Laparotomy

Last updated
Laparotomy
Other namesCeliotomy
Specialty General surgery

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.

Contents

Origins and history

The first successful laparotomy was performed without anesthesia by Ephraim McDowell in 1809 in Danville, Kentucky. On July 13, 1881, George E. Goodfellow treated a miner outside Tombstone, Arizona Territory, who had been shot in the abdomen with a .32-caliber Colt revolver. Goodfellow was able to operate on the man nine days after he was shot, when he performed the first laparotomy to treat a bullet wound. [1]

Terminology

The term comes from the Greek word λᾰπάρᾱ (lapara) 'the soft part of the body between the ribs and hip, flank' [2] and the suffix -tomy, from the Greek word τομή (tome) '(surgical) cut'.

In diagnostic laparotomy (most often referred to as an exploratory laparotomy and abbreviated ex-lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause.

In therapeutic laparotomy, a cause has been identified (e.g. colon cancer) and the operation is required for its therapy.

Usually, only exploratory laparotomy is considered a stand-alone surgical operation. When a specific operation is already planned, laparotomy is considered merely the first step of the procedure.

Spaces accessed

Depending on incision placement, laparotomy may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include:[ citation needed ]

Types of incisions

Midline

The most common incision for laparotomy is a vertical incision in the middle of the abdomen which follows the linea alba.[ citation needed ]

Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity.

Midline incision

  1. Cut (incise) the skin in midline
  2. Cut (incise) subcutaneous tissue
  3. Divide the linea alba (white line of the abdomen)
  4. Pick up peritoneum, confirm that there is no bowel adhesion (intestinal adhesion)
  5. Nick peritoneum
  6. Insert finger beneath the wound to make sure that there is no adhesion
  7. Cut the peritoneum with scissors

Other

Other common laparotomy incisions include:

Complications following laparotomy

Globally, there are few studies comparing perioperative mortality following laparotomy across different health systems.

A study in the UK with more than 180,000 patients aimed to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the United Kingdom National Emergency Laparotomy Audit (NELA) database. A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013–December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Results showed that quantitative futility occurred in 4% of patients (7442/180,987) and median age was 74 years. Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality and surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery. These findings suggest that quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively and should be incorporated into shared decision-making discussions with extremely high-risk patients. [11]

There are also several national studies looking at 30-day mortality in various health systems including the United Kingdom (the National Emergency Laparotomy Audit- NELA) and Australia and New Zealand (ANZELA). One major prospective study of 10,745 adult patients undergoing emergency laparotomy from 357 centres in 58 high-, middle-, and low-income countries found that mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. [12] In this study the overall global mortality rate was 1.6 percent at 24 hours (high 1.1 percent, middle 1.9 percent, low 3.4 percent; P < 0.001), increasing to 5.4 percent by 30 days (high 4.5 percent, middle 6.0 percent, low 8.6 percent; P < 0.001). Of the 578 patients who died, 404 (69.9 percent) did so between 24 h and 30 days following surgery (high 74.2 percent, middle 68.8 percent, low 60.5 percent). Patient safety factors were suggested to play an important role, with use of the WHO Surgical Safety Checklist associated with reduced mortality at 30 days.[ citation needed ]

Taking a similar approach, a unique global study of 1,409 children undergoing emergency laparotomy from 253 centres in 43 countries showed that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed in these settings. Internationally, the most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries. [13]

Absorption of drugs administered orally was shown to be significantly affected following abdominal surgery. [14]


A related procedure is laparoscopy, where cameras and other instruments are inserted into the peritoneal cavity via small holes in the abdomen. For example, an appendectomy can be done either by a laparotomy or by a laparoscopic approach.

There is no evidence of short-term or long-term advantages for peritoneal closure during laparotomy. [15]

See also

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">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.

<span class="mw-page-title-main">Appendicitis</span> Inflammation of the appendix

Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications of a ruptured appendix include widespread, painful inflammation of the inner lining of the abdominal wall and sepsis.

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

Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.

<span class="mw-page-title-main">Appendectomy</span> Surgical removal of the vermiform appendix

An appendectomy or appendicectomy is a surgical operation in which the vermiform appendix is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acute appendicitis.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the partial or total surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. Partial hysterectomies allow for hormone regulation while total hysterectomies do not.

Perioperative mortality has been defined as any death, regardless of cause, occurring within 30 days after surgery in or out of the hospital. Globally, 4.2 million people are estimated to die within 30 days of surgery each year. An important consideration in the decision to perform any surgical procedure is to weigh the benefits against the risks. Anesthesiologists and surgeons employ various methods in assessing whether a patient is in optimal condition from a medical standpoint prior to undertaking surgery, and various statistical tools are available. ASA score is the most well known of these.

<span class="mw-page-title-main">Uterine rupture</span> Medical condition

Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth. Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. Disability or death of the mother or baby may result.

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.

Diagnostic peritoneal lavage (DPL) or diagnostic peritoneal aspiration (DPA) is a surgical diagnostic procedure to determine if there is free floating fluid in the abdominal cavity.

<span class="mw-page-title-main">Retropubic space</span>

Retropubic space is a potential avascular space located between the pubic symphysis and the urinary bladder. The retropubic space is a preperitoneal space, located behind the transversalis fascia and in front of peritoneum.

Tubal reversal, also called tubal sterilization reversal, tubal ligation reversal, or microsurgical tubal reanastomosis, is a surgical procedure that can restore fertility to women after a tubal ligation. By rejoining the separated segments of the fallopian tube, tubal reversal can give women the chance to become pregnant again. In some cases, however, the separated segments cannot actually be reattached to each other. In some cases the remaining segment of tube needs to be re-implanted into the uterus. In other cases, when the end of the tube has been removed, a procedure called a neofimbrioplasty must be performed to recreate a functional end of the tube which can then act like the missing fimbria and retrieve the egg that has been released during ovulation.

<span class="mw-page-title-main">Pfannenstiel incision</span> Surgical incision of the abdomen

A Pfannenstiel incision, Kerr incision, Pfannenstiel-Kerr incision or pubic incision is a type of abdominal surgical incision that allows access to the abdomen. It is used for gynecologic and orthopedics surgeries, and it is the most common method for performing Caesarian sections today. This incision is also used in Stoppa approach for orthopedics surgeries to treat pelvic fractures.

<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">Lower segment Caesarean section</span> Type of caesarean section

A lower (uterine) segment Caesarean section (LSCS) is the most commonly used type of Caesarean section. Most commonly to deliver the baby a transverse incision is made in the lower uterine segment above the attachment of the urinary bladder to the uterus. This type of incision results in less blood loss and is easier to repair than other types of Caesarean sections.

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.

In surgery, a surgical incision is a cut made through the skin and soft tissue to facilitate an operation or procedure. Often, multiple incisions are possible for an operation. In general, a surgical incision is made as small and unobtrusive as possible to facilitate safe and timely operating conditions.

The Cherney incision is an incision used in gynecologic surgery. It is similar to the Pfannenstiel incision but allows access to the space of Retzius and gives a larger area in which to operate.

<span class="mw-page-title-main">Maylard incision</span>

Maylard incision is a surgical incision in which a transverse cut is made on rectus abdominis muscle to allow wider access to the pelvic cavity. It is also called Mackenrodt incision. For gynaecological surgery, the skin incision is made 5–8 cm above the pubic symphysis. The site of skin incision is above and parallel to traditional Pfannenstiel incision. The rectus fascia and muscle are cut transversely and the incision is extended as far laterally as needed. The anterior rectus sheath is not separated from the muscle to facilitate easy closure at the end of the surgical procedure. The inferior epigastric vessels which span across more than half of the rectus muscle's width are identified and ligated. In patients with peripheral arterial disease, ligation of inferior epigastric vessels may lead to distal ischemia. Finally, the peritoneum is cut laterally.

References

  1. ↑ Quebbeman, Frances Elizabeth (1966). "Medicine In Territorial Arizona" (PDF). University of Arizona. Archived (PDF) from the original on 10 December 2013. Retrieved 7 December 2013.
  2. ↑ "Henry George Liddell, Robert Scott, A Greek-English Lexicon, λ , λα_ο-σεβής , λα^πάρα_". www.perseus.tufts.edu. Retrieved 2018-08-02.
  3. ↑ synd/1010 at Who Named It?
  4. ↑ Williams GR (May 1983). "Presidential Address: a history of appendicitis. With anecdotes illustrating its importance" (PDF). Annals of Surgery. 197 (5): 495–506. doi:10.1097/00000658-198305000-00001. PMC   1353017 . PMID   6342553. Archived from the original (PDF) on 2018-09-04. Retrieved 2017-03-01.
  5. ↑ synd/2500 at Who Named It?
  6. ↑ Pfannenstiel HJ (1900). "Ueber die Vortheile des suprasymphysären Fascienquerschnitts für die gynäkologischen Koeliotomien" [On the Advantages of the Suprasymphyseal Fascia Cross Section for Gynecological Coeliotomies]. (Volkmann's) Sammlung Klinischer Vorträge (in German). Leipzig. 268 (Gynäk. Nr. 97): 1735–1756.
  7. ↑ Giacalone PL, Daures JP, Vignal J, Herisson C, Hedon B, Laffargue F (May 2002). "Pfannenstiel versus Maylard incision for cesarean delivery: A randomized controlled trial". Obstetrics and Gynecology. 99 (5 Pt 1): 745–50. doi:10.1016/S0029-7844(02)01957-9. PMID   11978282. S2CID   12855909.
  8. ↑ Slater SD (June 1994). "Alfred Ernest Maylard, 1855-1947: Glasgow surgeon extraordinaire". Scottish Medical Journal. 39 (3): 86–90. doi:10.1177/003693309403900312. PMID   8720774. S2CID   21365098.
  9. ↑ Bajpai M, Kumar A, Gupta AK, Pawar DK (June 2004). "Lumbotomy approach for upper urological tract surgery in children--an analysis of 68 consecutive lumbotomies". European Journal of Pediatric Surgery. 14 (3): 163–7. doi:10.1055/s-2004-820903. PMID   15211405.
  10. ↑ Tizzano AP, Muffly TM (2007). "Historical milestones in female pelvic surgery, gynecology, and female urology." (PDF). Urogynecology and Reconstructive Pelvic Surgery (3rd ed.). pp. 3–15. Archived from the original (PDF) on 2015-05-01. Retrieved 2017-03-02.
  11. ↑ Javanmard-Emamghissi, Hannah (2023). "Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit". Techniques in Coloproctology. 27 (9): 729–738. doi: 10.1007/s10151-022-02747-1 . PMC   10404199 . PMID   36609892.
  12. ↑ GlobalSurg Collaborative (July 2016). "Mortality of emergency abdominal surgery in high-, middle- and low-income countries". The British Journal of Surgery. 103 (8): 971–988. doi:10.1002/bjs.10151. hdl: 20.500.11820/7c4589f5-7845-4405-a384-dfb5653e2163 . PMID   27145169. S2CID   20764511.
  13. ↑ GlobalSurg Collaborative (2016). "Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries". BMJ Global Health. 1 (4): e000091. doi:10.1136/bmjgh-2016-000091. PMC   5321375 . PMID   28588977.
  14. ↑ Gershkovich, Pavel; Itin, Constantin; Yacovan, Avihai; Amselem, Shimon; Hoffman, Amnon (2009-03-31). "Effect of abdominal surgery on the intestinal absorption of lipophilic drugs: possible role of the lymphatic transport". Translational Research. 153 (6): 296–300. doi:10.1016/J.TRSL.2009.02.008. PMID   19446284.
  15. ↑ Gurusamy KS, Cassar Delia E, Davidson BR (July 2013). Cochrane Wounds Group (ed.). "Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations". The Cochrane Database of Systematic Reviews. 2019 (7): CD010424. doi:10.1002/14651858.CD010424.pub2. PMC   6353057 . PMID   23828487.
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