Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Labarotomy
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Peritonitis
Stomac and duodenum
Gallbladder
Appendix
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
Labarotomy
 




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

:: The gallbladder
:: Stomach
:: Duodenum
:: Spleen
:: Liver.

Use a lower abdominal incision for patients with:

:: Intestinal obstruction
:: Pelvic problems.

Make an incision from the upper to lower abdomen to:

:: 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).
Figure 6.1
Figure 6.1
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).
Figure 6.2
Figure 6.2
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).
Figure 6.3
Figure 6.3
Figure 6.4
Figure 6.4
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.
Figure 6.5
Figure 6.5
6 Examine the abdominal contents to confirm the diagnosis.

Chart
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.
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).
Figure 6.6
Figure 6.6
Figure 6.7
Figure 6.7
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.

Figure 6.8
Figure 6.8
Figure 6.9
Figure 6.9
Figure 6.10
Figure 6.10



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  Kep Points  
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


Most abdominal emergencies initially present for care at the district hospital and preparations for diagnosis and resuscitation should be in place there



 
Appendectomy, drainage of abdominal and pelvic abscesses, small bowel anastomosis, colostomy and elective herniorrhaphy capability should be available at district hospitals


 
Laparotomy is used to expose the abdominal organs so as to institute definitive diagnosis and treatment of abdominal trauma and acute abdominal conditions



 
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


 
In an emergency, a midline incision is the incision of choice

 
A general anaesthetic should be given for an upper midline incision; spinal anaesthesia may be used for low midline incisions in the stable patient

 
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.