Surgical approach to intraabdominal sepsis: a damage control approach can reduce stoma rates

In patients with perforated diverticulitis and/or intraabdominal sepsis (IAS), the best surgical strategy remains controversial. While open, non-restorative Hartmann's procedure represents the procedure of choice in many centers, ostomy-sparing and minimally invasive techniques have been increasingly utilized due to short- and long-term benefits, including a reduced stoma rate. This dynamic manuscript illustrates strategic and technical considerations of the standardized institutional staged or damage control approach to IAS.

The institutional strategy to IAS is demonstrated through an emergency procedure for perforated Hinchey IV diverticulitis in a 70-year-old woman developing an acute abdomen. After a diagnostic laparoscopy, stercoral peritonitis was confirmed and the patient underwent laparotomy. A two-stage approach (stage 1: damage control with resection of the perforated sigmoid, abdominal lavage, vacuum-assisted closure (VAC) - stage 2 (36-48 h later and during daytime): primary colorectal anastomosis and abdominal closure) was performed. While laparoscopic exploration represents the standard approach in hemodynamically stable patients, the staged procedure (resection and sepsis control) helped refine the definite strategy (goal of reconstruction and no ostomy) in a clinically improved patient during the second step. The patient recovered well during the critical therapeutic window, allowing to perform primary anastomosis and a stoma-free discharge.

Clinical condition during surgery, surgeon expertise, and comorbidities are key determinants to decide whether to proceed to primary anastomosis in the case of IAS. An institutional series of our group revealed feasibility and safety of the staged approach, with 65% stoma-free patients at discharge. A standardized algorithm based on intraoperative hemodynamic parameters intends to guide surgical decision-making during staged procedures to seek optimized conditions allowing to proceed to primary anastomosis.

A staged approach according to a predefined decisional framework may help decrease the need for ostomy creation in patients with IAS.