ABSTRACT
Emergency abdominal surgery differs from elective surgery in that a surgeon is often forced to intervene with only a provisional diagnosis but with the knowledge that surgical intervention is urgent. The value of exhaustive investigations has to be balanced against any deterioration that may occur during the inevitable delay. A short delay, for both active resuscitation and preliminary investigations, is, however, usually beneficial as surgery on severely shocked or septic patients carries a high mortality. There are also situations where during this period the underlying pathology is clarified and found to be more appropriately managed conservatively or by some alternative non-surgical intervention. Intensive preoperative resuscitation has the potential to improve physiological status and reduce the risk of perioperative death, but unfortunately, deterioration can also occur. Cardiovascular stability and adequate tissue perfusion may not be attainable in the presence of continuing haemorrhage, and as overall blood loss rises, coagulopathy will inevitably develop. Infarction of tissue already compromised by ischaemia or excessive dilatation may result in perforation and sepsis, and absorption of toxic products from any dead tissue will also continue (see Chapter 12). The timing of surgery is therefore very important. The surgeon, aware of the deteriorating intra-abdominal situation, is often impatient to operate on a patient still unfit for major intervention. The anaesthetist, in contrast, may strive too long to optimise a patient preoperatively in situations where deterioration is inevitable until the underlying pathology has been addressed. Any apparent conflict of interest needs discussion and compromise. Despite the value of intensive preoperative resuscitation of very ill patients, the ‘window of opportunity’ must not be missed and delay beyond 4 hours is usually counterproductive.
