Preprocedural Planning
The patient's physiologic status at laparotomy is an important determinant of outcome. Accordingly, whenever possible, efforts should be made to optimize the patient's general condition. This includes correction of fluid and electrolyte imbalances, blood transfusions, and bronchodilator nebulizations as required.
Before the procedure, a nasogastric tube and an indwelling urinary catheter are inserted to decompress the stomach and the urinary bladder. Decompression of the stomach reduces the risk of aspiration of gastric contents during induction of anesthesia. The risk of such aspiration is high in these patients because of the emergency nature of the procedure and because of paralytic ileus. Decompression of the bladder reduces the risk that the bladder may be injured as the midline incision is extended inferiorly for better exposure.
The Emergency Surgery Score (ESS) can be used to predict the outcomes in patients undergoing emergency laparotomies. [23] It is calculated on the basis of a few demographic variables, the presence of comorbidities, and preoperative laboratory test results. This score is a useful bedside tool for risk stratification that can facilitate the decision-making process and aid in counseling the patient and family.
Equipment
Exploratory laparotomy is performed in an operating room (OR). The OR should contain anesthetic equipment, overhead lights, electrodiathermy equipment, and suctioning systems. A standard laparotomy tray is usually sufficient for an exploratory laparotomy.
If vascular intervention is anticipated, vascular instruments may be required. If major abdominal organ resection may be needed, appropriate instruments, facilities, and expertise should be available. Similarly, abdominal trauma necessitates major abdominal surgery, for which appropriate infrastructure and expertise are required.
Patient Preparation
Anesthesia
Exploratory laparotomy is performed with the patient under general anesthesia. Patients who are anesthetized for emergency surgery are at higher risk for aspiration of gastric contents. Adequate care must be taken to empty the stomach before induction. Rapid-sequence induction considerably reduces the risk of aspiration. [24]
Positioning
The patient is placed in the supine position, with the arms abducted at right angles to the body. The lithotomy position may be employed instead when a pelvic pathology is suspected and a simultaneous vaginal or rectal intervention is necessary.
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Laparotomy in patient with peritonitis. Image shows perforated duodenal ulcer.
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Upper midline incision. Incision is deepened through subcutaneous tissue to expose linea alba.
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Linea alba is divided to reveal preperitoneal fat.
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Abdominal incision is completed to reveal intra-abdominal organs.
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Laparotomy in patient with intestinal obstruction. Intraoperatively, single peritoneal band causing intestinal obstruction was found.
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Laparotomy in patient with acute intestinal obstruction. Sigmoid volvulus with gangrene was found intraoperatively.
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Multiple omental deposits in patient with disseminated carcinoma of stomach.
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Multiple metastatic deposits over small bowel in patient with colonic malignancy.
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Liver laceration in traffic accident victim who presented with hemoperitoneum.
