What is the definitive surgical approach for a perforated viscus with generalized peritonitis?

• A. Emergent exploratory laparotomy with source control
• B. Laparoscopic washout
• C. CT-guided percutaneous drainage
• D. Antibiotics alone

Answer: (A)

In generalized peritonitis from a perforated viscus, the priority is rapid source control to stop ongoing contamination and remove infectious material. An emergent exploratory laparotomy allows full Abdomen inspection to locate the perforation, perform definitive repair or resection, restore intestinal continuity if feasible, and perform thorough peritoneal lavage with placement of drains. This approach directly addresses the ongoing leak and sepsis, which nonoperative options cannot control in the setting of widespread contamination.

Laparoscopic washout, while useful in selected cases with localized contamination and in stable patients, often cannot reliably identify and control a perforation in the face of diffuse peritonitis, and may miss occult sources or insufficiently drain the abdomen. CT-guided percutaneous drainage targets localized collections, not a free perforation with diffuse contamination. Antibiotics alone do not resolve the active source of infection and leak. Therefore, the definitive and appropriate management is emergent exploratory laparotomy with source control.