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Use
the laparotomy technique to expose abdominal organs. It also
allows confirmation or correction of the preoperative diagnosis
in a patient presenting with an acute abdomen. Avoid laparotomy
in pancreatitis. Be thoroughly familiar with the midline incision,
which is simple, causes relatively little bleeding and can
be performed rapidly, closed quickly and extended easily.
Make an incision in the upper abdomen to expose
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The
gallbladder |
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Stomach |
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Duodenum |
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Spleen |
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Liver. |
Use
a lower abdominal incision for patients with:
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Intestinal
obstruction |
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Pelvic
problems. |
Make
an incision from the upper to lower abdomen to:
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Evaluate
all abdominal organs in a trauma laparotomy. |
Midline incision
| 1 |
With
the patient in the supine position, prepare the skin
and drape the area from the level of the nipples to the
pubic region and to the flank on either side. Incise
the skin in the midline between the xiphoid process and
the umbilicus. Extend the incision below the umbilicus
as needed for additional exposure (Figure
6.1). |
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| 2 |
Incise
through the subcutaneous layer and to the loose tissue
over the linea alba. Control bleeding with gauze swabs
held against the wound edge and ligate persistent bleeding
points. Display the linea alba with its longitudinal
line of decussating fibres and incise it directly in
the midline, exposing the extraperitoneal fat and the
peritoneum (Figure 6.2). |
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| 3 |
Exercise
care if the incision is through a previous laparotomy
scar as the gut may be adherent to the undersurface of
the abdominal wall and liable to injury. Clear the extraperitoneal
fat laterally with blunt dissection, securing the vessels
as necessary. |
| 4 |
Lift
the peritoneum, making it into a “tent” by
holding it with forceps on either side of the midline.
Squeeze the tent between the fingers and thumb to free
any gut on the undersurface, and make a small opening
with a knife (Figures 6.3, 6.4). |
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| 5 |
If
the peritoneum opens readily, steady the undersurface
with the index and middle fingers and extend the opening
with scissors (Figure 6.5). Extend the peritoneal incision
the full length of the wound. |
|
| 6 |
Examine
the abdominal contents to confirm the diagnosis.
|
| 7 |
Systematically
examine the abdominal organs for signs of injury or other
abnormality:
| • |
Begin
examination with the small intestine at the ligament
of Trietz, progress along its entire length and
then examine the large intestine and rectum |
| • |
In
the lower abdomen, examine the bladder and uterus |
| • |
In
the upper abdomen, examine the stomach, duodenum
and spleen |
| • |
Visualize
and palpate the liver and diaphragm and finally
examine the retroperitoneum including the pancreas
and kidneys |
| • |
Plan
the appropriate surgical procedure after you have
made a complete assessment. |
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| 8 |
Carry
out the appropriate procedures as indicated by the pathological
findings. These techniques are explained in the following
sections. |
| 9 |
At
the end of the operation, close the wound in layers.
Use several pairs of large artery forceps to hold the
ends and edges of the peritoneal incision. Close the
peritoneum with a continuous 0 absorbable suture on a
round-bodied needle (Figure 6.6).
Maintaining the intestine
within the abdominal cavity during the closure is often
a problem. If needed, use a muscle relaxant medication
or a malleable metal spatula placed under the peritoneum
(Figure 6.7). |
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| 10 |
Close
the linea alba with interrupted No. 1 polyglycolic
acid or continuous monofilament nylon on a round or
trocar needle (Figure 6.8). If the wound is contaminated
or infected, use loosely placed No. 1 nylon sutures.
Close the skin with interrupted 2/0 stitches, keeping
the sutures 1 cm apart and 1 cm from the wound edge
(Figure 6.9). Apply a 2 layer gauze dressing.
If closing the abdomen is difficult, check the adequacy of the anaesthesia
to reduce abdominal wall tension and empty the stomach with a nasogastric tube.
An alternative to multi-layer closure is a simple all-layer retention suture
for closure. Retention sutures are indicated in patients debilitated as a result
of malnutrition, old age, advanced cancer or HIV/AIDS when healing is likely
to be impaired. Monofilament nylon is a suitable material. Insert retention
sutures through the entire thickness of the abdominal wall before closing the
peritoneum, leaving them untied at first (Figure 6.10). If it is impossible
or very difficult to close the linea alba due to excess intra-abdominal pressure,
it is acceptable to close the skin only. Refer the patient to a surgical specialist
when stabilized.
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Patients with life threatening abdominal
conditions, including trauma, should be given life saving
treatment at the district hospital, particularly if they
are likely to die before arrival at a referral hospital
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Most
abdominal emergencies initially present for care at
the district hospital and preparations for diagnosis
and resuscitation should be in place there
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Appendectomy,
drainage of abdominal and pelvic abscesses, small bowel
anastomosis, colostomy and elective herniorrhaphy capability
should be available at district hospitals
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Laparotomy
is used to expose the abdominal organs so as to institute
definitive diagnosis and treatment of abdominal trauma
and acute abdominal conditions
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At
the district hospital, non-specialist practitioners
with specific training can capably perform laparotomy
and, on occasion, will perform laparotomy on complex
cases in order to save lives
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In an emergency, a midline incision is the incision of
choice
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A general anaesthetic should be given for an upper midline
incision; spinal anaesthesia may be used for low midline
incisions in the stable patient
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If there is doubt about the diagnosis, you may use a
short paraumbilical incision and extend it up or down in
the midline, as indicated.
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