Extraperitoneal versus transperitoneal drainage of the intra-abdominal abscess

Controversy as to whether the intra-abdominal abscess should be drained extraperitoneally or through formal laparotomy still rages. Arguments for a transperitoneal approach include no need to identify specific locus preoperatively and uniform drainage of all abscesses, especially any otherwise unrecognized pus collection. Proponents for the extraperitoneal route stress failure to contaminate previously uninvolved peritoneal spaces and more reliable avoidance of injury to intestine, predisposing to subsequent intestinal fistula. To resolve this impasse, a prospective study of each method was based upon a schedule of previously randomized treatment options. After 32 months of study, 60 patients had been enrolled without obvious differences between treatment groups with respect to demographic features, preoperative definition and locus of infection, precipitating cause of sepsis, associated diseases, responsible bacteria and antibiotic therapy. With the transperitoneal approach, five patients had hollow viscus injury, while seven eventually had an intestinal fistula develop, causing major problems in four. Despite no obvious intestinal injury with the extraperitoneal route, two transient intestinal fistulas did occur. Seven patients drained transperitoneally had additional abscesses discovered, yet another operation was required to drain at least one complicating abscess in seven of this same group. With the extraperitoneal route, only two patients needed reoperation to drain another abscess. Although there were more deaths and complications in the group drained transperitoneally, morbidity (47 per cent) and mortality (7 per cent) were not significantly different statistically. Such data refute the professed superiority of a transperitoneal approach to intra-abdominal abscess drainage, both from need to reoperative for second abscess as well as incidence of latter intestinal fistula. Best results were noted with abscess identification through computerized tomography followed by extraperitoneal drainage.