Pneumoperitoneum

In the OR

Find the hole, control contamination, then choose the safest reconstruction.

Systematically identify the source of perforation rather than assuming the first abnormal segment is responsible
Assess contamination burden, tissue quality and the degree of local or diffuse peritonitis
Resect or repair the perforated source according to etiology and tissue viability
Choose anastomosis, diversion or damage-control strategy based on physiology, contamination and operative findings
Irrigate/remove gross contamination as appropriate and ensure adequate source control

After the OR

Monitor closely for persistent sepsis, abscess, leak, organ dysfunction and ileus.
Tailor antimicrobial duration to source control, contamination and clinical response rather than continuing indefinitely by default.
Review pathology when perforation may be related to malignancy or inflammatory disease.
Plan ostomy education and reversal discussion when diversion was required.