Open Exploration of Abdomen
After appropriate preparation (see Periprocedural Care), exploratory laparotomy is performed as follows.
Midline incision and opening of peritoneum
A vertical midline incision is the best choice: It affords a rapid entry into the peritoneum and is relatively bloodless and safe. [25] The incision may be made in the upper, middle, or lower midline, depending on the anticipated pathology, and may be extended in either direction if necessary. Exposure of the peritoneum should never be compromised in an attempt to keep the incision small.
The skin is incised with a surgical knife. An electrocautery device can be used instead of the traditional scalpel for making the incision; skin incisions made by cutting diathermy are quicker, are associated with less blood loss, and demonstrate no significant difference in the rate of wound complications, scar cosmesis, or postoperative pain. [26, 27]
The incision is then deepened through the subcutaneous fat (see the image below). Electrodiathermy in coagulation mode provides bloodless access through this layer. The linea alba is identified as a glistening layer deep to the subcutaneous tissues.
Upper midline incision. Incision is deepened through subcutaneous tissue to expose linea alba.
The orientation of the fibers on the linea alba is appreciated; these fibers are directed medially and inferiorly from either side, and the midline is identified as the axis where they criss-cross. This is opened carefully by means of electrodiathermy or heavy Mayo scissors (see the images below).
Every effort must be made to avoid injury to the intraperitoneal contents. This can be done by lifting the peritoneum in two straight artery forceps placed close to each other at right angles to the incision. Careful palpation should be performed to ensure that no bowel or omentum is picked up in the artery forceps.
In reoperations, extreme care is necessary because the underlying bowel may be adherent to the parietal peritoneum. In these cases, the peritoneum is opened in a virgin area, preferably by extending the incision appropriately.
Exploration of abdominal cavity
The steps of exploration depend on the initial findings and are governed by the principles of systematic survey and priority for life-saving maneuvers.
Massive hemoperitoneum suggests two things. First, the patient may have a major source of bleeding. Second, the presence of blood within the peritoneum will interfere with adequate exploration. The ideal strategy is to lift the small bowel and its mesentery out of the peritoneal cavity, to rapidly suction the blood within the peritoneum, and to place laparotomy pads in the four quadrants of the peritoneum. Once this is done, each pad is carefully removed to allow inspection of each quadrant.
In the absence of massive hemoperitoneum, identification of the source of bleeding is much easier. Common sources include injuries to the liver (see the image below) or spleen, ruptured ectopic pregnancies, mesenteric tears, hollow visceral injuries, aortic aneurysms, and splenic or hepatic artery aneurysms. Once the source of bleeding is identified, necessary corrective measures must be taken.
If enteric contents are the finding, they are suctioned out with a sump suction catheter, and the source of the enteric contamination is sought. This search must be performed systematically, starting from the stomach. The anterior aspect of the stomach is inspected for a perforation, followed by the duodenum.
Subsequently, the small bowel is inspected carefully, starting from the duodenojejunal flexure.
Each segment of the intestine is held up by the surgeon, and all surfaces are inspected. Any slough on the serosal surface is gently separated to allow identification of an underlying perforation (see the image below).
If no source of enteric contents is found in the small intestine, the appendix and then the colon are examined. Any perforation found in the intestine is controlled. Methods of controlling the source include direct repair, buttressed repair, resection, and anastomosis or exteriorization of the perforation with stoma formation. The choice between the different options depends on the site of perforation, the suspected pathology, the extent of the disease, and the patient's physiologic status.
In patients with intestinal obstruction, possible findings on exploratory laparotomy include adhesive intestinal obstruction, a single intraperitoneal band with intestinal compression or torsion, and tumors (see the images below).
Laparotomy in patient with intestinal obstruction. Intraoperatively, single peritoneal band causing intestinal obstruction was found.
Laparotomy in patient with acute intestinal obstruction. Sigmoid volvulus with gangrene was found intraoperatively.
Multiple metastatic deposits over small bowel in patient with colonic malignancy.
Staging laparotomy should include a thorough search for foci of malignancy, splenectomy, wedge and core liver biopsies, and sampling of retroperitoneal lymph nodes. In premenopausal women, oophoropexy is performed in anticipation of radiotherapy.
Completion and closure
Placement of drains after an exploratory laparotomy remains a subject of debate. The evidence currently available is insufficient to support routine drain placement. Patients with extensive contamination may benefit from drains in the subhepatic space and the pelvis. [28]
Once the procedure is completed, the abdominal wall is closed. Before closure, however, the instrument and pad counts must be double-checked. The surgeon should manually inspect the peritoneum for any retained pads or instruments, even if scrub nurse has found the count to be correct.
Closure is carried out with either nonabsorbable suture material (eg, polypropylene) or a delayed absorbable suture material (eg, polydioxanone) in either a continuous suture or interrupted sutures. The standard approach is to place sutures about 1 cm from the edge of the incised linea alba, maintaining a distance of 1 cm between successive bites.
Sometimes, the Smead-Jones closure technique (ie, single-layer mass closure) may be employed to close the abdomen if the abdominal wall is plastered and separate layers are unavailable as a result of previous operations. This technique makes use of figure-eight sutures. [29]
At times, closure may be rendered difficult by an edematous or distended bowel. In such circumstances, forced closure may have adverse postoperative outcomes in the form of impaired ventilation, intra-abdominal hypertension, pain, and dehiscence. Laparostomy and delayed closure may be a better option in such cases. [30]
Complications
An exploratory laparotomy is associated with the same complications that are associated with any laparotomy. Immediate complications include the following:
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Paralytic ileus
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Intra-abdominal collection or abscess
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Abdominal wall dehiscence
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Pulmonary atelectasis
Delayed complications include the following:
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Adhesive intestinal obstruction
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Incisional hernia
Wound infections remain the most common complication after exploratory laparotomy. The incidence is higher in cases where there is gross intra-abdominal contamination with hollow viscus involvement. Very often, there is a correlation between the postoperative surgical-site infection (SSI) and the intra-abdominal sepsis; accordingly, an appropriate prophylactic antibiotic regimen can contribute to reducing SSI rates. Negative-pressure wound therapy (NPWT) is increasingly being used to enhance the healing of resistant abdominal wounds in the postoperative period.
Mortality after emergency laparotomy remains high. It is particularly high in cases where laparotomy is performed for trauma, the major cause of death being hemorrhage. [31]
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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.
