3. • Yes even in the era of CT and MRI abdomen can be
FULL OF SURPRISES.
• Usually, the surgeon speculates about the predicted
diagnosis but always remains ready for the unexpected.
4. Objectives
• Learn the correct operative sequence.
• Review what to do once you get inside.
• Organize your exploration.
• Understand basic exposure techniques.
• Summary points
5. • A laparotomy is a surgical procedure involving a incision through
the abdominal wall to gain access into the abdominal cavity.
• It is also known as celiotomy
Explorative Therapeutic
Need for operation “+”
Pre op definitive diagnosis ”-”
Need for operation “+”
Pre op definitive diagnosis ”+”
6. • Acute Abdomen due to:
Trauma (Blunt & Penetrating).
Infections (Acute & Chronic).
• Removal of Foreign Bodies like dislodged copper T.
• Staging laprotomy in malignancy.
• Abdominal apoplexy.
Indications :
7. Pre op preparation
• 5 Tube Principle:
1- Intravenous Line
2- Nasogastric tube
3- Urinary Catheter.
4- Endotracheal tube.
5- CVP line in intensive monitoring.
• Preop Antibiotics.
• Arrangement of blood & Blood products.
11. Patient with previous midline incision.
• If at all possible, an attempt should be made to enter the
abdomen above or below the previous incision, in an
area less likely to have adhesions.
• If not possible alternatively chevron incision should be
considered.
12. Gaining Access
• “Hey diddle diddle, right down the middle”
• Three passes
• Skin and subcutaneous tissue
• Land on the linea alba
• Divide the fascia, expose preperitoneal fat
• Push through the peritoneum just cranial to umbilicus
• Cut peritoneum, divide falciform ligament
13. Once Inside…
• Evisceration
• Up and to the right, remove clot/blood
• Blunt trauma
• Empiric, yet directed packing
• Penetrating trauma
• Direct hemorrhage control
• Exsanguinating hemorrhage
• Supraceliac aorta
14. Empiric Packing in hemoperitoneum.
• Right upper quadrant—Above and below liver.
• Right gutter
• Left upper quadrant—Above and medial to spleen
• Left gutter
• Pelvis
• Survey solid organs, look back at the eviscerated bowel,
start making decisions…
15. Survey the Battlefield
Divide the peritoneal cavity at the
transverse mesocolon
• Supramesocolic
• Liver, stomach, spleen
• Inframesocolic
• Small bowel, colon,
bladder, female
reproductive organs
16. Inframesocolic Exploration
• Lift transverse mesocolon cranially.
• Run the gut
• Visualize the pelvis and female reproductive organs
The posterior portions of the transverse mesocolon,
hepatic, and splenic flexures are common sites for
missed injuries
17. Supramesocolic Exploration
• Move transverse colon caudal.
• Inspect and palpate
• Liver, GB, right kidney
• Stomach to GE junction and diaphragms
• Duodenum
• Spleen, left kidney
• Lesser sac.
18. Pathway of exploration
• The exploratory procedure used by surgeons differs, but
should be absolutely consistent for any one operator.
23. • Mattox maneuver. Facilitates exploration of Abdominal
aorta, left renal veins.
24. Peritoneal toileting or debridement.
• The goal of peritoneal toileting is mechanical removal of as
much as possible of contaminant from the abdominal cavity.
• There is no scientific evidence that intra-operative
peritoneal lavage reduces mortality or infective
complications in patients receiving adequate systemic
antibiotics.
• Peritoneal irrigation with antibiotics is not advantageous.
• Should you choose to remain a dedicated irrigator,
remember to suck out all the lavage fluid before you close
25. • It is impossible to effectively drain the free peritoneal
cavity.
• Drains provide a false sense of security and reassurance.
• Times have changed
when in doubt, drain
WHEN IN DOUBT, DON’T DRAIN
Drainage of abdomen.
26. Drainage of abdomen.
• Their use should be limited
Evacuation of an “established” abscess.
To allow escape of potential visceral secretions (e.g.,
biliary, pancreatic)
Rarely, to establish a controlled intestinal fistula when
the latter cannot be exteriorized
• CLOSED ACTIVE (low pressure) drains are preferable.
28. Abdominal closure
• Permanent closure.
• “MASS CLOSURE”
• Using non absorbable/ delayed absorbable sutures.
• 1cm wide bites.
• Max 1cm gap between two bites.
• Ideally suture length to wound length ratio 3:1
• Subcutaneous sutures are of no value.
29. • Temporary closure/open abdomen.
• Commonly done in DCS.
• Fascial layer left open with temporary
occlusive dressings.
• Secondary closure may be done after
physiological stability is achieved.
31. • With advent of wide variety of sophisticated investigations exploratory
laparotomy became a rare entity.
• Nowadays most exploratory laparotomies are performed in the
emergency situation.
• Whenever possible, however, an attempt should be made to arrive at
an accurate, or at least a provisional, diagnosis before surgery.
Summary
32. References
• Farquharsons textbook of operative surgery.
• Hamilton & baileys book of emergency surgery.
• Scheins book of emergency surgery.
• Internet.
Hinweis der Redaktion
Sir george murray humphry
This is what makes emergency abdominal
surgery so exciting and demanding
Many approaches are suitable. Choice of incision is mainly related to access required.
Para median They were favored for their additional strength when catgut was the suture material for abdominal wall closure.
Transverse incision Access however is partially dependent on patient build, and this incision generally allows better access in those with a short wide abdomen and a wide costal angle. Good cosmetic scar.
(when the ensuing cavity would not collapse or cannot be filled with omentum or adjacent structures),
Time for diagnostic investigations is not available.
