Exploratory laparotomy

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Exploratory laparotomy
ICD-10-PCS 0WJG0ZZ
ICD-9-CM 54.11
MeSH = OPS301 =

An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the staging of some cancers. [1] [2]

Contents

During an exploratory laparotomy, a large incision is made vertically in the middle of the abdomen to access the peritoneal cavity, then each of the quadrants of the abdomen is examined. [1] Various other maneuvers, such as the Kocher maneuver, or other procedures may be performed concurrently. Overall operative mortality ranges between 10% and 20% worldwide for emergent exploratory laparotomies. [3] [4] [5] Recovery typically involves a prolonged hospital stay, sometimes in the intensive care unit, and may include rehabilitation with one or more therapies. [1]

Indications

A database that tracks exploratory laparotomies performed in the United Kingdom estimates that about 30,000 are done across England and Wales each year out of a population of 59.5 million people. [6] Reasons why a patient may require an exploratory laparotomy include:

Procedure

General technique

Scar from midline incision for exploratory laparotomy Exploratory Laparotomy Scar (02).jpg
Scar from midline incision for exploratory laparotomy

A vertical cut, or incision, is made in the middle of the abdomen. This midline incision extends from the xiphoid process at the bottom of the chest to the pubic symphysis at the bottom of the pelvis. The fibrous tissue of the linea alba, which separates the right and the left abdominal muscles, serves as a guide for where to cut. After opening the fascia, the abdominal cavity, or peritoneum, is entered. The surgeon then looks for evidence of injury, infection, or disease. In trauma exploratory laparotomy, any immediate, life-threatening bleeding is first identified and controlled. In these cases, sponges are often packed in the spaces around the liver and the spleen to slow bleeding until a source can be found. This allows the surgeon to focus on one area at a time by removing the sponges from that quadrant. [1]

A systematic approach is taken to examining the abdominal organs for disease. The small bowel is "run", or looked at segment by segment, along its entire length from the ligament of Treitz to the terminal ileum. The gastrocolic ligament is incised and the lesser sac is explored, including the posterior stomach and the anterior pancreas. The surfaces of the spleen and the liver also are examined for injury. [1] If being performed for cancer staging, special attention will be paid during the exploratory laparotomy to the lymph nodes, which may be biopsied, or removed and assessed with a microscope or other special tests to see whether they contain cancerous cells indicative of cancer spread. [7] [9]

If necessary, several other surgical maneuvers or procedures may be performed.

Additional maneuvers

DefinitionPurposeStructures mobilizedStructures exposed
Mattox maneuver ("left medial visceral rotation") [10] [11] surgical maneuver named for Dr. Kenneth Mattox in which left-sided abdominal organs are mobilized and moved temporarily out of the wayto provide access to deeper retroperitoneal left-sided abdominal structures stomach, pancreatic tail, spleen, left kidney, left hemicolon aorta, left iliac vessels, left renal vessels, pelvic vessels
Cattell-Braasch maneuver ("right medial visceral rotation") [10] [12] surgical maneuver named for Dr. Richard Cattell and Dr. John Braasch in which right-sided abdominal organs are mobilized and moved temporarily out of the wayto provide access to deeper retroperitoneal right-sided abdominal structures duodenum, pancreatic head, right hemicolon inferior vena cava, portal vein, right iliac vessels, right renal vessels
Kocher maneuver [10] surgical maneuver named for Dr. Emil Theodor Kocher in which the duodenum and the head of the pancreas are mobilized and moved out of the way to the leftto fully inspect the duodenum and the pancreas and to access deeper structures behind them duodenum, pancreatic head aorta, inferior vena cava, posterior duodenum, posterior pancreas

Additional procedures

Based on where and what injury or disease is identified, one or more additional procedures may be performed during an exploratory laparotomy, including:

Depending on the stability of the patient following an exploratory laparotomy, the abdomen may be sutured back together ("primary closure") or one or more tissue layers may be left open ("open abdomen") to facilitate further non-surgical resuscitation. In cases where the abdomen is left open, a vacuum dressing, a saline bag, or towel clips may be placed to protect the internal organs until the patient is stable enough to return to the operating room for definitive closure. [1]

Outcomes

Postoperative mortality

The likelihood of death after an exploratory laparotomy depends on several factors including the age of the patient, injury or disease severity, other comorbid medical conditions, the skill of the surgeon, and what resources are available in the hospital. [6] [17] Overall, the mortality rate typically ranges between 10% and 20% worldwide for emergent exploratory laparotomies. [3] [4] [5] It is lower for scheduled (elective) exploratory laparotomies, since patients are typically less sick and more optimized when procedures are able to be planned ahead of time. [18]

Postoperative complications

Like with any major surgery, a variety of complications may occur during and after an exploratory laparotomy. These include minor problems, such as superficial skin infection or delayed bowel motility, and major problems, such as bleeding, blood clots in the legs or in the lungs, stroke, deep intraabdominal infection which can lead to sepsis, and reopening of the wound due to a failure to heal properly. [17] A minority of patients will require reoperation for complications of exploratory laparotomy. [1]

Recovery

Most patients spend at least several days in the hospital after having an exploratory laparotomy, sometimes in the intensive care unit, depending on the severity of the injury, infection, or disease. It can take weeks or months to heal completely. During the recovery period, there may be restrictions on activities such as driving, exercising, lifting, swimming, and showering. Depending on how long they were in the hospital, how severe their illness was, and whether they sustained other injuries or complications, some patients may require rehabilitation with physical therapy, occupational therapy, or speech-language pathology. [1]

History

Exploratory laparotomy originated as a technique for the treatment of acute trauma. In 1881, Dr. George E. Goodfellow performed the first documented exploratory laparotomy for a ballistic injury, however the use of the procedure for blunt trauma has been described previously. [19] In 1888, Dr. Henry O. Marcy first discussed using exploratory laparotomy as a means of diagnosing acute nontraumatic abdominal and pelvic problems at the 39th Annual Meeting of the American Medical Association, citing how improvements in safe surgical methods "so greatly increased the utility of the operation". [20] Since the early 2000s, the opposite trend has been seen thanks to improvements in laboratory testing; CT, MRI, and other medical imaging; and less invasive laparoscopic surgical techniques, all of which have made exploratory laparotomy less common for diagnostic purposes outside of the severe trauma setting. [21] [22] [8] [1]

Related Research Articles

The term abdominal surgery broadly covers surgical procedures that involve opening the abdomen (laparotomy). Surgery of each abdominal organ is dealt with separately in connection with the description of that organ Diseases affecting the abdominal cavity are dealt with generally under their own names.

<span class="mw-page-title-main">General surgery</span> Medical specialty

General surgery is a surgical specialty that focuses on alimentary canal and abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder, appendix and bile ducts, and often the thyroid gland. They also deal with diseases involving the skin, breast, soft tissue, trauma, peripheral artery disease and hernias and perform endoscopic as such as gastroscopy, colonoscopy and laparoscopic procedures.

<span class="mw-page-title-main">Laparoscopy</span> Minimally invasive operations within the abdominal or pelvic cavities

Laparoscopy is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.

A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, Is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.

<span class="mw-page-title-main">Diverticulitis</span> Digestive disease of the large intestine

Diverticulitis, also called colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—that can develop in the wall of the large intestine. Symptoms typically include lower-abdominal pain of sudden onset, but the onset may also occur over a few days. There may also be nausea; and diarrhea or constipation. Fever or blood in the stool suggests a complication. Repeated attacks may occur.

<span class="mw-page-title-main">Pancreaticoduodenectomy</span> Major surgical procedure involving the pancreas, duodenum, and other organs

A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove cancerous tumours from the head of the pancreas. It is also used for the treatment of pancreatic or duodenal trauma, or chronic pancreatitis. Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the duodenum, proximal jejunum, gallbladder, and, occasionally, part of the stomach.

<span class="mw-page-title-main">Gastrointestinal perforation</span> Medical condition

Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, sports-related injuries, and are notably common among the elderly who experience falls.

Hemoperitoneum is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemoperitoneum is generally classified as a surgical emergency; in most cases, urgent laparotomy is needed to identify and control the source of the bleeding. In selected cases, careful observation may be permissible. The abdominal cavity is highly distensible and may easily hold greater than five liters of blood, or more than the entire circulating blood volume for an average-sized individual. Therefore, large-scale or rapid blood loss into the abdomen will reliably induce hemorrhagic shock and, if untreated, may rapidly lead to death.

<span class="mw-page-title-main">Bowel resection</span> Surgical procedure in which a part of an intestine is removed

A bowel resection or enterectomy is a surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often the word enterectomy is reserved for the sense of small bowel resection, in distinction from colectomy, which covers the sense of large bowel resection. Bowel resection may be performed to treat gastrointestinal cancer, bowel ischemia, necrosis, or obstruction due to scar tissue, volvulus, and hernias. Some patients require ileostomy or colostomy after this procedure as alternative means of excretion. Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be digestive and metabolic challenges afterward, such as short bowel syndrome.

<span class="mw-page-title-main">Blunt splenic trauma</span>

Blunt splenic trauma occurs when a significant impact to the spleen from some outside source damages or ruptures the spleen. Treatment varies depending on severity, but often consists of embolism or splenectomy.

<span class="mw-page-title-main">Penetrating trauma</span> Type of injury

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.

<span class="mw-page-title-main">Obturator hernia</span> Medical condition

An obturator hernia is a rare type of hernia, encompassing 0.07-1% of all hernias, of the pelvic floor in which pelvic or abdominal contents protrudes through the obturator foramen. The obturator foramen is formed by a branch of the ischial as well as the pubic bone. The canal is typically 2-3 centimeters long and 1 centimeters wide, creating a space for pouches of pre-peritoneal fat.

<span class="mw-page-title-main">Abdominal trauma</span> Medical condition

Abdominal trauma is an injury to the abdomen. Signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen. Complications may include blood loss and infection.

<span class="mw-page-title-main">Diaphragmatic rupture</span> Tear in the thoracic diaphragm, usually caused by physical trauma

Diaphragmatic rupture is a tear of the diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in breathing. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from blunt or penetrating trauma and occurs in about 0.5% of all people with trauma.

Trauma surgery is a surgical specialty that utilizes both operative and non-operative management to treat traumatic injuries, typically in an acute setting. Trauma surgeons generally complete residency training in general surgery and often fellowship training in trauma or surgical critical care. The trauma surgeon is responsible for initially resuscitating and stabilizing and later evaluating and managing the patient. The attending trauma surgeon also leads the trauma team, which typically includes nurses and support staff, as well as resident physicians in teaching hospitals.

Damage control surgery (DCS) is surgical intervention to keep the patient alive rather than correct the anatomy. It addresses the "lethal triad" for critically ill patients with severe hemorrhage affecting homeostasis leading to metabolic acidosis, hypothermia, and increased coagulopathy.

<span class="mw-page-title-main">Spleen pain</span> Human pain from the area of the spleen

Spleen pain is a pain felt from the left upper quadrant of the abdomen or epigastrium where the human spleen is located or neighboring.

Pelvic abscess is a collection of pus in the pelvis, typically occurring following lower abdominal surgical procedures, or as a complication of pelvic inflammatory disease (PID), appendicitis, or lower genital tract infections. Signs and symptoms include a high fever, pelvic mass, vaginal bleeding or discharge, and lower abdominal pain. It can lead to sepsis and death.

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  11. ↑ Gogna S, Saxena P, Tuma F (2020). "Mattox Maneuver". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   30335295 . Retrieved 2020-11-10.
  12. ↑ D'Cruz JR, Misra S, Shamsudeen S (2020). Pancreaticoduodenectomy. Treasure Island (FL): StatPearls Publishing. PMID   32809582 . Retrieved 2020-11-10.{{cite book}}: |work= ignored (help)
  13. 1 2 3 4 5 6 7 8 9 American College of Surgeons Committee on Trauma (2018). ATLS Advanced Trauma Life Support Student Course Manual (Tenth ed.). American College of Surgeons. ISBN   978-0-9968262-3-5.
  14. ↑ Ansari D, Toren W, Lindberg S, Pyrhonen H, Andersson R (2019). "Diagnosis and management of duodenal perforations: a narrative review". Scandinavian Journal of Gastroenterology. 54 (8): 939–944. doi: 10.1080/00365521.2019.1647456 . PMID   31353983. S2CID   198965786.
  15. ↑ Singh S, Sookraj K (2020). "Kidney Trauma". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   30422491 . Retrieved 2020-11-20.
  16. ↑ Dave S, Toy FK, London S (2020). "Pancreatic Trauma". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   29083741 . Retrieved 2020-11-20.
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  18. ↑ Mallol M, Sabaté A, Dalmau A, Koo M (September 2013). "Risk factors and mortality after elective and emergent laparatomies for oncological procedures in 899 patients in the intensive care unit: a retrospective observational cohort study". Patient Safety in Surgery. 7 (1): 29. doi: 10.1186/1754-9493-7-29 . PMC   3847296 . PMID   24007279.
  19. ↑ Quebbeman FE (1966). "Medicine In Territorial Arizona" (PDF). University of Arizona. Archived (PDF) from the original on 10 December 2013. Retrieved 7 December 2013.
  20. ↑ Marcy HO (1889-01-26). "EXPLORATORY LAPAROTOMY.: Read in the Section on Surgery, at the Thirty-ninth Annual Meeting of the American Medical Association, May, 1888". Journal of the American Medical Association. XII (4): 115–116. doi:10.1001/jama.1889.02400810007001a. ISSN   0002-9955.
  21. ↑ Medeiros LR, Rosa DD, Bozzetti MC, Fachel JM, Furness S, Garry R, et al. (April 2009). "Laparoscopy versus laparotomy for benign ovarian tumour". The Cochrane Database of Systematic Reviews (2): CD004751. doi:10.1002/14651858.cd004751.pub3. hdl: 10183/181311 . PMID   19370607.
  22. ↑ Galaal K, Donkers H, Bryant A, Lopes AD, et al. (Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group) (October 2018). "Laparoscopy versus laparotomy for the management of early stage endometrial cancer". The Cochrane Database of Systematic Reviews. 2018 (10): CD006655. doi:10.1002/14651858.CD006655.pub3. PMC   6517108 . PMID   30379327.
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