Diagnostic Peritoneal Lavage 

Since the time of its original description in 1965 by Root,^[1] diagnostic peritoneal lavage (DPL) continues to provide useful information in the evaluation of patients with blunt or penetrating trauma. However, the development of computed tomography (CT), which carries near comparable sensitivity and superior specificity,^[3] has limited the use of diagnostic peritoneal lavage to the diagnosis of unstable trauma patients who need immediate diagnosis of a possible intra-abdominal hemorrhage. Currently, diagnostic peritoneal lavage is mostly required for the unstable, critically injured patient.

Diagnostic peritoneal lavage is most useful in patients who are hemodynamically unstable or those with an unreliable examination who are at high risk for hollow viscus injury (HVI), particularly when CT or ultrasonography detects minimal fluid or when the patient manifests fever, peritonitis, or both. This circumstance usually occurs 6-12 hours after a hollow viscus injury.

Traditionally, diagnostic peritoneal lavage is performed in 2 steps. First, the clinician attempts to aspirate free intraperitoneal blood. If 10 mL or more of blood is aspirated, the procedure stops because intraperitoneal injury is likely. Second, if little or no blood is detected, the clinician performs a lavage of the peritoneal cavity with either normal saline or lactated Ringer’s solution and the effluent is sent for laboratory evaluation.

• Diagnostic peritoneal lavage can be used to evaluate both blunt and penetrating abdominal trauma in patients who are hemodynamically unstable or who require urgent surgical intervention for associated extra-abdominal injuries. Diagnostic peritoneal lavage can rapidly determine or exclude the presence of intraperitoneal hemorrhage. Thus, the patient with a closed head injury, the unstable patient who has been in a motor vehicle accident, or the patient with a pelvic fracture and potential retroperitoneal hemorrhage can be appropriately triaged to emergent laparotomy.
• A negative result on peritoneal aspiration allows the clinician to proceed to alternative management steps and allows the patient to forego unnecessary laparotomy. Additionally, diagnostic peritoneal lavage can be used in less emergent circumstances as a means of detecting solid or hollow viscus injury requiring laparotomy.^{[4, 5]}
• In the evaluation of patients with penetrating abdominal wounds, diagnostic peritoneal lavage provides the following:

  • Rapid determination of the presence or absence of hemoperitoneum
  • Presence of intraperitoneal injury requiring laparotomy in stable patients
  • Establishment of diaphragmatic injury
  • Rapid triage tool when the source of hemodynamic instability is unknown

• An obvious need for laparotomy is the only absolute contraindication to diagnostic peritoneal lavage.
• Prior abdominal surgery, abdominal infections, coagulopathy, obesity, and second- or third-trimester pregnancy are all relative contraindications.^[2]

• Lidocaine 1% with epinephrine, if used for local infiltration (For more information, see Local Anesthetic Agents, Infiltrative Administration.)

• A diagnostic peritoneal lavage kit, either commercially available or preassembled in hospital, contains the following (see image below): Diagnostic peritoneal lavage kit.

  • Scalpel (Nos. 11 and 15 blade)
  • Hemostats, 2
  • Alice forceps, 2
  • Toothed dissecting forceps
  • Retractors, 2
  • Syringes, 5 mL, 2
  • Syringe, 10 mL
  • Needles, 18 and 21 gauge (ga)
  • Lidocaine 1% with epinephrine
  • Warm Ringer lactate or normal saline (0.9% NaCl), 1 L
  • Intravenous bottle or bag connected to an intravenous set
  • Absorbable sutures, 4-0, and needle holder
  • Fenestrated drape

• The patient should be kept in a supine position.

• Decompression of the stomach and bladder is recommended with a nasogastric tube and Foley catheter, respectively, to prevent inadvertent gastric or bladder injury.
• Prepare the site of placement with standard skin antiseptics (eg, povidone-iodine [Betadine] or chlorhexidine), and drape the patient appropriately. Be sure to observe sterile precautions throughout the procedure.
• Liberally infiltrate local anesthesia (lidocaine 1% with epinephrine) into the area for incision and passage of the needle and catheter. See video below.

  Open diagnostic peritoneal lavage preparation.
• Using the Seldinger technique, insert a small-gauge guide needle into the peritoneal cavity in the infraumbilical midline. Pass a J-wire through the needle and direct it caudad and toward the right or left pelvic gutter. Then withdraw the needle over-the-wire, leaving the wire in place and allowing for the placement of a soft catheter into the peritoneal cavity.
• Stab the entry site of the wire with a No. 11 scalpel; this facilitates passage of the catheter through the abdominal wall. Gentle twisting or rotation of the catheter and passing it over the guidewire while aiming toward the right or left pelvic gutter is recommended to facilitate passage into the peritoneal cavity. See videos below.

  Open diagnostic peritoneal lavage incision.

  Open diagnostic peritoneal lavage dissection.

  Open diagnostic peritoneal lavage retraction.
• Withdraw the wire, leaving the catheter in place. Aspirate, followed by lavage, if necessary. The recovery of 10 mL of blood is considered positive, and the procedure is terminated. In penetrating trauma, the acquisition of lesser amounts may be meaningful because of the tendency for the diaphragm and bowel to hemorrhage minimally when injured.

  Open diagnostic peritoneal lavage catheter insertion.
• For lavage, attach intravenous extension tubing to the catheter and instill 1 L of warmed normal saline or lactated Ringer solution in adults or 15 mL/kg in children. When possible, roll or shift the patient from side to side after infusion to increase mixing.
• Then place the intravenous bag on the floor (or below abdominal level) and allow the fluid to return by gravity. It is generally accepted that the return of greater than or equal to 700 mL in the adult is adequate for interpretation. However, as little as 10-20% of the infusate may be sufficient for both gross and microscopic determinations. Only 10 mL of fluid needs to be sent to the laboratory for cell count analysis, and another 10 mL can be sent for enzyme analysis. See image below. Positive result from diagnostic peritoneal lavage.
• The infused fluid may not return or stop after a short while because of several factors. Some intravenous tubing contains a one-way valve or inadequate suction. This problem can be corrected by insertion of a needle into the second opening at the bottom of the intravenous bag for aspiration of 10 mL of air. Alternatively, the catheter may be adherent to the peritoneum. If so, gently twisting or rotating the catheter as well as applying abdominal pressure may aid flow return.
• Once enough fluid is returned, remove the catheter and close the skin with an absorbable subcuticular suture, cuticular nylon, or staple(s). See the illustration below for the complete closed technique. Closed diagnostic peritoneal lavage (DPL) technique. The guidewire (Seldinger technique) is inserted into the peritoneal cavity via the midline approach just below the umbilicus and should be aimed caudad. The wire should be directed toward the left or right pelvic gutter as it is advanced through the needle and should enter the peritoneal cavity without resistance. Next, the needle is withdrawn while stabilizing the wire, and a stab incision is made using a No. 11 scalpel adjacent to the wire. The DPL catheter is placed over the wire while using a twisting motion directed toward the right or left pelvic gutter and advanced into the peritoneal cavity.

• Routine bile staining, Gram stain, and microscopy to identify vegetable fibers are rarely productive and of untested accuracy.

• Local or systemic infection, hematoma (occurs in < 0.3% of cases)^{[6, 7]}
• Intraperitoneal injury
• False-positive results from insertion through iatrogenic misadventure, placement of the catheter through an abdominal wall hematoma, inadequate hemostasis, or bleeding from the penetrating abdominal wall injury
• Unnecessary laparotomy (This may occur if hemoperitoneum is detected in a hemodynamically stable patient.)
• Potential failure to recover lavage fluid because of the following:

  • Inadvertent placement of the catheter into the preperitoneal space
  • Compartmentalization of fluid by adhesions
  • Obstruction of fluid outflow (eg, by omentum)
  • Fluid pooling in the intrathoracic cavity due to diaphragmatic injury

Table 1. Diagnostic Peritoneal Lavage Red Blood Cell Criteria (per mm³)^[8] (Open Table in a new window)

Table 2. Diagnostic Peritoneal Lavage Non-Red Blood Cell Criteria^[9] (Open Table in a new window)