Diagnostic Peritoneal Lavage Technique

Updated: Jul 21, 2021
  • Author: Liudvikas Jagminas, MD, FACEP; Chief Editor: Vikram Kate, MBBS, PhD, MS, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, FFST(Ed), MAMS, MASCRS  more...
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Technique

Approach Considerations

Traditionally, diagnostic peritoneal lavage (DPL) is performed in two 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 solution, and the effluent is sent for laboratory evaluation. Routine bile staining, Gram staining, and microscopy to identify vegetable fibers are rarely productive and are of untested accuracy.

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Aspiration and Lavage

Decompression of the stomach and the bladder is recommended with a nasogastric tube and a Foley catheter, respectively, to prevent inadvertent gastric or bladder injury.

Prepare the site of placement with standard skin antiseptics (eg, povidone-iodine or chlorhexidine), and drape the patient appropriately. Be sure to observe sterile precautions throughout the procedure.

Liberally infiltrate the local anesthetic (lidocaine 1% with epinephrine) into the area for incision and passage of the needle and catheter. (See the 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 guide wire while aiming toward the right or left pelvic gutter is recommended to facilitate passage into the peritoneal cavity. (See the 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. Perform aspiration, followed by lavage, if necessary. Recovery of 10 mL of blood is considered a positive finding, 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 (IV) extension tubing to the catheter, then 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.

Next, place the IV bag on the floor (or below abdominal level), and allow the fluid to return through the effect of gravity. It is generally accepted that the return of 700 mL or more in adults 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 need be sent to the laboratory for cell count analysis, and another 10 mL can be sent for enzyme analysis. (See the image below.)

Positive result from diagnostic peritoneal lavage. Positive result from diagnostic peritoneal lavage.

The infused fluid may not return or may stop after a short while, because of several factors. Some IV 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 IV 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 and 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 image below.)

Closed diagnostic peritoneal lavage (DPL) techniqu Closed diagnostic peritoneal lavage (DPL) technique. Guide wire (Seldinger technique) is inserted into peritoneal cavity via midline approach just below umbilicus and should be aimed caudad. Wire should be directed toward left or right pelvic gutter as it is advanced through needle and should enter peritoneal cavity without resistance. Next, needle is withdrawn while wire is stabilized, and stab incision is made with No. 11 scalpel adjacent to wire. DPL catheter is placed over wire with twisting motion directed toward right or left pelvic gutter and advanced into peritoneal cavity.
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Analysis of Fluid

Diagnostic criteria for analysis of fluid obtained with DPL are outlined in Tables 2 and 3 below. [13, 14]

Table 2. Diagnostic Peritoneal Lavage Red Blood Cell Criteria [13] (Open Table in a new window)

 

Positive

Indeterminate

Blunt trauma

100,000/μL

20-100,000/μL

Stab wound

 

 

Anterior abdomen

100,000/μL

20,000-100,000/μL

Flank

100,000/μL

20,000-100,000/μL

Back

100,000/μL

20,000-100,000/μL

Low chest

5000/μL

1000-5000/μL

Gunshot wound

5000/μL

1000-5000/μL

Table 3. Diagnostic Peritoneal Lavage Non–Red Blood Cell Criteria [14] (Open Table in a new window)

 

Positive

Indeterminate

Amylase level

≥20 IU/L

10-19 IU/L

Alkaline phosphatase level

≥3 IU/L

NA

White blood cells

>500/μL

250-500/μL

NA = Not applicable.

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Complications

Potential complications of DPL include the following:

  • Local or systemic infection, hematoma (occurs in < 0.3% of cases) [15, 16]
  • Intraperitoneal injury
  • False-positive results - These may result from (1) insertion through iatrogenic misadventure, (2) placement of the catheter through an abdominal-wall hematoma, (3) inadequate hemostasis, or (4) 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 - This may be the result of (1) inadvertent placement of the catheter into the preperitoneal space, (2) compartmentalization of fluid by adhesions, (3) obstruction of fluid outflow (eg, by omentum), or (4) fluid pooling in the intrathoracic cavity due to diaphragmatic injury
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