Exploratory Laparotomy

By definition, an exploratory laparotomy is a laparotomy performed with the objective of obtaining information that is not available via clinical diagnostic methods. It is usually performed in patients with acute or unexplained abdominal pain, in patients who have sustained abdominal trauma, and occasionally for staging in patients with a malignancy.

Once the underlying pathology has been determined, an exploratory laparotomy may continue as a therapeutic procedure; sometimes, it may serve as a means of confirming a diagnosis (as in the case of laparotomy and biopsy for intra-abdominal masses that are considered inoperable). These applications are distinct from laparotomy performed for specific treatment, in which the surgeon plans and executes a therapeutic procedure.

With the increasing availability of sophisticated imaging modalities and other investigative techniques, the indications for and scope of exploratory laparotomy have shrunk over time. The increasing availability of laparoscopy as a minimally invasive means of inspecting the abdomen has further reduced the applications of exploratory laparotomy. ^[1] Nevertheless, the importance of exploratory laparotomy as a rapid and cost-effective means of managing acute abdominal conditions and trauma cannot be overemphasized.

Acute-onset abdominal pain and clinical findings suggestive of intra-abdominal pathology necessitating emergency surgery

In these conditions, exploratory laparotomy is carried out both to diagnose the condition and to perform the necessary therapeutic procedure.

Patients with clinical features of peritonitis may have pneumoperitoneum on erect chest and abdominal radiographs. They usually have a perforated viscus, most commonly the duodenum, stomach, small intestine, cecum, or sigmoid colon. Exploratory laparotomy is done first to determine the exact cause of pneumoperitoneum, followed by the therapeutic procedure. In the absence of pneumoperitoneum, appendicular perforation and intestinal ischemia are possible diagnoses; a high index of suspicion for possible intestinal ischemia should be maintained.

Patients with vomiting, obstipation, and abdominal distention are likely to have intestinal obstruction. Abdominal radiographs in these patients may reveal dilated intestinal loops and air-fluid levels. Hernia, especially an incarcerated inguinal hernia, should be ruled out as a possible cause of the obstruction.

Patients with pain in the abdomen and fever may have intra-abdominal collections. These are usually detected by means of ultrasonography (US) or computed tomography (CT) and can often be managed percutaneously. A persistently high aspirate or the presence of enteric contents may suggest perforation, and laparotomy may be required to control the source.

In rare instances, exploratory laparotomy may be performed for highly unusual presentations (eg, adnexal torsion induced by an endometrioma). Hua et al reported a 25-year-old primigravida in week 8 of gestation who presented with acute-onset lower abdominal pain. ^[2]  US showed an intrauterine single viable embryo with a right ovarian cyst measuring 6 × 6 cm in diameter. Exploratory laparotomy revealed 360° torsion of the right adnexa, for which a right adnexectomy was performed. Because of the rarity of endometrioma-induced torsion, diagnosis and treatment are challenging; exploratory laparotomy or diagnostic laparoscopy must be done to confirm the diagnosis.

Greene et al reported the use of exploratory laparotomy to retrieve a fishbone in the porta hepatis, which migrated through the gastric wall into the periportal space, leading to a contained gastric perforation and a porta hepatis abscess. ^[3]  As a consequence of the abscess, the patient developed portal vein thrombosis, for which for which he received antibiotics and anticoagulant therapy. The patient recovered without further sequelae. 

Abdominal trauma with hemoperitoneum and hemodynamic instability

Hemodynamically unstable trauma patients with hemoperitoneum should undergo exploratory laparotomy without any delay. They are likely to have intraperitoneal bleeding after injury to the liver, spleen, or mesentery. They may also have associated intestinal perforations that call for emergency repair.

In patients with penetrating abdominal trauma (PAT), exploratory laparotomy was conventionally carried out to rule out intra-abdominal injury. However, Kevric et al found that peritoneal breach does not necessarily equate to visceral injury mandating surgery; they suggested sequential examination when the CT scan is normal. ^[4]  Sanie et al reported similar findings. ^[5]  

Military trauma and civilian injuries may have differing presentations. ^[6] Hollow visceral injuries are more often seen with military trauma than with civilian trauma, and exploratory laparotomy is more commonly used for assessment and therapy. Vascular injuries are more often reported with civilian trauma.

The role of laparoscopy was highlighted in a systematic review in patients with PAT. ^[7]  Laparoscopy has been found to be useful in identifying diaphragmatic injury but has been found to be less sensitive for detecting hollow visceral injuries. It is, however, very good for identifying the need for exploratory laparotomy.

Chronic abdominal pain

The availability of good imaging facilities has restricted the use of exploratory laparotomy in these conditions; however, when only limited facilities are available, exploratory laparotomy becomes an important diagnostic tool. These patients may have intra-abdominal adhesions, tuberculosis, or tubo-ovarian pathology. ^[8]

Staging of ovarian malignancy and Hodgkin disease

The role of surgical staging in Hodgkin disease is controversial, and recommendations are restricted to patients who may be considered for primary radiotherapy as the sole modality of treatment. ^[9]

Obscure gastrointestinal bleeding

Over the past few years, with the increased availability of good imaging, endoscopic techniques, and laparoscopy, the role of exploratory laparotomy has diminished. However, in centers with limited facilities or when the bleeding is profuse, exploratory laparotomy, with on-table enteroscopy when indicated, can help identify the source. ^[10]

In the current era of video capsule endoscopy and deep enteroscopy, the probability of negative intraoperative enteroscopy is high if the preoperative imagings are negative. A study by Manatsathit et al identified patients with tumors and those with Meckel diverticulum as the best candidates for laparotomy and intraoperative enteroscopy. ^[11]

Ambiru et al used exploratory laparotomy with capsule endoscopy, CT, and mesenteric angiography for the diagnosis of ileal and ovarian varices in a patient with obscure gastrointestinal bleeding. ^[12]

Rare entities

Sometimes, with unusual presentations of certain rare disorders, an exploratory laparotomy can serve as a method of diagnosis and treatment.

For example, in a 16-year-old girl, a gastric trichobezoar leading to gastric perforation was diagnosed on exploratory laparotomy; extraction of a giant trichobezoar with duodenal extension was carried out, and repair of the perforation was performed. ^[13]  Phytobezoars can also lead to intestinal obstruction and intussusception. In a case reported by Kosmidis et al, an 81-year-old man presented with symptoms of intestinal obstruction, and on exploratory laparotomy it was found that multiple phytobezoars led to this obstuction with incipient intussusception. ^[14]

Similarly, in another unusual presentation, Bouveret syndrome with suspected choledochoduodenal fistula, which presented as gastric outlet obstruction, was diagnosed on exploratory laparotomy. ^[15]  Gastroduodenotomy with extraction of the calculus, pyloroplasty, and cholecystectomy were performed.

Rarely, eosinophilic myenteric ganglionitis (EMG) can mimic sigmoid volvulus, as reported by Kim et al in a case involving a 73-year-old male patient. ^[16]  Exploratory laparotomy revealed diffuse colonic dilation and distal ischemia necessitating a Hartmann procedure, when earlier abdominal radiographs were suggestive of a sigmoid volvulus. The pathology report confirmed EMG.

In a systematic review involving 56 cases of another rare condition, intestinal aspergillosis, Yelika et al found that exploratory laparotomy was used for diagnostic purposes in 35 (63%) of the patients. ^[17]  Early exploratory laparotomy in these patients was helpful in reducing mortality.

The primary contraindication for exploratory laparotomy is unfitness for general anesthesia. Peritonitis with severe sepsis, advanced malignancy, and other comorbid conditions may render patients unfit for general anesthesia.

Exploratory laparotomy is sometimes a good diagnostic tool. However, anticipation of the diagnosis is necessary, and a hasty exploration should be avoided if the center is not well equipped to perform the therapeutic procedure that will be necessary if the suspected condition is confirmed.

Nontherapeutic laparotomy is associated with significant long-term morbidity, including adhesive intestinal obstruction and incisional hernia. Consequently, exploratory laparotomy should be performed in accordance with standard protocols and guidelines for laparotomy.

The authors have found that in equivocal cases of acute abdomen, diagnostic peritoneal lavage (DPL) is often helpful in determining the need for exploratory laparotomy. If DPL findings are positive, then an exploratory laparotomy is performed; if DPL findings are negative, the patient is closely monitored. ^[18]

In a meta-analysis of 677 patients, Chaijareenont et al evaluated the role of focused assessment with sonography for trauma (FAST) in predicting the need for exploratory laparotomy in patients with major pelvic fractures. ^[19]  The pooled sensitivity, specificity, and accuracy of FAST in identifying significant abdominal hemorrhage were determined to be 79%, 90%, and 93%, respectively. Although there was no significant correlation between FAST accuracy and the Injurity Severity Score (ISS) on regression analysis, FAST was found to be helpful in making the decision whether to consider exploratory laparotomy.

A report on the role of multidetector CT (MDCT) found that when CT is performed 24-48 hours after damage-control surgery, it helps identify anatomic derangements and foreign bodies that were missed earlier, during the initial assessment. ^[20]  This modality can also be used in patients requiring critical care, facilitating an accurate diagnosis and timely initiation of appropriate therapy.

Evidence in the literature regarding the use of antibiotic prophylaxis in penetrating abdominal trauma is limited. ^[21]  Further studies are needed to document its benefit (or lack thereof) so as to avoid unnecessary antibiotic use and prevent the development of multidrug-resistant organisms.

A retrospective study on metastatic melanoma reported that 33% of the patients underwent emergency laparotomy for ileus, small-bowel perforation, and abdominal abscess. ^[22]  The authors reported a median overall survival of 14 months and a 5-year survival rate of 23%.