Abdominal Sepsis Managed by Leaving Abdomen Open

Intra-abdominal sepsis and necrotizing infection of the abdominal wall are usually fatal unless adequate drainage and wide debridement are possible. To follow these principles, we managed 18 seriously ill patients with abdominal sepsis by leaving the abdomen completely open. All except two of the patients had severe intra-abdominal sepsis. Eight patients had full-thickness wound infections and intra-abdominal infections refractory to the usual surgical drainage techniques. Two had necrotizing wound infections only. In 12 an upper abdominal incision was managed open, and in six the open incision was lower. As part of the initiating illness, there were eight small bowel and six colon fistulas. They were managed by colostomy in five patients and ileostomy in two. More than one organism was cultured in all patients and 12 of 18 had a positive blood culture. Respiratory failure made mechanical ventilation necessary in 13 patients for an average of 44 days. Previous adhesions, usually present, or an intact greater omentum, were necessary to prevent bowel evisceration, but three patients required paralysis and mechanical ventilation until adhesions became strong enough to prevent evisceration. There were seven deaths (39%), six caused by continuing sepsis and one from hemorrhage. In those surviving, granulation tissue grew over omentum or bowel loops to eventually seal the abdominal cavity. The late management was split-skin grafting in five and secondary closure in two. Four healed by second intention. We conclude that leaving the abdomen completely open facilitates the widest possible drainage, uncompromising debridement of the abdominal wall, and is compatible with good recovery. The ultimate result in survivors is acceptable. This technique is preferable to closing an abdominal wall of questionable viability in the face of intraperitoneal sepsis.