**6. Conclusions**

Whether you are an experienced (old) surgeon, an enthusiastic (not quite old) fellow, or a young trainee, you will be facing, again and again, patients with acute diverticulitis. When called upon to assess them, you will know beforehand that most of them will be Hinchey I–II, and commonly only a small number of them will have diffuse peritonitis, purulent, or fecal. As an experienced clinician, you should be assessing the patient's physiologic status even before considering whether your patient has acute diverticulitis or other conditions. Early in your evaluation, you should determine whether you are dealing with septic but contained infection or a patient with septic shock. Patients with sepsis should be treated promptly and appropriately to avoid fatal outcomes.

Currently, the application of the Sepsis-Six protocol is indicated, and it should be applied as soon as possible. This approach implies being very aggressive in management. It is advisable to start resuscitation even before having made a diagnosis of the cause. Once you have started your resuscitation and treatment based on your clinical experience, you can confirm your findings with blood-test results and imaging studies in cases of sepsis due to severe acute diverticulitis the CT scan (always with IV contrast) will provide you with valuable information.

If you have done things correctly, you will not only have diagnosed the etiology but also, and most importantly, you will have a diagnosis of severity. Sepsis due

**81**

*Damage Control in Hinchey III and IV Acute Diverticulitis*

to acute diverticulitis with diffuse peritonitis without septic shock or contained is not the same as "unresponsive" septic shock due to the same condition. There is a massive difference in morbidity and mortality among both presentations. When in shock, all the derangement of the physiological status and its response to resuscitation should not be delayed. If you wait to complete the work-up and delay initial treatment, you will waste precious time and have an unfavorable outcome and

You should follow your clinical instinct and make a correct initial evaluation, anticipating the needs of your patient, and preparing your team approach. Surgeons, anesthetists, radiologists, OR nurses, are all part of this team and should be prepared. For those patients with unresponsive septic shock, consider damage-control as the approach that will maximize the possibility of recovery to your patient. Imagine a patient with an unresponsive septic shock as a KO-ed boxer. He needs to stop the fight, has his opponent removed from the ring, and be allowed to rest and recover before being able to fight another match and maybe win it. Damage-control is removing the opponent (source control) and resting and recovering (ICU). Even if there are no guarantees, your patient may return to fight another day. In our scenario, it is all about doing a quick source control followed by resuscitation in ICU, leaving the definitive procedure for when your patient is in a

Your team of clinicians formed by the surgeon, anesthetist, intensivist, knows

As an experienced surgeon, remember that is not the patient for a key-hole surgical approach. It is mandatory to have good exposure and to be quick: nothing less than a good (almost)-full midline laparotomy is advisable. Surgery should be easy; try not to complicate it yourself: non-oncological resection with stapler, leave everything inside, do a temporary closure of the abdomen and come back after

A final word for the forgotten actors of this play: the patient and their family. We are not going to linger on the consent form or other bureaucratic matters. We want to stress that they should be kept involved in the decision process and also be informed frankly on the expected timeline. People do not quickly grasp the concept of open abdomen and second look. The standard expectation for surgical treatment is not to start today and finish after 2 or 3 days if all goes well. The information you give to them and honest expectations are critical in these complex scenarios. So, try to be consensual with your colleagues and avoid discrepancies in the information provided; this maintains the patients' and family members' trust in the assisting team. Sometimes you have to sit down again and again and go through everything

you have already explained with your patient and family members.

patient and his family's concerns is never a waste of time.

You should provide not only surgical techniques and medications but also provide support to the worried families as well. Sometimes they only need some empathy and a word of comfort, or just feeling that you (or whoever is in charge) cares about their dear ones. Taking time to give your support and listen to the

*DOI: http://dx.doi.org/10.5772/intechopen.92669*

higher mortality.

better physiological status.

24–48 h if the patient survives.

how to do it.

#### *Damage Control in Hinchey III and IV Acute Diverticulitis DOI: http://dx.doi.org/10.5772/intechopen.92669*

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

indicated, during a former repair of an incisional hernia.

and 4 days but which can be maintained for 7–10 days.

appropriately to avoid fatal outcomes.

et al., which in our hands is what works best [1].

you do, it is more or less easy.

this chapter.

**6. Conclusions**

always leave a pelvic drain, only to drain the stump should it leak.

Just a word about the rectal stump. It is quite uncommon to detect any problem at this level now, but not uncommon to have a dehiscence of the stump later on. We

Usually, the "bowel" part of the second-look causes no big problem: whatever

The challenge of the second-look is often the abdominal closure. Sometimes, it can be difficult to approximate the abdominal wound edges, mainly because of the edema of the intra-abdominal organs that can result in a high intra-abdominal pressure and difficulty to approximate the midline laparotomy edges successfully. The extent to which you can close the abdomen under tension is difficult to judge. We rely much on IAP, and feel safe to close if IAA is <12 mmHg. But also the quality of the tissue is crucial, and this is something that you cannot judge objectively. As a rule, we do primary closure of the fascia is IAP <12 mmHg and accept the need of following surgeries for incisional hernia. We do not routinely do advanced abdominal wall reconstruction surgery at this stage, and prefer to do them, if

In the few cases, where you cannot close the abdomen due to elevated IAP, we use a **mesh**-**mediated** vacuum-assisted wound closure as proposed by Petersson

An in-depth discussion of abdominal wall reconstruction is beyond the topic of

Usually, after the second look, the patient will go back to the ICU. If the evolution is favorable in the following days, we can minimize the necessary support measures. In patients who have presented septic shock and multiorgan failure, we will progressively withdraw invasive mechanical ventilation, renal replacement therapies, and vasoactive drugs, depending on the recovery of these organs.

It is essential after overcoming the initial shock situation, at 24–48 h, to initiate adequate nutritional therapy since patients in septic shock suffer a hypercatabolic phase mediated by increased cytokines and lipid mediators with a peak between 3

Whether you are an experienced (old) surgeon, an enthusiastic (not quite old) fellow, or a young trainee, you will be facing, again and again, patients with acute diverticulitis. When called upon to assess them, you will know beforehand that most of them will be Hinchey I–II, and commonly only a small number of them will have diffuse peritonitis, purulent, or fecal. As an experienced clinician, you should be assessing the patient's physiologic status even before considering whether your patient has acute diverticulitis or other conditions. Early in your evaluation, you should determine whether you are dealing with septic but contained infection or a patient with septic shock. Patients with sepsis should be treated promptly and

Currently, the application of the Sepsis-Six protocol is indicated, and it should be applied as soon as possible. This approach implies being very aggressive in management. It is advisable to start resuscitation even before having made a diagnosis of the cause. Once you have started your resuscitation and treatment based on your clinical experience, you can confirm your findings with blood-test results and imaging studies in cases of sepsis due to severe acute diverticulitis the CT scan (always

If you have done things correctly, you will not only have diagnosed the etiology but also, and most importantly, you will have a diagnosis of severity. Sepsis due

with IV contrast) will provide you with valuable information.

**80**

to acute diverticulitis with diffuse peritonitis without septic shock or contained is not the same as "unresponsive" septic shock due to the same condition. There is a massive difference in morbidity and mortality among both presentations. When in shock, all the derangement of the physiological status and its response to resuscitation should not be delayed. If you wait to complete the work-up and delay initial treatment, you will waste precious time and have an unfavorable outcome and higher mortality.

You should follow your clinical instinct and make a correct initial evaluation, anticipating the needs of your patient, and preparing your team approach. Surgeons, anesthetists, radiologists, OR nurses, are all part of this team and should be prepared. For those patients with unresponsive septic shock, consider damage-control as the approach that will maximize the possibility of recovery to your patient. Imagine a patient with an unresponsive septic shock as a KO-ed boxer. He needs to stop the fight, has his opponent removed from the ring, and be allowed to rest and recover before being able to fight another match and maybe win it. Damage-control is removing the opponent (source control) and resting and recovering (ICU). Even if there are no guarantees, your patient may return to fight another day. In our scenario, it is all about doing a quick source control followed by resuscitation in ICU, leaving the definitive procedure for when your patient is in a better physiological status.

Your team of clinicians formed by the surgeon, anesthetist, intensivist, knows how to do it.

As an experienced surgeon, remember that is not the patient for a key-hole surgical approach. It is mandatory to have good exposure and to be quick: nothing less than a good (almost)-full midline laparotomy is advisable. Surgery should be easy; try not to complicate it yourself: non-oncological resection with stapler, leave everything inside, do a temporary closure of the abdomen and come back after 24–48 h if the patient survives.

A final word for the forgotten actors of this play: the patient and their family. We are not going to linger on the consent form or other bureaucratic matters. We want to stress that they should be kept involved in the decision process and also be informed frankly on the expected timeline. People do not quickly grasp the concept of open abdomen and second look. The standard expectation for surgical treatment is not to start today and finish after 2 or 3 days if all goes well. The information you give to them and honest expectations are critical in these complex scenarios. So, try to be consensual with your colleagues and avoid discrepancies in the information provided; this maintains the patients' and family members' trust in the assisting team. Sometimes you have to sit down again and again and go through everything you have already explained with your patient and family members.

You should provide not only surgical techniques and medications but also provide support to the worried families as well. Sometimes they only need some empathy and a word of comfort, or just feeling that you (or whoever is in charge) cares about their dear ones. Taking time to give your support and listen to the patient and his family's concerns is never a waste of time.
