Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Introduction:  
Typhoid fever is a bacterial infection caused 
by Salmonella typhi. It is spread by ingesting 
contaminated food or water. If not treated with early 
antibiotics, it can lead to serious surgical 
complications most often presenting with typhoid 
intestinal perforations in the terminal ileum. It can 
also less frequently cause gangrenous or perforated 
acalculous cholecystitis, or can involve both ileal and 
gallbladder disease concurrently. 
 
Single typhoid intestinal perforation (Black circle) on the 
antimesenteric border of the terminal ileum 
 
 
Gangrenous acalculous cholecystitis with necrosis of most of 
the gallbladder wall, consistent with severe typhoid infection. 
 
 
Gangrenous acute cholecystitis and typhoid intestinal 
perforations in the same patient. 
 
 
A patient with gangrenous acute acalculous cholecystitis (top 
specimen, opened) and multiple intestinal perforations 
 
The intestinal injury starts internally on the 
antimesenteric border and is thought to be related to 
the location of the infection in the lymphoid follicles 
of the terminal ileum (“Peyer’s patches”). The injury 
to the intestinal wall can worsen to violaceous or 
erythematous areas on the serosal surface that 
represent concern for underlying mucosal injury 
(pre-perforations). Sometimes the bowel can feel 
thinner in these places, but tactile sense alone can be 
inaccurate because of the edema in the bowel wall. 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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External and internal images of the same terminal ileum 
segment. The internal mucosal damage (bottom image) is often 
much more extensive than external appearance (top image) 
may imply. This can contribute to the patient having additional 
perforations after repair of the initial full thickness perforation- 
these areas often do not look like they’re “at risk” since there 
is no evidence of external tissue loss. 
 
These pre-perforations can also develop into 
necrosis of the intestinal wall before they develop 
full thickness perforations, so the patient can have 
peritonitis without evidence of free fluid. These 
patients still need to have an operation and these 
areas resected and not just oversewn.   
 
 
 
 
Both above pictures show pre-perforations that have developed 
necrosis and are close to full thickness perforations. 
 
Patients with typhoid intestinal perforations 
often present with two weeks of fever and then 
develop severe abdominal pain as they develop pre-
perforations and then full thickness perforations with 
spillage and peritonitis. They may also present with 
other symptoms such as obstipation, nausea, and 
vomiting. In areas without the ability to perform 
blood cultures or more advanced imaging, it is very 
important to obtain a clear history to rule out trauma, 
to perform a good clinical examination, and to obtain 
laboratory 
analyses 
looking 
especially 
for 
abnormalities such as hyponatremia, anemia, or renal 
failure. Patients might not have a leukocytosis, as 
would be expected in other infectious cases of 
peritonitis. 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Abdominal ultrasound helps to assess the 
presence of free fluid, though patients can be 
perforated and may have only a localized  fluid 
collection, contained by omentum and not easily 
seen on ultrasound. An upright abdominal x-ray is 
not always useful, as pneumoperitoneum is not 
always seen if the infectious process has been sealed 
off by the omentum or adjacent loops of bowel. 
Therefore, 
do 
not 
wait 
for 
free 
fluid 
or 
pneumoperitoneum on imaging to operate on these 
patients. 
 When there is suspicion of intestinal 
perforation, these are the steps to follow to prepare 
the patient for surgery: 
• Insert a nasogastric tube  
• Insert a urinary catheter 
• Start broad-spectrum intra-venous antibiotics:  
• Children: Ceftriaxone 100mg/kg daily (not to 
exceed 
4 
grams) 
and 
Metronidazole 
30mg/kg/day every 8 hours (not to exceed 
500 grams/dose)  
• Adults: Ceftriaxone 2 grams daily and 
Metronidazole 500mg every 8 hours 
• Intravenous fluid resuscitation 
• Consent for exploratory laparotomy: every 
patient needs to understand there will be a 
possible bowel resection and a possible ostomy. 
 
Surgical procedures for typhoid perforations 
proceed according to the following general steps: 
• Midline exploratory laparotomy 
• Aspiration of purulent fluid or succus and initial 
washout and exploration, to identify perforations 
• Visualization of the gallbladder to ensure no 
evidence of gangrene or perforation 
• Careful, systematic examination of all the small 
bowel with identification of the full thickness 
perforations and pre-perforations  
• Surgical procedure, chosen depending on the 
location of the perforations, the number of 
perforations, the degree of contamination, the 
extent of inflammation of the bowel wall, and the 
clinical state of the patient (hypotension, 
malnutrition, etc.) 
• Possible surgical procedures include: primary 
repair or resection (small bowel resection or 
ileocecectomy) with anastomosis vs. ostomy 
creation (end ileostomy and mucus fistula vs. 
diverting loop ileostomy). Both operations are 
discussed separately in detail below.  
• Final irrigation of the abdominal cavity 
 
PRIMARY REPAIR OF A PERFORATION 
Steps: 
1. Perform initial assessment, as described above. 
Assess 
also 
for 
malnutrition, 
abdominal 
compartment 
syndrome, 
signs 
of 
shock, 
electrolyte imbalance. 
2. Perform abdominal ultrasound to assess the 
presence or absence of free fluid. Particulate free 
fluid is more concerning for thick purulence or 
succus. 
3. Insert a nasogastric tube and a urinary catheter. 
Administer IV fluid for resuscitation, antibiotics, 
correct electrolyte abnormalities, and transfuse if 
needed (we prefer a hemoglobin >8g/dL / 
Hct>24%). 
4. Obtain surgical consent by explaining to the 
patient the importance of the surgery needed, the 
risks and benefits, and the possibility of an 
ostomy. 
5. General endotracheal anesthesia: the patient is at 
risk for circulatory collapse during induction if 
not sufficiently resuscitated. Surgical safety 
checklist with time out is performed before the 
start of the surgery. 
6. A vertical midline incision is made, passing to 
the left of the umbilicus to leave room for a right 
lower quadrant ostomy if necessary. 
7. Aspirate the purulence or succus and perform the 
initial washout  
8. Survey the abdomen, looking especially for any 
gallbladder 
necrosis 
or 
terminal 
ileum 
perforations. 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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The gallbladder must be examined for perforation or necrosis. 
In this photo, the thickened exudate has been peeled off to allow 
inspection of all of its intraperitoneal surface.  
 
9. Gently remove any adherent exudate that is easy 
to remove, making sure to not cause serosal tears. 
Methodically examine all of the small intestine 
from the duodenojejunal junction (ligament of 
Treitz) 
to 
the 
ileocecal 
valve. 
Typhoid 
perforations and pre-perforations can be multiple, 
so this thorough inspection of all the small 
intestine is critical to not miss a pre-perforation 
or perforation under the exudate. 
 
Inflammatory exudative “peel” on the small bowel. This should 
be removed so that the entire surface of the small bowel can be 
inspected, especially the region near the ileocecal valve.  
 
 
A surgeon gently removes the exudative “peel” with a sponge 
while examining the bowel.  
 
10. Identify the perforation and measure the location 
from the ileocecal valve for documentation and 
repair planning. 
 
Decompress the small bowel by removing stool through the 
perforation. This facilitates pressure-free closure of the 
abdomen and removes traditional herbal remedies that have 
been administered previously, that might be harmful to the 
patient. The traditional medication usually causes hard and 
thick succus and can lead to delayed return of bowel function 
after surgery. 
 
11. Perform full thickness debridement of any 
necrotic tissues at the edges of the perforation site 
and debride back to healthy bleeding mucosa. 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Dusky or necrotic tissue should be sharply debrided prior to 
closure.  
 
12. Repair the perforation in two layers.  The first 
layer is repaired with a running absorbable 3-0 
suture (such as Vicryl). We prefer the Connell 
stitch for this layer, as shown below. The repair 
is performed in a transverse orientation, not 
longitudinally, to avoid a stricture during healing.  
 
Diagram of a Connell stitch. Source: Pal M and 
Bandyopadhyay S, DOI: 10.4172/2329-9126.1000125  
 
 
Closure of the perforation site in two layers, starting with a 
Connell running stitch 
 
 
Completed first layer of the closure 
 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Adding a second layer using interrupted seromuscular 
(Lembert) stitches making sure not to enter into the mucosa.  
 
Completed second layer 
 
13. Irrigate the abdominal cavity quadrant by 
quadrant. We usually use multiple liters of warm 
normal saline. Make sure to clean well in the 
bilateral subdiaphragmatic spaces and remove 
exudative “peel” over the right and left lobes of 
the 
liver, 
to 
avoid 
reoperation 
for 
a 
subdiaphragmatic abscess. Make sure to extend 
your incision as necessary if you cannot visualize 
these spaces well for adequate source control.  
 
Washing and removing exudative “peel” found superior and 
lateral to the liver 
 
 
Irrigating the pelvis after primary repair and removing the 
exudative peel to prevent postoperative abscess formation. 
 
 
Irrigating the left upper quadrant. Be gentle when cleaning 
superior and lateral to the spleen to avoid bleeding. 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
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14. Make sure that the nasogastric tube is in a good 
position and that the stomach is decompressed 
before closing the abdomen, to decrease the risk 
of immediate postoperative aspiration. 
15. Determine whether to return for further washouts 
of the abdomen if extensive purulent or succus 
contamination was seen at this first surgery. If 
further washouts are needed, close the skin only 
(not fascia) with a running nonabsorbable stitch 
(Nylon 3-0) and return within 48 hours. See the 
chapter on Temporary Abdominal Closure. 
16. If no additional operations are needed, close the 
fascia with slowly absorbing suture (such as PDS 
or in our center #1 Vicryl) and strongly consider 
placing retention sutures (1-0 Nylon) for those 
who have malnutrition or who have had multiple 
repeat washouts- both of these groups of patients 
are at risk of fascial dehiscence. See the chapter 
on Closure of Laparotomy Dehiscence for more 
details on full thickness retention sutures.  
Sometimes a closed suction drain is placed if 
there is concern about a large amount of 
contamination in one particular quadrant. We do 
NOT routinely recommend a drain placed in each 
patient, as we cannot drain all the abdominal 
cavity, if all the abdominal cavity had purulence 
or succus. The key is large volume saline 
irrigation and meticulous attention to ensuring no 
major exudate and purulence is still present 
before fascial closure. If you do decide to place 
an abdominal drain, place it through the left 
abdominal wall as far lateral as possible, to allow 
future right lower quadrant ostomy placement if 
needed during a subsequent operation.  
 
 
Simple horizontal external retention sutures placed, but not tied, 
while closing the fascia with a running stitch. 
 
 
Final appearance of the skin after abdominal closure with 
running fascial suture supplemented with simple horizontal 
external retention sutures. We have found that latex urinary 
(Foley) catheter pieces often cause less skin damage than 
intravenous catheter tubing. 
 
17. If need for a repeat washout was determined at 
the first surgery, the patient returns in 48 hours 
and there is close assessment of the repair site to 
ensure it is still intact without leak and that there 
are no new perforations or new areas of pre-
perforation.  
18. The patient will need to continue IV antibiotics 
for 7 days (ceftriaxone and metronidazole) and 
transition to oral antibiotics such as ciprofloxacin 
and metronidazole when tolerating an oral liquid 
diet. In areas where resistance to ciprofloxacin is 
high, consider substituting azithromycin. 
 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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ILEOCECECTOMY, END ILEOSTOMY, AND 
MUCUS FISTULA 
Indications: 
This procedure is recommended for those 
patients with multiple perforations (usually more 
than 3) or especially one close to the ileocecal valve 
with concern for viability of this tissue (usually 
within 3 to 5 cm of the ileocecal valve). Even one 
perforation 
close 
to 
the 
valve 
with 
high 
contamination and friable bowel would lead to 
consideration of an ostomy or a resection with 
anastomosis. 
An anastomosis is not recommended in 
patients with any of the following: hemodynamic 
instability during the case, malnutrition (especially 
with a Z score ≥-3: See Nutrition in the Surgical 
Patient), high contamination, and/or friable tissue 
with multiple other pre-perforations. 
 
Multiple small bowel perforations (arrows) with the most distal 
(Black arrow) too close to the ileocecal valve to undergo 
primary repair. 
 
Steps: 
1. The procedure is started the same as a primary 
repair (as described above). 
2. Identify the extent of your resection of the small 
bowel making sure to look for not only full 
thickness perforations, but also pre-perforations 
that could later perforate.  
3. Start with resection of the proximal small bowel 
working distally to the ileocecal valve.  
 
Creating a “window” with a clamp in the mesentery adjacent 
to the planned proximal division of the small bowel  
 
 
Dividing the proximal bowel between a non-crushing bowel 
clamp proximally (bottom clamp) and a heavy clamp (Kocher, 
top clamp) distally. 
 
4. Divide the mesentery of the small bowel to be 
resected, starting at the divided bowel and 
proceeding to the ileocecal valve. Be sure to not 
go too close to the root of the mesentery, as there 
are often enlarged lymph nodes here and it can be 
difficult to have good tissue to ligate. 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Dividing the small bowel mesentery down to the level of the 
ileocecal valve between clamps, then using ties to ligate the 
mesentery. Note that the division is close to the bowel, where 
the mesentery is less thickened with inflammatory lymph tissue. 
 
5. Divide the ascending colon adjacent to the cecum, 
clamping and tying any remaining mesentery, 
and remove the specimen from the operative field. 
 
The diseased ileum and cecum now removed. Non-crushing 
bowel clamps are on the distal ileum and the ascending colon, 
with hemostats on the small bowel mesentery.  
 
6. Mobilize the end ileostomy and mucus fistula to 
be able to bring them through the abdominal wall 
without tension. 
7. Create an opening in the abdominal wall to the 
right of the umbilicus for the end ileostomy and 
mucus fistula. We often do our ostomies at the 
lateral edge of the rectus or even lateral to the 
entire rectus just so that we have enough 
distance between the midline closure and the 
ostomy (especially in malnourished children, so 
there is enough room for retention sutures and 
packing of the skin if needed.) Creating the 
ostomy too close to the midline wound leads to 
difficulty in fitting the ostomy appliance and 
painful excoriation of the skin underneath it due 
to leakage. 
 
Mobilization of the two divided ends of bowel. The ileum will 
usually reach the anterior abdominal wall without much 
dissection, but the ascending colon (in the upper non-crushing 
bowel clamp) usually needs to be mobilized further along its 
right retroperitoneal attachments.  
 
8. Copiously irrigate the abdominal cavity, as it can 
be harder to irrigate after the ostomy is created. 
9. Create an opening in the abdominal wall to the 
right of the umbilicus for the end ileostomy and 
mucus fistula. Sharply divide fascia and bluntly 
divide muscle to make a hole through the 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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abdominal wall. In an adult, this hole should 
easily admit two fingers. 
 
Create an ostomy directly to the right of the umbilicus by 
grasping skin here and cutting horizontally just below the 
clamp. Note that we prefer the right mid-abdomen rather than 
the right lower quadrant, to allow the ascending colon mucus 
fistula to reach the site easily.  
 
10. Pass both the terminal ileum and the ascending 
colon through the ostomy site. Both should sit 
easily in their location and not be under excess 
tension.  
11. Close the fascia and skin of the midline incision, 
or the skin alone if performing a temporary 
abdominal closure. 
12. Secure the stoma to the fascia of the abdominal 
wall with absorbable suture (3-0 Vicryl). Then 
“mature” both limbs of the stoma by suturing the 
mucosa circumferentially to the skin with 
interrupted absorbable sutures. The first four 
circumferential sutures evert the bowel and are 
placed as below: 
 
For ileostomy maturation, the cut end of the small bowel is 
intentionally brought out 3-4cm above the level of the skin. 
Then, four sutures are placed at four corners of the ostomy. 
These are through the skin, then the serosa, then the mucosal 
edge, as shown above. The effect is to evert the ostomy so that 
it sticks 2cm above the skin level. This is especially important 
for an ileostomy, as the ostomy appliance can more easily be 
crafted to avoid contact between the enteric succus and the skin.  
 
 
“Mature” the ostomy by suturing the edges of both limbs to the 
skin circumferentially, starting with four sutures as shown 
above.  
 
13. Cut and shape the ostomy appliance to fit the 
ostomy. Clean the skin thoroughly and make sure 
it is dry, then clean it again with alcohol and 
allow that to dry. If any moisture wants to leak 
out of the ostomy onto the skin, prevent it from 
doing so; these measures help the appliance to 
stick to the skin as much as possible.  
If you are using a “wafer” and detachable bag, 
cut the wafer so that there is a small amount of 
space between it and the ostomy, so it does not 
“strangulate” the ostomy. Do not cut this hole too 
big, or else succus from the small bowel will 
come in contact with the skin and cause 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
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excoriation, making future placement of ostomy 
appliances more difficult.  
 
Correctly sized ostomy wafer, with minimal space between the 
cut edges and the ostomy itself.  
 
 
Ostomy creation and management of output 
can be very challenging, especially for patients with 
limited resources. Use loperamide to thicken the 
ileostomy output and oral rehydration solutions to 
replace fluid losses from an ileostomy.  
 
Pitfalls: 
• Anastomotic Leak: At the initial operation, do 
not attempt a primary repair or an anastomosis in 
a patient with malnutrition, high levels of 
contamination, or inflamed and friable bowel. If 
any of these are present, an anastomotic leak is 
likely to develop even with excellent surgical 
technique. This is not the same scenario as 
operating on a young healthy patient with a 
traumatic small bowel perforation. 
 
Anastomotic 
leak 
after 
ill-considered 
primary 
bowel 
anastomosis for typhoid perforation.  
 
These patients will present with their leak either 
acutely with postoperative peritonitis (often with 
a fascial dehiscence) or with a more delayed 
enterocutaneous or entero-atmospheric fistula. 
Absolutely do not attempt another primary 
repair or resection with another anastomosis, or 
just adding additional sutures over the leak. 
Proceed with an ostomy. See Recognizing 
Postoperative 
Intra-Abdominal 
Sepsis 
and 
Management of the Open Abdomen and Enteric 
Fistula for more on decision-making and 
management in these difficult situations.  
 
Malnourished patient with an entero-atmospheric fistula who 
presented to our hospital after attempt at anastomosis at 
another hospital. Note also that the original abdominal incision 
was likely not large enough to adequately perform the steps 
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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outlined in this chapter, including complete assessment and 
mobilization of the bowel and thorough inspection, irrigation 
and debridement.  
 
• Intraabdominal Abscess: Make sure to irrigate 
the abdominal cavity well, especially in the 
subdiaphragmatic area. If inflammatory exudate 
and succus are left behind, these may act as a 
nidus for an abscess to develop in the future.  
 
Left upper quadrant postoperative abscess with 
purulent drainage superior and lateral to the spleen. 
 
• Fascial Dehiscence: Make sure to consider 
reoperating on a patient who develops a fascial 
dehiscence within the first two weeks of surgery. 
Often there is an underlying abscess or leak in 
these patients. The dehiscence can lead to an 
increased risk for an enterocutaneous fistula if 
treated non operatively. In malnourished patients, 
place retention sutures pre-emptively during 
fascial closure, as described above.  
 
Fascial dehiscence (despite placement of a few retention 
sutures) with loops of exposed bowel in the wound. Note also 
the closeness of the ileostomy to the midline wound: as 
described in the text, this would make the ostomy appliance 
more difficult to fit and potentially expose the skin or wound to 
enteric succus.  
 
• Ostomy complications: Make sure to leave 
enough length on the end ileostomy or mucus 
fistula to ensure healthy perfused ostomies. The 
mucus fistula may be either small bowel or colon, 
depending on what part of the bowel was resected, 
but under all circumstances it must pass through 
the abdominal wall without being strangulated 
and reach the skin without tension. Make sure to 
examine the ostomy every day to ensure that it is 
pink and viable, and that there is no dehiscence 
of the skin around the ostomy. 
 
Ischemia of the mucus fistula.  Make sure to consider causes 
such as: excess tension, devascularization during mobilization, 
ischemia related to pressors for severe sepsis,  or a defect in the 
muscle that is too tight.  
Surgical Procedures for Severe Typhoid Fever 
Katherine Shafer, Brad-Lot Igiraneza, Yakoubou Sanoussi 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Dehiscence of the ostomy, with the potential for succus to enter 
into the subcutaneous space (causing cellulitis or subcutaneous 
abscess) or into the abdominal space (causing intra-abdominal 
abscess). 
 
Photo credits: Dr. Brad-lot Igiraneza, Issiakou 
Boube, Dr. Katherine Shafer, Dr. Andrew Avery, Dr. 
Gracious Sankhulani 
 
Katherine Shafer MD FACS  
Brad-Lot Igiraneza, MBBS 
Yakoubou Sanoussi FWACS FCS(ECSA) 
 
Galmi Hospital 
Niger  
 
January 2024 
