EXPLORATORY

LAPROTOMY

Finding what's wrong?

Introduction

Eyes first and most; fingers next and little; tongue last and least.

• Yes even in the era of CT and MRI abdomen can be

FULL OF SURPRISES.

• Usually, the surgeon speculates about the predicted diagnosis but always remains ready for the unexpected.

Objectives

• Learn the correct operative sequence.

• Review what to do once you get inside.

• Organize your exploration.

• Understand basic exposure techniques.

• Summary points

• A laparotomy is a surgical procedure involving a incision through the abdominal wall to gain access into the abdominal cavity.

• It is also known as celiotomy

Explorative Therapeutic

Need for operation “+”Pre op definitive diagnosis ”-”

Need for operation “+”Pre op definitive diagnosis ”+”

• Acute Abdomen due to:

Trauma (Blunt & Penetrating).

Infections (Acute & Chronic).

• Removal of Foreign Bodies like dislodged copper T.

• Staging laprotomy in malignancy.

• Abdominal apoplexy.

Indications :

Pre op preparation

• 5 Tube Principle:

1- Intravenous Line

2- Nasogastric tube

3- Urinary Catheter.

4- Endotracheal tube.

5- CVP line in intensive monitoring.

• Preop Antibiotics.

• Arrangement of blood & Blood products.

Abdominal exploration.

Traumatic abdomen

1. Primary survey

2. Secondary survey

Hemodynamic stability achieved

Infected abdomen.

1. Source control. (character of fluid determines)

2. Damage control. (peritoneal toileting)

Abdominal exploration.

Surgical access into abdominal cavity

• Midline.

• Para median.

• A long transverse muscle-cutting (Infants).

Patient with previous midline incision.

• If at all possible, an attempt should be made to enter the abdomen above or below the previous incision, in an area less likely to have adhesions.

• If not possible alternatively chevron incision should be considered.

Gaining Access

• “Hey diddle diddle, right down the middle”

• Three passes

• Skin and subcutaneous tissue

• Land on the linea alba

• Divide the fascia, expose preperitoneal fat

• Push through the peritoneum just cranial to umbilicus

• Cut peritoneum, divide falciform ligament

Once Inside…

• Evisceration

• Up and to the right, remove clot/blood

• Blunt trauma

• Empiric, yet directed packing

• Penetrating trauma

• Direct hemorrhage control

• Exsanguinating hemorrhage

• Supraceliac aorta

Empiric Packing in hemoperitoneum.

• Right upper quadrant—Above and below liver.

• Right gutter

• Left upper quadrant—Above and medial to spleen

• Left gutter

• Pelvis

• Survey solid organs, look back at the eviscerated bowel, start making decisions…

Survey the Battlefield

Divide the peritoneal cavity at the transverse mesocolon

• Supramesocolic

• Liver, stomach, spleen

• Inframesocolic

• Small bowel, colon, bladder, female reproductive organs

Inframesocolic Exploration

• Lift transverse mesocolon cranially.

• Run the gut

• Visualize the pelvis and female reproductive organs

The posterior portions of the transverse mesocolon, hepatic, and splenic flexures are common sites for

missed injuries

Supramesocolic Exploration

• Move transverse colon caudal.

• Inspect and palpate

• Liver, GB, right kidney

• Stomach to GE junction and diaphragms

• Duodenum

• Spleen, left kidney

• Lesser sac.

Pathway of exploration• The exploratory procedure used by surgeons differs, but

should be absolutely consistent for any one operator.

Retroperitoneum exploration.

• Clinical suspicion of retroperitoneal pathology.

• Limited exposure of relevant structures—medial visceral rotation

Exploration of retroperitoneum

• Kochers maneuver. Facilitates exploration behind the duodenum and pancreas.

• Cattle Braasch maneuver. Facilitates exploration of IVC, SMV, Rt renal vessels, abdominal aorta.

• Mattox maneuver. Facilitates exploration of Abdominal aorta, left renal veins.

Peritoneal toileting or debridement.

• The goal of peritoneal toileting is mechanical removal of as much as possible of contaminant from the abdominal cavity.

• There is no scientific evidence that intra-operative peritoneal lavage reduces mortality or infective complications in patients receiving adequate systemic antibiotics.

• Peritoneal irrigation with antibiotics is not advantageous.

• Should you choose to remain a dedicated irrigator, remember to suck out all the lavage fluid before you close

• It is impossible to effectively drain the free peritoneal cavity.

• Drains provide a false sense of security and reassurance.

• Times have changed

when in doubt, drain

WHEN IN DOUBT, DON’T DRAIN

Drainage of abdomen.

Drainage of abdomen.

• Their use should be limited

Evacuation of an “established” abscess.

To allow escape of potential visceral secretions (e.g., biliary, pancreatic)

Rarely, to establish a controlled intestinal fistula when the latter cannot be exteriorized

• CLOSED ACTIVE (low pressure) drains are preferable.

Before landing

• TAKE OFFS ARE OPTIONAL, LANDINGS ARE MANDATORY

Abdominal closure

• Permanent closure.

• “MASS CLOSURE”

• Using non absorbable/ delayed absorbable sutures.

• 1cm wide bites.

• Max 1cm gap between two bites.

• Ideally suture length to wound length ratio 3:1

• Subcutaneous sutures are of no value.

• Temporary closure/open abdomen.• Commonly done in DCS.

• Fascial layer left open with temporary occlusive dressings.

• Secondary closure may be done after physiological stability is achieved.

Complications

Immediate complications:

• Abdominal compartment syndrome

• Paralytic ileus

• Intra-abdominal collection or abscess.

• Wound infections.

• Abdominal wall dehiscence.

• Pulmonary atelectasis.

• Enterocutaneous fistula.

• Pseudocellulitis (post op air entrapment).

• Acute dermal gangrene.

Delayed complications :

• Adhésive intestinal obstruction.

• Incisional hernia.

• With advent of wide variety of sophisticated investigations exploratory laparotomy became a rare entity.

• Nowadays most exploratory laparotomies are performed in the emergency situation.

• Whenever possible, however, an attempt should be made to arrive at an accurate, or at least a provisional, diagnosis before surgery.

Summary

References

• Farquharsons textbook of operative surgery.

• Hamilton & baileys book of emergency surgery.

• Scheins book of emergency surgery.

• Internet.