survived along with three others with negative DPL/DL. Eight patients died (67%), four from their surgically untreated intra-abdominal pathology. One patient sustained a procedure-related complication of bradycardia and high ventilatory airway pressures. Peak airway pressures increased an average of 8 mmHg and were significantly higher (p < 0. 001) than pre-DL pressures without any significant change in end-tidal CO2 or pCO2. There were no statistically significant hemodynamic changes based on mean arterial pressure (MAP), central venous pressure (CVP), or pulmonary artery diastolic pressure (PADP).

CONCLUSIONS

Bedside laparoscopy can be performed rapidly and safely in the ICU. In predicting the need for laparotomy, DL was more accurate than DPL.

Open versus closed diagnostic peritoneal lavage: a comparison on safety, rapidity, efficacy

There is considerable debate between the proponents of open and closed diagnostic peritoneal lavage (DPL). A prospective study was undertaken on 130 patients submitted to DPL. We performed 55 (42.3%) closed and 75 (57.7%) open lavages with sensitivity and specificity of 100 and 96.6% for the former and 92.2 and 100% for the latter. The mean time for insertion of the catheter and initiation of fluid infusion was significantly less in the closed DPL group, and so were the number of cases with prolonged procedures. No intra-abdominal or wound complications were detected with either method, but there were 10 DPL failures due to inability to conclude the procedure successfully and derive a definite result. Eight of these (10.6%) belonged to the open group and two (3.6%) to the closed (P < 0.05). Our findings suggest closed DPL is as equally sensitive and specific as closed DPL, but is more expeditious and offers inconclusive results less often. Both procedures are useful and should be parts of surgical training.

Percutaneous diagnostic peritoneal lavage using a Veress needle versus an open technique: a prospective randomized trial

OBJECTIVE

To prospectively compare the speed, sensitivity, complications, and technical failures of percutaneous diagnostic peritoneal lavage (DPL) using a Veress needle versus open DPL.

METHODS

One hundred seventy-six blunt trauma patients requiring DPL were prospectively randomized to undergo either open DPL using a standard technique or percutaneous DPL using an 18-gauge Veress needle to penetrate the peritoneal cavity, with the lavage catheter then being inserted over a guide wire.

RESULTS

Mean time to successful placement of the lavage catheter for the percutaneous Veress needle technique was 2.73 minutes versus 7.28 minutes for the open DPL technique (p < 0.001). Sixteen percent of open lavage procedures took more than 11 minutes; the majority (60%) of Veress needle lavage procedures took less than 2 minutes. There were no false-negative findings in either group, and there was one false-positive result in each group. A wound infection after an open DPL was the only complication. Poor return of lavage fluid (<200 mL) accounted for most technical failures; this was more prevalent with the percutaneous method (11.2%) than with the open technique (3.8%) (p < 0.05).

CONCLUSION

The percutaneous DPL method using a Veress needle is significantly faster than the open DPL method. The Veress needle lavage was as safe and as sensitive as the open lavage; however, technical failure occurred more frequently with the Veress needle lavage than with the open DPL.

Is closed diagnostic peritoneal lavage contraindicated in patients with previous abdominal surgery?

OBJECTIVE

To compare the accuracies and complication rates of diagnostic peritoneal lavage (DPL) in trauma patients with and without previous abdominal surgery.

METHODS

A retrospective review of DPL accuracy and complication rate was performed using all ED trauma patients who underwent DPL during 1993 as identified by the trauma registry. Care was provided at a Level-1 trauma center, a 1,100-bed, central-city teaching hospital with an annual ED census of 84,000. Records were reviewed for a history of previous surgery, DPL results, complications, mechanism of injury, and location of abdominal scars. DPL was performed using the Seldinger technique with a standard Arrow Diagnostic Peritoneal Lavage Kit using an 8-Fr catheter. Rates for patient groups with and without previous abdominal surgery were compared using Fisher's exact test. A "misclassified" DPL was defined as either a positive DPL with negative laparotomy or a negative DPL with subsequent need for laparotomy. "Complications" were defined as iatrogenic injury during the procedure or inability to obtain return of fluid during the lavage.

RESULTS

A total of 372 DPLs were performed; 42 in patients with previous surgery and 330 in patients without prior surgery. The groups were similar with respect to proportion with blunt trauma (95% vs 97%), positive DPL (19% vs 19%), misclassified rate (2.4% vs 1.8%), and complication rate (2.4% vs 0.9%); no significant difference was found between groups. The previous abdominal surgeries were appendectomy (n = 20), tubal ligation (n = 5), abdominal hysterectomy (n = 4), cholecystectomy (nonlaparoscopic) (n = 4), pyloric stenosis (n = 1), uterine prolapse (n = 1), undescended testis (n = 1), partial gastrectomy (n = 1), and unknown (n = 5). The analysis had a 90% power of detecting a 10% difference between the 2 groups.

CONCLUSION

The complication rate and accuracy of closed DPL in patients with previous abdominal surgery were similar to those for DPL performed in patients without previous abdominal surgery.

[Use of planned intermittent peritoneal lavage (open abdomen) in severe forms of peritonitis due to gynecologic-obstetric procedures]

Five women in whom the technique of intermittent peritoneal lavage (the so called "open abdomen") was applied following severe diffuse peritonitis have been presented. The details of operational technique have been given. Four patients have been cured without complications. In one patient a subhepatic abscess occurred but it was successfully operated.

[Postoperative lavage. Experimental study of the use of antiseptic solutions]

The authors report their experience of surgical infections and particularly peritoneal intraoperative lavage. In a previous study they have standardized the technique. In this study they report on the lavage adding antiseptic substances in the solution. The experimental, controlled study, was carried out on Wistar rat stock, which were submitted to median laparotomy through which was injected a standard bacterial dose composed of 5 bn E. Coli. The peritoneal cavity was washed out after a few minutes with physiological solution with clorhexidine or PVPI dissolved. The main results were an increase of aderential syndrome and a less survival percent age (physiological solution = 100%, clorhexidine = 60%, iodophors = 23%). The authors concluded by pointing out that the use of antiseptic peritoneal lavage solution is a method that should be proscribed from operating rooms because it is unnecessary and detrimental to health.

Mechanically assisted intraoperative peritoneal lavage for generalized peritonitis as a result of perforation of the upper part of the gastrointestinal tract

BACKGROUND

The efficiency of intraoperative peritoneal lavage (IOPL) and peritoneal drainage in patients with generalized peritonitis remains controversial. The benefit of large volume IOPL, using a newly designed device, and of peritoneal drainage were evaluated in 101 patients with generalized peritonitis.

STUDY DESIGN

Patients were divided into two groups, one treated by mechanically assisted IOPL (group 1), and the other treated by manual IOPL (group 2). They were further divided into two groups, one undergoing drainage (DR group) and the other undergoing no drainage (ND group). Based on data in the progress notes, patients in these groups were compared with each other with respect to disease process, volume of IOPL fluid, incidence of infectious complications, and other prognostic factors.

RESULTS

In group 1, the incidence of infectious complications was significantly lower than in group 2 (10.8 versus 62.9 percent, p < 0.01). Patients who underwent operative treatment 12 hours or more after onset of peritonitis had a lower incidence of infection following high volume IOPL (greater than or equal to 30 L) compared with those patients who underwent low volume IOPL. The incidence of infectious complications was significantly higher in the DR group (32.8 versus 12.9 percent).

CONCLUSIONS

A large volume of saline (greater than or equal to 30 L) was needed for IOPL. The new device for IOPL proved to be very successful and efficient. When IOPL was successful, it seemed that peritoneal drainage did not provide any additional benefits to the treatment of generalized peritonitis.

Omental herniation after operative laparoscopy. A case report

Omental herniation through an 11-mm umbilical incision occurred 36 hours after operative laparoscopy. It was attributed to large amounts of residual irrigation fluid in the abdominopelvic cavity and failure to close the fascia of the umbilical incision. This case stresses the importance of closing the fascia of larger laparoscopic incisions, especially if irrigation fluid is left in the abdominal cavity postoperatively.

Staged peritoneal lavages with the aid of a Zipper system in the treatment of diffuse peritonitis

A major problem in the surgical treatment of diffuse peritonitis is to obtain a complete clearance of septic foci in the peritoneal cavity which may lead to persistence of sepsis and multiple organ failure. We describe our experience with staged abdominal re-explorations using a Zipper system in 23 patients with a mean APACHE II score of 20.3 (s.e.m: 1.5). A total of 91 lavages were done in these patients. Overall mortality was 39%. None of the patients having an APACHE II score between 10 and 20 died whereas the predicted mortality was 15%-45%. After successful treatment, primary closure was possible in 8 of the 14 surviving patients. Large incisional hernias developed in 6 patients. One patient eviscerated two years after complete granulation of his laparostoma. Staged abdominal re-explorations using a Zipper system is an useful tool in the treatment of diffuse peritonitis.

Pelvic kidney laceration: an unusual complication of percutaneous diagnostic peritoneal lavage--case report

Diagnostic peritoneal lavage (DPL) is considered the gold standard in the evaluation of patients with suspected blunt abdominal trauma when the results of the abdominal examination are equivocal or when the patient's mental status is altered. In recent years a percutaneous method using the Seldinger technique has been performed. We present a case report of an unusual complication of DPL using the percutaneous method.

Peritoneal catheterization

Procedures involving invasion of the peritoneal cavity are often performed on critically ill or injured patients. Like any invasive procedure, they require a thorough understanding not only of their techniques and indications, but also of their contraindications and complications. Used appropriately, these procedures may serve as invaluable diagnostic or therapeutic tools in the care of acutely ill patients.

Randomized, prospective comparison of open and closed peritoneal lavage for abdominal trauma

STUDY OBJECTIVE

The study was designed to determine if open peritoneal lavage is superior to closed peritoneal lavage.

DESIGN AND PARTICIPANTS

Patients who were admitted to a trauma center and needed peritoneal lavage were assigned to alternate trauma teams. Team 1 performed only open lavages one month and then switched to closed lavages; team 2 did only closed lavages and then switched to open lavages.

MEASUREMENTS

The incidences of positive lavages and lavage complication were noted. Also measured were the length of time for catheter insertion, length of time of fluid retrieval, volume of effluent, technical difficulty of lavage, training level of the operator, effluent RBC count, and material cost.

RESULTS

Two hundred twenty patients were randomized. No differences were noted in complication rate, volume of effluent, or length of time for fluid retrieval. Significant differences were noted for catheter insertion time (3.6 minutes for closed lavage and 6.9 minutes for open), ease of catheter insertion (closed technique is favored), and material cost ($96.26 for open lavage and $69.70 for closed lavage).

CONCLUSION

Closed peritoneal lavage is superior to open peritoneal lavage in abdominal trauma; it is faster, easier to use, cheaper, and as safe as open lavage.

Effect of glycine on retroperitoneal and intraperitoneal organs in the rat model

Twenty Sprague Dawley rats were administered various doses of 1.5% amino acetic acid (glycine), lactated Ringer's, and water, both intravenously and retroperitoneally, in an attempt to recreate the post-transurethral resection syndrome in a rat model. The kidneys, liver, and pancreas were harvested 6 hours after exposure and examined pathologically. Water and lactated Ringer's had no histologic effect on these organs. Glycine was found to have a toxic effect on the kidneys and liver and this effect was dose related. Based on these results, it is postulated that glycine toxicity may play a significant role as a causative factor in producing the post-transurethral resection syndrome.

Complications in evaluating abdominal trauma: diagnostic peritoneal lavage versus computerized axial tomography

We reviewed our experience with 2,809 DPL's and 1,331 CT's obtained in the resuscitative phase over a 3-year period in our trauma system to determine the significant complications associated with each modality. There were 25 DPL complications: eight false negatives, three false positives, and 14 technical errors. There were 46 CT complications including 25 false negative scans, three false positive scans, and 18 delays to the operating room from obtaining abdominal CT evaluation, with two of these delays resulting in preventable deaths. Although both modalities had low complication rates (0.9% DPL vs. 3.4% CT), DPL was associated with less preventable mortality and morbidity than CT in the evaluation of abdominal trauma.

How to perform a diagnostic peritoneal lavage

Peritoneal lavage can be a very helpful investigation in the initial management of trauma patients. The technique demands some basic surgical skills but has been shown to be relatively safe and accurate when performed by appropriately trained junior doctors.

Diagnostic peritoneal lavage in evaluation of acute abdominal disease

Diagnostic peritoneal lavage (DPL) is an established procedure in evaluation of trauma victims but is less well established for use in patients suspected of having acute intra-abdominal disease. Twenty-six seriously ill patients at our institution who had DPL for acute intra-abdominal disease form the basis of this report. Use of DPL indicated sepsis in ten patients; in seven of the ten, findings were confirmed at celiotomy or autopsy. Only one of the ten survived without laparotomy or confirmatory necropsy indicating the result of DPL had been false-positive. Sepsis was not indicated by DPL in 16 patients. Fourteen patients appeared to have true-negative results confirmed by operation (three patients), autopsy (four patients), or survival longer than two weeks (seven patients). Complications occurred in one patient whose DPL showed sepsis. Two patients with negative results of DPL died within two weeks of examination without confirmatory operation or autopsy and could not be evaluated. We therefore, consider the overall diagnostic accuracy in our patient group to be 95%. We recommend the use of DPL in patients suspected of an acute intra-abdominal disease process who are unable to undergo other evaluation for reasons such as critical illness.

Is diagnostic peritoneal lavage for blunt trauma obsolete?

Diagnostic peritoneal lavage was 97 percent accurate, with a 2 percent false positive rate and a 1 percent false negative rate in this series of 414 patients. The ease, safety, and accuracy of diagnostic peritoneal lavage justify its continued use in evaluating these patients. Recent studies show computerized tomography (CT) can be highly accurate in detecting intra-abdominal injuries after blunt trauma. We reviewed our experience with diagnostic peritoneal lavage (DPL) to evaluate whether the accuracy, safety, speed, and cost justified its continued use. Four hundred fifteen DPLs were performed on 414 patients from February 1, 1983, through December 31, 1987. All DPLs were done by the open technique. The lavage was considered grossly positive if 10 cc gross blood were aspirated. If there were greater than 100,000 red blood cells (RBC)/mm3, greater than 500 white blood cells (WBC)/mm3, elevated amylase or bilirubin, or bacteria or vegetable fibers the lavage was microscopically positive. There were no cases with elevated bilirubin, amylase, or presence of bacteria. All four cases with "rare vegetable fibers" were false positive. Six DPLs were for penetrating trauma to the lower chest or back. There were 291 negative lavages, including five false negatives (1%), and 124 positive DPLs, including seven false positives (2%), resulting in a crude accuracy of 97 percent. Three of the five false negative lavages had a ruptured diaphragm as the only intra-abdominal injury. There was one minor complication. DPL was usually performed in the trauma resuscitation room during the secondary survey. At our institution, the total fees for DPL are +185 less than the fees for CT. DPL is accurate, rapid, safe, and avoids the disruption of patient care that results in the radiology suite. DPL remains our procedure of choice for evaluating blunt abdominal trauma in the adult.

[The effect of staged lavages in peritonitis on the vital functions]

In 16 consecutive patients with diffuse peritonitis 93 staged lavages were undertaken. In a retrospective study the changes of some vital functions due to transport in the operating room and staged lavage were evaluated. 9 patients (56%) survived the diffuse peritonitis. The vital parameters showed no significant changes following staged lavages. Intraabdominal specimen cultures were positive in 62% of cases, showing no correlation of the underlying disease and mortality. Only an elevation of C-reactive protein and rise of thrombocyte count correlated significantly with the outcome of diffuse peritonitis.

Dehiscence with evisceration: a rare complication of diagnostic peritoneal lavage

Diagnostic peritoneal lavage (DPL) is a well-established procedure for evaluating the patient suspected of having intraabdominal injury secondary to blunt abdominal trauma. Its accuracy and safety have been clearly documented; however, the procedure does have the potential for morbidity. This paper reports on the occurrence of a rare complication, dehiscence with evisceration, and reviews the literature regarding complications of DPL.

Open versus closed peritoneal lavage with particular attention to time, accuracy, and cost

One hundred consecutive patients with blunt abdominal trauma, thoracoabdominal stab wounds, or anterior abdominal stab wounds with fascial penetration were prospectively randomized to either an open or closed technique for diagnostic peritoneal lavage. The closed or percutaneous technique of lavage was consistently faster to perform, of comparable cost, associated with fewer complications, and as accurate as the open technique.