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Цитата из одной из книг М. Шайна (эта переведена на русский) Peritoneal Toilet
Once the source of infection is eradicated, cleaning the peritoneal cavity is
aimed at minimizing the intraperitoneal bacterial load. Several maneuvers deserve discussion. Liquid contaminants and infected exudates should be aspirated and particulate matter removed by swabbing or mopping the peritoneal surfaces with moist laparotomy pads. Although cosmetically appealing and popular with surgeons, there is no scientific evidence that intraoperative peritoneal lavage reduces mortality or infectious complications in patients receiving adequate systemic antibiotics. Similarly, peritoneal irrigation with antibiotics is not advantageous, and the addition of antiseptics may produce local toxic effects.
Irrigate copiously (to use a term popular among American surgeons) if you wish, but know that, beyond wetting your own underwear and shoes, you will not accomplish much. Should you choose to remain a dedicated irrigator, try to confine the irrigation to the contaminated area—to avoid spreading s**t all around—and do remember to suck out all the lavage fluid before you close; there is evidence that leaving irrigation fluids behind interferes with peritoneal defenses by “diluting the macrophages.” Bacteria swim perhaps better than macrophages. The concept of radical debridement of the peritoneal cavity is based on the
premise that fibrin is a nidus for microbial implantation, hence the recommendation to peel off every bit of fibrin coating peritoneal surfaces and viscera. The procedure is tedious, results in excessive bleeding from the denuded peritoneal surfaces, and endangers the integrity of an already friable intestine. It did not withstand the test of a prospective randomized study comparing it to a more conservative approach.
Despite the dictum that it is impossible to effectively drain the free peritoneal cavity, drains are still used (and often misused). Their aim must be restricted to the evacuation of an “established” abscess (when the residual cavity
will not collapse or cannot be filled with omentum or adjacent structures), to
allowing escape of potential secretions (e.g., bile, pancreatic juice), or, rarely, to establishing a controlled intestinal fistula when exteriorization is not possible.
To prevent intestinal erosion, soft drains should be left in place for the shortest duration possible and well away from bowel wall. In general, active suction drainage may be more effective than the passive kind, and infectious complications can be reduced by choosing “closed” systems. Drains provide a false sense of security and reassurance. We have all seen a moribund postoperative patient with an abdomen “crying” to be re-explored and a surgeon in denial because the tiny four-quadrant drains are dry and nonproductive. This is particularly true of drains inserted to deal with postoperative hemorrhage (> Chap. 56); a tiny trickle of blood from a drain may hide a huge intra-abdominal clot. Drains inserted close to an anastomosis “just in case it leaks” are more likely to cause an anastomotic dehiscence than to establish a controlled fistula. For more on drains, refer to > Chap. 42.
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