Exploratory Laparotomy

Overview
Background
By definition, an exploratory laparotomy is a laparotomy performed with the objective of obtaining information that is not
available via clinical diagnostic methods. It is usually performed in patients with acute or unexplained abdominal pain, in patients
who have sustained abdominal trauma, and occasionally for staging in patients with a malignancy.
Once the underlying pathology has been determined, an exploratory laparotomy may continue as a therapeutic procedure;
sometimes, it may serve as a means of confirming a diagnosis (as in the case of laparotomy and biopsy for intra-abdominal
masses that are considered inoperable). These applications are distinct from laparotomy performed for specific treatment, in
which the surgeon plans and executes a therapeutic procedure.
With the increasing availability of sophisticated imaging modalities and other investigative techniques, the indications for and
scope of exploratory laparotomy have shrunk over time. The increasing availability of laparoscopy as a minimally invasive
means of inspecting the abdomen has further reduced the applications of exploratory laparotomy. [1] Nevertheless, the importance
of exploratory laparotomy as a rapid and cost-effective means of managing acute abdominal conditions and trauma cannot be
overemphasized.

Indications
Primary indications for an exploratory laparotomy are as follows.
Acute-onset abdominal pain and clinical findings suggestive of intra-abdominal pathology necessitating emergency surgery
In these conditions, exploratory laparotomy is carried out both to diagnose the condition and to perform the necessary
therapeutic procedure.
Patients with clinical features of peritonitis may have pneumoperitoneum on erect chest and abdominal radiographs. They
usually have a perforated viscus, most commonly the duodenum, stomach, small intestine, cecum, or sigmoid colon. Exploratory
laparotomy is done first to determine the exact cause of pneumoperitoneum, followed by the therapeutic procedure. In the
absence of pneumoperitoneum, appendicular perforation and intestinal ischemia are possible diagnoses; a high index of
suspicion for possible intestinal ischemia should be maintained.
Patients with vomiting, obstipation, and abdominal distention are likely to have intestinal obstruction. Abdominal radiographs in
these patients may reveal dilated intestinal loops and air-fluid levels. Hernia, especially an incarcerated inguinal hernia, should
be ruled out as a possible cause of the obstruction.
Patients with pain in the abdomen and fever may have intra-abdominal collections. These are usually detected by means of
ultrasonography or computed tomography (CT) and can often be managed percutaneously. A persistently high aspirate or the
presence of enteric contents may suggest perforation, and laparotomy may be required to control the source.
Abdominal trauma with hemoperitoneum and hemodynamic instability
Hemodynamically unstable trauma patients with hemoperitoneum should undergo exploratory laparotomy without any delay.
They are likely to have intraperitoneal bleeding after injury to the liver, spleen, or mesentery. They may also have associated
intestinal perforations that call for emergency repair.
In patients with penetrating abdominal trauma (PAT), exploratory laparotomy was conventionally carried out to rule out intraabdominal injury. However, Kevric et al found that peritoneal breach does not necessarily equate to visceral injury mandating
surgery; they suggested sequential examination when the CT scan is normal. [2] Sanie et al reported similar findings.[3] The role of
laparoscopy was highlighted in a systematic review in patients with PAT.[4] Laparoscopy has been found to be useful in identifying
diaphragmatic injury but has been found less sensitive for detecting hollow visceral injuries. It is, however, very good for
identifying the need for exploratory laparotomy.
Chronic abdominal pain
Availability of good imaging facilities have restricted the use of exploratory laparotomy in these conditions; however, when limited
facilities are available, exploratory laparotomy becomes an important diagnostic tool. These patients may have intra-abdominal
adhesions, tuberculosis, or tubo-ovarian pathology.[5]
Staging of ovarian malignancy and Hodgkin disease
The role of surgical staging in Hodgkin disease is controversial, and recommendations are restricted to patients who may be
considered for primary radiotherapy as the sole modality of treatment. [6]
Obscure gastrointestinal bleeding

The role of exploratory laparotomy has diminished over the last few years with the availability of good imaging, endoscopic
techniques, and laparoscopy. However, in centers with limited facilities or when the bleeding is profuse, exploratory laparotomy,
with on-table enteroscopy when indicated, can help identify the source. [7] Ambiru et al used exploratory laparotomy with capsule
endoscopy, CT, and mesenteric angiography for the diagnosis of ileal and ovarian varices in a patient with obscure
gastrointestinal bleeding.[8]

Contraindications
The primary contraindication for exploratory laparotomy is unfitness for general anesthesia. Peritonitis with severe sepsis,
advanced malignancy, and other comorbid conditions may render patients unfit for general anesthesia.

Technical considerations
Exploratory laparotomy is sometimes a good diagnostic tool. However, anticipation of the diagnosis is necessary, and a hasty
exploration should be avoided if the center is not well equipped to perform the therapeutic procedure that will be necessary if the
suspected condition is confirmed.
Nontherapeutic laparotomy is associated with significant long-term morbidity, including adhesive intestinal obstruction and
incisional hernia. Consequently, exploratory laparotomy should be performed in accordance with standard protocols and
guidelines for laparotomy.
The authors have found that in equivocal cases of acute abdomen, diagnostic peritoneal lavage (DPL) is often helpful in
determining the need for exploratory laparotomy. If DPL findings are positive, then an exploratory laparotomy is performed; if
DPL findings are negative, the patient is closely monitored.[9]

Periprocedural Care
Preprocedural planning
The patient's physiologic status at laparotomy is an important determinant of outcome. Accordingly, whenever possible, efforts
should be made to optimize the patient's general condition. This includes correction of fluid and electrolyte imbalances, blood
transfusions, and bronchodilator nebulizations as required.
Before the procedure, a nasogastric tube and an indwelling urinary catheter are inserted to decompress the stomach and the
urinary bladder. Decompression of the stomach reduces the risk of aspiration of gastric contents during induction of anesthesia.
The risk of such aspiration is high in these patients because of the emergency nature of the procedure and because of paralytic
ileus. Decompression of the bladder reduces the risk that the bladder may be injured as the midline incision is extended
inferiorly for better exposure.

Equipment
Exploratory laparotomy is performed in an operating room (OR). The OR should contain anesthetic equipment, overhead lights,
electrodiathermy equipment, and suctioning systems. A standard laparotomy tray is usually sufficient for an exploratory
laparotomy.
If vascular intervention is anticipated, vascular instruments may be required. If major abdominal organ resection may be needed,
appropriate instruments, facilities, and expertise should be available. Similarly, abdominal trauma necessitates major abdominal
surgery, for which appropriate infrastructure and expertise are required.

Patient preparation
Patient preparation includes adequate anesthesia and appropriate patient positioning.
Anesthesia
Exploratory laparotomy is performed with the patient under general anesthesia. Patients who are anesthetized for emergency
surgery are at higher risk for aspiration of gastric contents. Adequate care must be taken to empty the stomach before induction.
Rapid-sequence induction considerably reduces the risk of aspiration. [10]
Positioning
The patient is placed in the supine position, with the arms abducted at right angles to the body. The lithotomy position may be
employed instead when a pelvic pathology is suspected and a simultaneous vaginal or rectal intervention is necessary.

Technique
Procedure
After appropriate preparation (see Periprocedural Care), exploratory laparotomy is performed as follows.
Midline incision and opening of peritoneum

A vertical midline incision is the best choice: it affords a rapid entry into the peritoneum and is relatively bloodless and safe.
[11]
The incision may be made in the upper, middle, or lower midline, depending on the anticipated pathology, and may be
extended in either direction if necessary. Exposure of the peritoneum should never be compromised in an attempt to keep the
incision small.
The skin is incised with a surgical knife. Electrocautery can be used instead of the traditional scalpel for making the incision, as
skin incisions made by cutting diathermy are quicker, associated with less blood loss, and demonstrate no significant difference
in the rate of wound complications, scar cosmesis, or postoperative pain. [12, 13] The incision is then deepened through the
subcutaneous fat (see the image below). Electrodiathermy in coagulation mode provides a bloodless access through this layer.
The linea alba is identified as a glistening layer deep to the subcutaneous tissues.

Upper midline incision. Incision is deepened through subcutaneous tissue to expose

linea alba.

The orientation of the fibers on the linea alba is appreciated; these fibers are directed medially and inferiorly from either side,
and the midline is identified as the axis where they criss-cross. This is opened carefully by means of electrodiathermy or heavy
Mayo scissors (see the images below).

Linea alba is divided to reveal preperitoneal fat.

Abdominal incision is completed to reveal intra-abdominal organs.

Every effort must be made to avoid injury to the intraperitoneal contents. This can be done by lifting the peritoneum in two
straight artery forceps placed close to each other at right angles to the incision. Use careful palpation to ensure that no bowel or
omentum is picked up in the artery forceps. In reoperations, extreme care is necessary because the underlying bowel may be
adherent to the parietal peritoneum. In these cases, the peritoneum is opened in a virgin area, preferably by extending the
incision appropriately.
Exploration of abdominal cavity
The steps of exploration depend on the initial findings and are governed by the principles of systematic survey and priority for
life-saving maneuvers.
Massive hemoperitoneum suggests two things. First, the patient may have a major source of bleeding. Second, the presence of
blood within the peritoneum interferes with adequate exploration. The ideal strategy is to lift the small bowel and its mesentery

out of the peritoneal cavity, to rapidly suction the blood within the peritoneum, and to place laparotomy pads in the four
quadrants of the peritoneum. Once this is done, each pad is carefully removed to allow inspection of each quadrant.
Identification of the source of bleeding is much easier in the absence of massive hemoperitoneum. Common sources include
injuries to the liver (see the image below) or spleen, ruptured ectopic pregnancies, mesenteric tears, hollow visceral injuries,
aortic aneurysms, and splenic or hepatic artery aneurysms. Once the source of bleeding is identified, necessary corrective
measures must be taken.

Liver laceration in traffic accident victim who presented with

hemoperitoneum.

If enteric contents are the finding, they are suctioned out with a sump suction catheter, and the source of the enteric
contamination is sought. This search must be performed systematically, starting from the stomach. The anterior aspect of the
stomach is inspected for a perforation, followed by the duodenum.
Subsequently, the small bowel is inspected carefully, starting from the duodenojejunal flexure.
Each segment of the intestine is held up by the surgeon, and all surfaces are inspected. Any slough on the serosal surface is
gently separated to allow identification of an underlying perforation (see the image below).

Laparotomy in patient with peritonitis. Image shows perforated

duodenal ulcer.

If no source of enteric contents is found in the small intestine, the appendix and then the colon are examined. Any perforation
found in the intestine is controlled. Methods of controlling the source include direct repair, buttressed repair, resection, and
anastomosis or exteriorization of the perforation with stoma formation. The choice between the different options depends on the
site of perforation, the suspected pathology, the extent of the disease, and the patient's physiologic status.
In patients with intestinal obstruction, possible findings on exploratory laparotomy include adhesive intestinal obstruction, a
single intraperitoneal band with intestinal compression or torsion, and tumors (see the images below).

Laparotomy in patient with intestinal obstruction. Intraoperatively,

single peritoneal band causing intestinal obstruction was found.

Laparotomy in patient with acute intestinal obstruction. Sigmoid

volvulus with gangrene was found intraoperatively.

Multiple omental deposits in patient with disseminated carcinoma of stomach.

Multiple metastatic deposits over small bowel in patient with colonic malignancy.

Staging laparotomy should include a thorough search for foci of malignancy, splenectomy, wedge and core liver biopsies, and
sampling of retroperitoneal lymph nodes. In premenopausal women, oophoropexy is performed in anticipation of radiotherapy.
Completion and closure
Placement of drains after an exploratory laparotomy is still a subject of debate. The evidence currently available is inadequate to
support routine drain placement. Patients with extensive contamination may benefit from drains in the subhepatic space and the
pelvis.[14]
Once the procedure is completed, the abdominal wall is closed. Before closure, however, the instrument and pad counts must
be double-checked. The surgeon should manually inspect the peritoneum for any retained pads or instruments, even if scrub
nurse has found the count to be correct.
Closure is carried out with either nonabsorbable suture material (eg, polypropylene) or a delayed absorbable suture material (eg,
polydioxanone) in either a continuous suture or interrupted sutures. The standard approach is to place sutures about 1 cm from
the edge of the incised linea alba, maintaining a distance of 1 cm between successive bites.
Sometimes, the Smead-Jones closure technique (ie, single-layer mass closure) may be employed to close the abdomen if the
abdominal wall is plastered and separate layers are unavailable as a result of previous operations. This technique makes use of
figure-eight sutures.[15]
At times, closure may be rendered difficult by an edematous or distended bowel. In such circumstances, forced closure may
have adverse postoperative outcomes in the form of impaired ventilation, intra-abdominal hypertension, pain, and dehiscence.
Laparostomy and delayed closure may be a better option in such cases. [16]

Complications
An exploratory laparotomy is associated with the same complications that are associated with any laparotomy. Immediate
complications include the following:

Paralytic ileus
Intra-abdominal collection or abscess
Wound infections
Abdominal wall dehiscence
Pulmonary atelectasis
Enterocutaneous fistula
Delayed complications include the following:
Adhesive intestinal obstruction
Incisional hernia

What is a Laparotomy?
A surgical opening through the skin layer and abdominal wall into the peritoneal cavity.

Examples of a laparotomy procedure are:

Bowel procedures

What is an exploratory laparotomy?

Procedure done when the surgeon is not completely sure of a diagnosis

Equipment and instrument sets unique to a laparotomy procedure:

Major laparotomy set

Supplies unique to a laparotomy procedure:

Laparotomy back table pack

Preoperative preparation of a laparotomy procedure:

Supine position; skin prep: mid-chest to symphysis pubis and laterally as far as possible;
may extend to mid-thigh for extended procedures

Suction tools used in a laparotomy procedure:

Yankauer and Poole suction tips; when using the Poole suction tip within the abdominal
cavity the surgeon may want to wrap a wet lap sponge around the tip to prevent tissue
attaching to the tip and being damaged

Irrigation used in a laparotomy procedure:

The surgeon may irrigate the abdominal cavity with an antibiotic solution using a
graduated pitcher

Retractors used in a laparotomy procedure:

Either handheld or self-retaining retractors

General surgery steps during an exploratory laparotomy procedure (opening)

1. Midline incision (knife)
* have 2 lap sponges, ESU pencil and forceps ready
2. The incision is deepened
* The larger, deeper retractors, are often used
3. Bleeding vessels are clamped with small hemostats; ligated with non absorbable ties or
cauterized
4. The external oblique muscle is opened
* have Mayo scissors, ESU, or scalpel ready
* bleeding vessels are controlled (step #3)
5. Medium retractors are placed to retract the external oblique muscle
*Richardson retractors often used
6. The internal oblique muscle, transverse muscle, and transversalis fascia are split in the
direction of the muscle fibers
*a scalpel or curved Mayo scissors are used
*medium retractors are replaced with large Richardson retractors
7. The peritoneum is exposed; a small incision is made
*smooth forceps and a scalpel is used
*surgeon may prefer a small hemostat to elevate the peritoneum
8. If abnormal fluid is encountered, sponges and suction are used
*cultures may be taken if necessary
9.The edges of the peritoneum and transversalis fascia are grasped with a Kocher
10. The peritoneal incision is lengthened
* a Metzenbaun, curved Mayo or scalpel may be used
11. Tissue in the direction of the pelvis may be cut; blood vessels in the fatty layer
between the fascia and the umbilicus could bleed
*ties, clamps, or cautery may be used
12. Richardson retractors are repositioned to allow the surgeon to conduct an initial
exploration of the abdomen
13. Affected and non affected organs are identified
* self-retaining retractors such as the Balfour or Bookwalter may be used

General surgery steps during an exploratory laparotomy procedure (closing)

1. The peritoneum and internal oblique fascia are closed

*Sponge, sharps and instruments counts are completed before the abdominal cavity is
closed
2. If peritoneum closed separately:
*have toothed forceps and clamps ready
*Synthetic absorbable sutures or interrupted nonabsorbable sutures may be used
*A ribbon retractor may be used under the peritoneal later
the internal oblique fascia is closed with absorbable or nonabsorbable sutures
3. If single-unit closure:
*a heavy looped or synthetic absorbable or nonabsorbable suture is used e.g. #0 or #1
4. The external oblique fascia and Scarpa's fascia are separately closed
*3-0 absorbable sutures are often used
*deeper retractor are replaced with smaller retractors
5. The subcuticular layer is closed
3-0 or 4-0 absorbable sutures are used
5. The skin is closed
*last count is completed
*toothed Adson forceps may be used to grasp the skin
*3-0 or 4-0 silk or nylon on a cutting needle may be used
6. Subcuticular closure
* 3-0, 4-0, or 5-0 synthetic absorbable/nonabsorbable sutures may be used
*skin staples may be used to approximate skin edges
http://www.youtube.com/watch?v=W-ZPa1NzcgM

INSTRUMENTS USED IN EXPLORATORY LAPAROTOMY Primary Set up - First Tray

CLAMPS:

SCISSORS:
A 4 ? Halstead Mosquito Forceps, Curved
M 1 ? Mayo Straight, 5 ?
B 2 ? Halstead Mosquito Forceps, Straight N
1 ? Mayo Curved, 5 ?
C 2 ? Rochester Pean Forceps, 5 ? Curved
O 1 ? Metzenbaum Straight, 5 ?
D 2 ? Rochester Pean Forceps, 6 ? Curved
P 1 ? Metzenbaum Curved, 5 ?
E 2 ? Mixter Forceps, Right Angle
Q 1 ? Metzenbaum Curved, 8?
F 2 ? Babcock Intestinal Forceps, 6?
G 2 ? Allis Tissue Forceps
FORCEPS:
H 3 ? Kocher Forceps, Straight
R 1 ? Adson Brown, 4?
I 2 ? Kocher Forceps, Curved
S 1 ? Adson Brown Multi-tooth
J 2 ? Foerster Sponge Forceps
T 1 ? Thumb Forceps
U 1 ? DeBakey Forceps

 KNIVES:
K 2 - #3 Scalpel Handle
L 1 - #3 Long Scalpel Handle