Scheduled reoperations (etappenlavage) for diffuse peritonitis.

Etappenlavage, a new concept of scheduled multiple laparotomies with abdominal lavage for diffuse peritonitis, has been in use since 1979. The purpose of etappenlavage is to ensure exclusion of the infected source, promote maximal elimination of toxic necrotic material, and allow prompt recognition of complications to effect immediate repair. Patients with diffuse peritonitis at high risk of developing multiple system organ failure (as assessed by high scores in the Peritonitis Index Altona and Acute Physiology and Chronic Health Evaluation classifications) were routinely reexplored on a daily basis until evidence of improvement or healing was noted. From 1980 to 1984, 61 patients with intra-abdominal sepsis were treated. Thirty-four cases were due to spontaneous perforation of an intestinal viscus, and 27 cases were secondary to postoperative infections. In 51 cases the primary process was present for more than 48 hours. A total of 235 etappenlavages were performed (mean, 3.9 per patient). In ten cases, additional bowel lacerations were noted and repaired at the second laparotomy. In the last 31 patients, closure with a zipper has facilitated reoperation. No drains were used. After definitive closure, primary wound healing was seen in 79% of cases. The overall mortality in this high-risk group was 22.9%.