Laparotomy

Laparotomy  - opening

Surgical entry to the peritoneal cavity

• Emergency – Traumatic,  Non traumatic
• Elective

Indications (emergency)

• Non responsive patient / unstable patient following initial adequate resuscitation.
• Unequivocal clinical evidence of peritonitis
• Penetrating missile and penetrating abdominal (discuss with senior) trauma.
• Positive diagnostic peritoneal lavage.
• Air present under the diaphragm.

Pre operative preparation

Elective – Well assessed, prepared consented patient

Emergency –

• Resuscitated, consented (except in non responsive / unstable) patients.
• Grouping DT at least 2 units of blood.
• Urinary catheter / NG tube (if needed) – in elective patients following anaesthetizing the patient)
• Prophylactic IV antibiotics (cefuroxime 1.5g / metronidazole 500mg)
• Have two “working” suckers and adequate number of abdominal packs ready, if expecting intra-abdominal bleeding.   

Procedure

• Under general anaesthesia
• Clean from nipples to mid thigh
• Drape from xiphisternum to pubic symphysis
• (For Emergency laparotomy in patients who are unresponsive to resuscitation, cleaning and draping is done prior to anaesthesia)
• Midline incision skirting the umbilicus
• Once reached the anterior rectus sheath lift the abdominal wall along with the assistant.
• Incise the linea alba without entering the peritoneum at a point close to the umbilicus. (Peritoneum is closest to the rectus sheath in this area. In a re laparotomy enter the peritoneal cavity though a virgin area to minimize the possibility of damage to bowel.)
• Lift the peritoneum with straight artery forceps and incise between them with the blade, having excluding catching of bowel.
• Extend the laparotomy appropriately while protecting the bowel.
• In case of Pus / bowel contents – send sample for culture ABST.
• Massive bleeding - Pack the four quadrants of abdominal cavity. (Inform senior)
• Always control bleeding before controlling contamination.

Peritoneal Survey

Laparotomy – closure            

Contraindications

 

• Continued blood loss despite definite surgery / packing
• Inability to close the laparotomy without tension due to gross dilatation / oedema of bowel

Procedure

• Irrigate appropriately
• Place and anchor drains as needed
• Check for instruments, towels and swabs.
• Place omentum covering the bowel overlying the laparotomy wound.
• Mass suture the anterior rectus sheath, with a continuous no 1 or 2 non absorbable suture material. 
• Make sure that the bowel is not caught in the mass closure.
• The suture should be at least 4 times the length.
• Sutures should be applied 1-2cm away from margin and 1-2cm apart.
• Bury the knot.
• Close the skin with an appropriate suture material.