Surgical Managment

Exploratory Laparotomy Definition A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside of the abdominal cavity.

Purpose Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. he procedure may be recommended for a patient who has abdominal pain of un!nown origin or who has sustained an in"ury to the abdomen. #n"uries may occur as a result of blunt trauma $e.g., road traffic accident% or penetrating trauma $e.g., stab or gunshot wound%. &ecause of the nature of the abdominal organs, there is a high ris! of infection if organs rupture or are perforated. #n addition, bleeding into the abdominal cavity is considered a medical emergency. Exploratory laparotomy is used to determine the source of pain or the extent of in"ury and perform repairs if needed. Laparotomy may be performed to determine the cause of a patient's symptoms or to establish the extent of a disease. (or example, endometriosis is a disorder in which cells from the inner lining of the uterus grow elsewhere in the body, most commonly on the pelvic and abdominal organs. Endometrial growths, however, are difficult to visualize using standard imaging techni)ues such as x ray, ultrasound technology, or computed tomography $* % scanning. Exploratory laparotomy may be used to examine the abdominal and pelvic organs $such as the ovaries, fallopian tubes, bladder, and rectum% for evidence of endometriosis. Any growths found may then be removed. Exploratory laparotomy plays an important role in the staging of certain cancers. *ancer staging is used to describe how far a cancer has spread. A laparotomy enables a surgeon to directly examine the abdominal organs for evidence of cancer and remove samples of tissue for further examination. +hen laparotomy is used for this use, it is called staging laparotomy or pathological staging. Some other conditions that may be discovered or investigated during exploratory laparotomy include,

cancer of the abdominal organs peritonitis $inflammation of the peritoneum, the lining of the abdominal cavity%

appendicitis $inflammation of the appendix% pancreatitis $inflammation of the pancreas% abscesses $a localized area of infection% adhesions $bands of scar tissue that form after trauma or surgery% diverticulitis $inflammation of sac-li!e structures in the walls of the intestines% intestinal perforation ectopic pregnancy $pregnancy occurring outside of the uterus% foreign bodies $e.g., a bullet in a gunshot victim% internal bleeding

Demographics &ecause laparotomy may be performed under a number of circumstances to diagnose or treat numerous conditions, no data exists as to the overall incidence of the procedure.

Description he patient is usually placed under general anesthesia for the duration of surgery. he advantages to general anesthesia are that the patient remains unconscious during the procedure, no pain will be experienced nor will the patient have any memory of the procedure, and the patient's muscles remain completely relaxed, allowing safer surgery.

Incision .nce an ade)uate level of anesthesia has been reached, the initial incision into the s!in may be made. A scalpel is first used to cut into the superficial layers of the s!in. he incision may be median $vertical down the patient's midline%, paramedian $vertical elsewhere on the abdomen%, transverse $horizontal%, -shaped, or curved, according to the needs of the surgery. he incision is then continued through the subcutaneous fat, the abdominal muscles, and finally, the peritoneum. Electrocautery is often used to cut through the subcutaneous tissue as it

During a laparotomy, and an incision is made into the patient's abdomen (A). Skin and connective tissue called fascia is divided ( ). !he lining of the abdominal cavity, the peritoneum, is cut, and any e"ploratory procedures are undertaken (#). !o close the incision, the peritoneum, fascia, and skin are stitched ($). has the ability to stop bleeding as it cuts. #nstruments called retractors may be used to hold the incision open once the abdominal cavity has been exposed. Abdominal exploration he surgeon may then explore the abdominal cavity for disease or trauma. he abdominal organs in )uestion will be examined for evidence of infection, inflammation, perforation, abnormal growths, or other conditions. Any fluid surrounding the abdominal organs will be inspected/ the presence of blood, bile, or other fluids may indicate specific diseases or in"uries. #n some cases, an abnormal smell encountered upon entering the abdominal cavity may be evidence of infection or a perforated gastrointestinal organ.

#f an abnormality is found, the surgeon has the option of treating the patient before closing the wound or initiating treatment after exploratory surgery. Alternatively, samples of various tissues and0or fluids may be removed for further analysis. (or example, if cancer is suspected, biopsies may be obtained so that the tissues can be examined microscopically for evidence of abnormal cells. #f no abnormality is found, or if immediate treatment is not needed, the incision may be closed without performing any further surgical procedures. 1uring exploratory laparotomy for cancer, a pelvic washing may be performed/ sterile fluid is instilled into the abdominal cavity and washed around the abdominal organs, then withdrawn and analyzed for the presence of abnormal cells. his may indicate that a cancer has begun to spread $metastasize%.

Closure 2pon completion of any exploration or procedures, the organs and related structures are returned to their normal anatomical position. he incision may then be sutured $stitched closed%. he layers of the abdominal wall are sutured in reverse order, and the s!in incision closed with sutures or staples.

Adhesiolysis
%P$& AD'$S(%)*S(S he abdomen is prepared and draped in a sterile fashion. A median $midline% incision is made from the subxiphoid region to the suprapubic region, with a curvilinear portion to either side of the umbilicus. #f necessary, the incision may be extended inferiorly as far as the symphysis pubis or superiorly as far as the xiphoid. #n reoperative surgery, it is advisable to enter the abdomen in virgin territory $if available% and then wor! from free space into the adhesions. #f an old midline incision exists, the new incision can retrace it in an effort to minimize scarring. After dissection through the subcutaneous tissues, the linea alba is identified and exposed over the entirety of the wound. he fascia is divided carefully and sharply with a scalpel to allow entry into the peritoneal cavity. he fascial defect is probed with a finger to detect any loops of bowel adhering to the undersurface of the abdominal wall. Any adherent bowel is bluntly swept away from the midline with the finger. he finger acts as a guide throughout this process to help prevent in"ury to the bowel and other intra-abdominal structures.

After the abdominal cavity is opened, the adhesions to the abdominal wall lateral to the facial incision are ta!en down and the viscera allowed to fall posteriorly so as to provide wor!ing space. he !eys here are patience and, again, wor!ing from !nown to un!nown. #t is important to start where dissection is easy and the anatomy obvious, and then wor! into the more difficult and scarred areas. .ften, wor!ing with gentle traction on the adhesions to elucidate the anatomy of the bowel loops proves relatively easy. his may re)uire wor!ing proximally and distally to the area of concern before approaching the clear area of obstruction. he clear area of obstruction will have dilated bowel proximally and decompressed bowel distally. All )uadrants of the abdomen are surveyed for any occult gross pathology or fluid collections. he entire visceral tract, from stomach to rectum, is examined. he ligament of reitz is identified, and the small bowel is run up to the terminal ileum. As the small bowel is mobilized, its viability and integrity are assessed continuously, and any problematic adhesions or tethering points are separated and ta!en down even if they do not seem to be responsible for the obstruction. .ther adhesions that mat the bowel together need not be lysed if luminal contents can be manually mil!ed through the bowel without signs of obstruction. #t is helpful to have a nasogastric tube attached to suction during the operation, and the proximal small bowel can be mil!ed in a distal-to-proximal fashion to decompress the distended bowel loops. he optimal extent of adhesiolysis remains sub"ect to debate, some believe that all adhesions should be ta!en down, whereas others believe that only the adhesions responsible for the obstruction should be separated. Any nonviable ischemic bowel is resected, and an end-to-end or end-to-side anastomosis is performed between viable, healthy portions of the bowel. 2nder circumstances in which the integrity of an anastomosis may be compromised $eg, ongoing local or regional infection, diffuse bowel ischemia, or hemodynamic instability%, a diverting ostomy is always a plausible option. #f bowel ischemia is present, a reoperation or second-loo! operation to confirm viability is a sound practice. #n women, the pelvic anatomy should be examined thoroughly to ensure that adhesions are not distorting the normal anatomic relations of the ovaries and fallopian tubes.

)APA+%S#%P(# AD'$S(%)*S(S

Laparotomy with open adhesiolysis has been the treatment of choice for acute complete bowel obstructions. 3atients who have partial obstructions, with some enteric contents traversing the obstruction, may also re)uire surgery if nonoperative measures fail. 4owever, operation often leads to formation of new intraabdominal adhesions in 56-768 of patients, which may re)uire another laparotomy for recurrent bowel obstruction in the future. Laparoscopic adhesiolysis was first described by a gynecologist for the treatment of chronic pelvic pain and infertility.#n the early days of laparoscopy, previous abdominal surgery was a relative contraindication to performing most laparoscopic procedures. Laparoscopic surgery to relieve bowel obstructions was not routinely performed. 4owever, in 5995, &astug et al reported the successful use of laparoscopic adhesiolysis for small bowel obstruction in one patient with a single adhesive band. Since then, many case series have documented this techni)ue. Advanced technology with high-definition imaging, smaller cameras, and better instrumentation have allowed for an increasing number of adhesiolysis to be performed laparoscopically with good outcomes. he laparoscopic approach provides patients with the following benefits, $5% less postoperative pain, $:% decreased incidence of ventral hernia, $7% fewer wound complications, $;% reduced recovery time and return of bowel function, and $<% shorter hospital stay. #t also has been shown to decrease the incidence, extent, and severity of intra-abdominal adhesions as compared to open surgery, hence potentially reducing the rate to recurrent adhesive small bowel obstruction.=>? (ndications 3atient selection is important in the success of the procedure. Laparoscopic adhesiolysis has a lot of potential advantages, but only if it is performed in patients best suited for the procedure. Laparoscopic adhesiolysis is indicated in the following patients, 3atients with a complete small bowel obstruction or partial small bowel obstruction not resolving with nonoperative therapy, but without signs of peritonitis or bowel perforation or ischemia 3atients with resolved bowel obstruction but with history of recurrent, chronic small bowel obstruction demonstrated by contrast study #ontraindications Laparoscopic adhesiolysis are only for a selected number of patients. *ontraindications to this procedure are the following, Acute perforation and peritonitis, re)uiring bowel resection and handling of severely inflamed organs Massive abdominal distention that precludes insufflation and a sufficient wor!ing space during laparoscopy.

4emodynamic instability 3atients unable to tolerate pneumoperitoneum due to severe comorbid conditions of the heart and lung Surgeon not trained to do this procedure Anesthesia @eneral anesthesia is re)uired for all cases. 3aralysis is needed to distend the abdomen. #n rare cases, high spinal anesthetics may be used. $,uipment At least : video monitors are re)uired. Additionally, one needs to be prepared to convert to an open procedure, so a ma"or abdominal tray should be in the room. he laparoscopic instruments needed included the following, 7-< trocars Angled laparoscopes $76 or ;< A% Laparoscopic bowel graspers Laparoscopic sheers Laparoscopic energy dissector of the surgeon's preference Positioning 3atients are placed in supine position with both arms tuc!ed. 3reoperative antibiotics are given in case an enterotomy or bowel resection is needed. 3reoperative deep vein thromboembolism prophylaxis is re)uired. 4eparin, low molecular weight heparin, and0or se)uential E1s should be used.

A nasal0orogastric tube is placed if not already present. A (oley catheter should be placed to decrease the bladder size and maximize room to wor!. 3atients should be strapped and secured to the bed so they can be placed in rendelenburg with left side down to allow visualization of the cecum and to run the bowel, steep rendelenburg to evaluate the pelvis, or reverse rendelenburg to evaluate the upper abdominal cavity. !echni,ue &ecause most patients have undergone previous abdominal surgery, extra care must be ta!en in placing the first trocar and establishing pneumoperitoneum. #deally, the initial trocar should be placed <-56 cm away from the patientBs previous scar. he 4assan, or open techni)ue, is preferred because it is generally a safer method for accessing the abdominal cavity, especially when dealing with dilated bowel loops and adhesions. !rocar placement .nce the first trocar is placed, the goal is to provide ade)uate visualization and wor!ing space in order insert the remaining trocars A minimum of 7 trocars are used. 1epending on the available laparoscopes, one can use three <-mm trocars or one 55-mm trocar for the camera, and two <-mm trocars for the laparoscopic instruments. @ood triangulation should be planned based on the planned site of dissection. Additional trocars should be placed as needed. 1issection Adhesion to the abdominal wall should be ta!en down first using laparoscopic scissors. #dentifying the white line where the abdominal wall peritoneum meets the adhesions facilitates dissection in a bloodless plane. #f patients have a ventral hernia or hernias, gentle pressure can be placed on the external abdominal wall to allow the retraction and visualization of the bowels attached to the hernia sac. &lunt and sharp dissection is preferred to using electrocautery because the heat can be transmitted to ad"acent bowel and can cause thermal in"ury and perforation. Energy devices may be used if ade)uate room exists along with certainty that no bowel is hidden in the adhesions.

Adhesiolysis can be safely performed if dissection is done carefully through avascular planes. Laparoscopy precludes feeling through these adhesions, so as a general rule, if you can see through it, you can cut it. #f the anatomy is still unclear despite meticulous dissection, changing the position or the angle of the camera can help in better visualizing the loops of bowels. +e cannot stress enough that the addition of additional trocars is encouraged as needed. +hen a point of obstruction is not clearly defined, the bowel should be run until all suspicious bands are removed. 2pon completion of the case, the authors run the bowel twice to ensure no missed serosal in"uries or enterotomies. hese are repaired laparoscopically in 5 layer.

LACA@E
13L is performed one of three different ways. he open techni)ue utilizes a vertical infraumbilical incision and direct visualization of peritoneal entry with a scalpel. he closed techni)ue relies on percutaneous needle access to the peritoneal cavity, followed by the insertion of a catheter using Seldinger techni)ue. he semi-open techni)ue follows the same principles of the open techni)ue except that the midline fascia is penetrated with a needle and the catheter is advanced using the Seldinger techni)ue. here is no difference in overall outcomes or rates of in"ury to visceral contents between the techni)ues . he closed method is faster, but often has more technical complications such as wire placement and inade)uate fluid return . Degardless of the techni)ue chosen, patient preparation is the same. (irst, the patient is positioned flat in the supine position. A (oley catheter and a nasogastric tube are inserted to decompress the bladder and stomach. he periumbilical area is surgically prepped and draped widely. A combination of local anesthesia and intravenous conscious sedation is used in hemodynamically normal patients. Local anesthesia alone will suffice in a hemodynamically abnormal patient. 58 lidocaine with epinephrine is used for local anesthesia to reduce the amount of cutaneous bleeding, which may lead to a false positive test. he semi-open techni)ue re)uires the periumbilical s!in to be anesthetized and a vertical midline incision is made approximately : cm below or above the umbilicus. Subcutaneous fat is dissected until the linea alba is identified. Detractors are placed to hold s!in and subcutaneous tissue laterally. he fascia is grasped with two towel clips or hemostats on either side of the midline. An 5>-guage needle is inserted at a ;<-degree angle to the fascia toward the pelvis. As the needle successfully traverses the fascia and subse)uent peritoneum, : EpopsE are often felt. (illing the needle hub with saline as the catheter is advanced is helpful in detecting peritoneal penetration. he saline will flow through the needle as the peritoneal cavity is entered. A guidewire is passed through the needle into the pelvis. he wire should pass easily with no resistance. #f the wire meets resistance, remove the needle and wire and start over. he needle is removed while !eeping the wire stable. A dilator is passed over the wire and through the fascia and subse)uently removed. (inally, the 13L catheter is introduced into the peritoneal cavity aimed toward the pelvis.

(igure 5 Ciew of the linea alba and anterior abdominal fascia following a midline infraumbilical incision for an open or semi-open approach to 13L.

(igure : +hile grasping and elevating the anterior abdominal fascia, an 5>-guage needle is inserted at a ;<-degree angle toward the pelvis. wo EpopsE are felt as the needle traverses the fascia and peritoneum.

-igure . -ollo/ing guide/ire placement through the needle, a dilator is passed through the fascia prior to placing the peritoneal catheter. A syringe is used to aspirate the peritoneal contents. #f blood flows easily into the syringe, most accept this as a positive aspirate and proceed with laparotomy. .thers suggest 56 ml of blood constitutes a positive result. #n the absence of 56 ml blood, the 13L catheter is connected to a warmed liter bag of Lactated Dingers or normal saline using standard intravenous tubing. *are must be ta!en that the tubing has no one-way valves which would not allow fluid to flow freely bac! into the #C fluid bag. +hile the fluid infuses, gently roc! the patient to allow mixing of the fluid with peritoneal contents. .nce the bag is almost empty, place it on the floor and allow the intraabdominal fluid to return. Ade)uate fluid analysis re)uires at least 768 of the original amount infused. his usually amounts to 766F7<6 ml in an adult. #n the pediatric patient, 56F5< ml0!g of fluid is infused and an ade)uate return is :6F768 of the total infusion. his fluid is sent for gram stain and analysis of the red blood cell count and white blood cell count. #t also should be grossly examined for enteric, bilious, or vegetable matter content. he wound is irrigated and only the s!in re)uires surgical closure with either sutures or staples. #f the open techni)ue is used, the incised fascia should be closed. his stitch can be placed while the fluid is infusing and secured once the catheter is removed. #f a closed techni)ue is used then no stitch is re)uired.

(igure ; After fluid is instilled, the bag is placed onto the floor to allow the intraabdominal fluid to return. 768 of the original amount of instilled fluid is re)uired for an ade)uate sample.