PubMed1988
The successful management of the contaminated or septic abdomen rests on at least three tenets: The use of systemic perioperative antibiotics, the control of the source of infection and the aspiration of the gross contaminants. The additional use of any modality of IOPL is well entrenched in modern surgical practice. It does, however, owe more to force of habit or prejudice than to sound scientific evidence. Most, if not all, experimental or clinical studies suggesting the benefits of IOPL suffer from many deficiencies, some of which we made a point of emphasizing. In broad terms, one could recognize three major pitfalls invalidating these studies. First, the design of some of the experimental studies bears no resemblance to clinical situations. For example, laparotomy was omitted in either both arms of the trial or in the control arm. Second, far too frequently, the data were drawn from retrospective or uncontrolled trials. Although the value of such studies cannot be denied, the literature is replete with examples of perpetuation of erroneuos concepts through lack of properly designed prospective, randomized controlled studies. Third, many of the trials were performed before the revolutionary introduction of perioperative antibiotics in clinical practice. Of greater concern is the existence of studies which, for unexplained reasons, have ignored this principle. From this review, it seems that neither the benefit nor the safety of IOPL with crystalloid or antiseptic solution has been established beyond any reasonable doubt. The theory for the addition of judicious antibiotics to the IOPL may be stronger, although no absolute proof exists to suggest that this practice will decrease mortality rates from intra-abdominal infections. Obviously, there is a need for well constructed, controlled, prospective clinical trials to examine the role of IOPL in modern surgical groups of patients assembled under the label intra-abdominal infection. Until some stratification of peritonitis in various clinical studies is undertaken, either by how ill the patient is or the source of contamination and its duration, it will be difficult to compare studies from different centers.