Laparotomy, exploratory

Definition

A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside of the abdominal cavity.

Purpose

Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure may be recommended for a patient who has abdominal pain of unknown origin or who has sustained an injury to the abdomen. Injuries may occur as a result of blunt trauma (e.g., road traffic accident) or penetrating trauma (e.g., stab or gunshot wound). Because of the nature of the abdominal organs, there is a high risk of infection if organs rupture or are perforated. In addition, bleeding into the abdominal cavity is considered a medical emergency. Exploratory laparotomy is used to determine the source of pain or the extent of injury and perform repairs if needed.

Laparotomy may be performed to determine the cause of a patient's symptoms or to establish the extent of a disease. For example, endometriosis is a disorder in which cells from the inner lining of the uterus grow elsewhere in the body, most commonly on the pelvic and abdominal organs. Endometrial growths, however, are difficult to visualize using standard imaging techniques such as x ray, ultrasound technology, or computed tomography (CT) scanning. Exploratory laparotomy may be used to examine the abdominal and pelvic organs (such as the ovaries, fallopian tubes, bladder, and rectum) for evidence of endometriosis. Any growths found may then be removed.

Exploratory laparotomy plays an important role in the staging of certain cancers. Cancer staging is used to describe how far a cancer has spread. A laparotomy enables a surgeon to directly examine the abdominal organs for evidence of cancer and remove samples of tissue for further examination. When laparotomy is used for this use, it is called staging laparotomy or pathological staging.

Some other conditions that may be discovered or investigated during exploratory laparotomy include:

• cancer of the abdominal organs
• peritonitis (inflammation of the peritoneum, the lining of the abdominal cavity)
• appendicitis (inflammation of the appendix)
• pancreatitis (inflammation of the pancreas)
• abscesses (a localized area of infection)
• adhesions (bands of scar tissue that form after trauma or surgery)
• diverticulitis (inflammation of sac-like structures in the walls of the intestines)
• intestinal perforation
• ectopic pregnancy (pregnancy occurring outside of the uterus)
• foreign bodies (e.g., a bullet in a gunshot victim)
• internal bleeding

Demographics

Because laparotomy may be performed under a number of circumstances to diagnose or treat numerous conditions, no data exists as to the overall incidence of the procedure.

Description

The patient is usually placed under general anesthesia for the duration of surgery. The advantages to general anesthesia are that the patient remains unconscious during the procedure, no pain will be experienced nor will the patient have any memory of the procedure, and the patient's muscles remain completely relaxed, allowing safer surgery.

Incision

Once an adequate level of anesthesia has been reached, the initial incision into the skin may be made. A scalpel is first used to cut into the superficial layers of the skin. The incision may be median (vertical down the patient's midline), paramedian (vertical elsewhere on the abdomen), transverse (horizontal), T-shaped, or curved, according to the needs of the surgery. The incision is then continued through the subcutaneous fat, the abdominal muscles, and finally, the peritoneum. Electrocautery is often used to cut through the subcutaneous tissue as it

During a laparotomy, and an incision is made into the patient's abdomen (A). Skin and connective tissue called fascia is divided (B). The lining of the abdominal cavity, the peritoneum, is cut, and any exploratory procedures are undertaken (C). To close the incision, the peritoneum, fascia, and skin are stitched (E). (

Illustration by GGS Inc.

)

Abdominal exploration

The surgeon may then explore the abdominal cavity for disease or trauma. The abdominal organs in question will be examined for evidence of infection, inflammation, perforation, abnormal growths, or other conditions. Any fluid surrounding the abdominal organs will be inspected; the presence of blood, bile, or other fluids may indicate specific diseases or injuries. In some cases, an abnormal smell encountered upon entering the abdominal cavity may be evidence of infection or a perforated gastrointestinal organ.

If an abnormality is found, the surgeon has the option of treating the patient before closing the wound or initiating treatment after exploratory surgery. Alternatively, samples of various tissues and/or fluids may be removed for further analysis. For example, if cancer is suspected, biopsies may be obtained so that the tissues can be examined microscopically for evidence of abnormal cells. If no abnormality is found, or if immediate treatment is not needed, the incision may be closed without performing any further surgical procedures.

During exploratory laparotomy for cancer, a pelvic washing may be performed; sterile fluid is instilled into the abdominal cavity and washed around the abdominal organs, then withdrawn and analyzed for the presence of abnormal cells. This may indicate that a cancer has begun to spread (metastasize).

Closure

Upon completion of any exploration or procedures, the organs and related structures are returned to their normal anatomical position. The incision may then be sutured (stitched closed). The layers of the abdominal wall are sutured in reverse order, and the skin incision closed with sutures or staples.

Diagnosis/Preparation

Various diagnostic tests may be performed to determine if exploratory laparotomy is necessary. Blood tests or imaging techniques such as x ray, computed tomography (CT) scan, and magnetic resonance imaging (MRI) are examples. The presence of intraperitoneal fluid (IF) may be an indication that exploratory laparotomy is necessary; one study indicated that IF was present in nearly three-quarters of patients with intra-abdominal injuries.

Directly preceding the surgical procedure, an intravenous (IV) line will be placed so that fluids and/or medications may be administered to the patient during and after surgery. A Foley catheter will be inserted into the bladder to drain urine. The patient will also meet with the anesthesiologist to go over details of the method of anesthesia to be used.

Aftercare

The patient will remain in the postoperative recovery room for several hours where his or her recovery can be closely monitored. Discharge from the hospital may occur in as little as one to two days after the procedure, but may be later if additional procedures were performed or complications were encountered. The patient will be instructed to watch for symptoms that may indicate infection, such as fever, redness or swelling around the incision, drainage, and worsening pain.

Risks

Risks inherent to the use of general anesthesia include nausea, vomiting, sore throat, fatigue, headache, and muscle soreness; more rarely, blood pressure problems, allergic reaction, heart attack, or stroke may occur. Additional risks include bleeding, infection, injury to the abdominal organs or structures, or formation of adhesions (bands of scar tissue between organs).

Normal results

The results following exploratory laparotomy depend on the reasons why it was performed. The procedure may indicate that further treatment is necessary; for example, if cancer was detected, chemotherapy, radiation therapy, or more surgery may be recommended. In some cases, the abnormality is able to be treated during laparotomy, and no further treatment is necessary.

Morbidity and mortality rates

The operative and postoperative complication rates associated with exploratory laparotomy vary according to the patient's condition and any additional procedures performed.

Alternatives

Laparoscopy is a relatively recent alternative to laparotomy that has many advantages. Also called minimally invasive surgery, laparoscopy is a surgical procedure in which a laparoscope (a thin, lighted tube) and other instruments are inserted into the abdomen through small incisions. The internal operating field may then be visualized on a video monitor that is connected to the scope. In some patients, the technique may be used for abdominal exploration in place of a laparotomy. Laparoscopy is associated with faster recovery times, shorter hospital stays, and smaller surgical scars.

Resources

BOOKS

Marx, John A., et al. Rosen's Emergency Medicine. St. Louis, MO: Mosby, Inc., 2002.

PERIODICALS

Hahn, David D., Steven R. Offerman, and James F. Holmes. "Clinical Importance of Intraperitoneal Fluid in Patients with Blunt Intra-abdominal Injury." American Journal of Emergency Medicine 20, no. 7 (November 2002).

OTHER

Awori, Nelson, et al. "Laparotomy." Primary Surgery. [cited April 6, 2003]. http://www.meb.uni-bonn.de/dtc/primsurg/index.html .

"Surgery by Laparotomy." Stream OR. 2001 [cited April 6, 2003]. http://www.streamor.com/opengyn/openindex.html .

Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Depending on the reason for performing an exploratory laparotomy, the procedure may be performed by a general or specialized surgeon in a hospital operating room . In the case of trauma to the abdomen, laparotomy may be performed by an emergency room physician.

QUESTIONS TO ASK THE DOCTOR

• Why is exploratory laparotomy being recommended?
• What diagnostic tests will be performed to determine if exploratory laparotomy is necessary?
• Are any additional procedures anticipated?
• What type of incision will be used and where will it be located?