Laparotomy

A laparotomy for an acute abdomen will be the major test of your surgical skill. When you decide to do one, you should usually be sure what you will need to do when you get inside it[md]so try to make a correct diagnosis first, and try to avoid a purely ''exploratory laparotomy'. Before you start, discuss the procedure with him and his family, and if he is to have a colostomy, or a T-tube, make sure they understand it.

Try to avoid wound infections and dehiscence (''burst abdomen'), and the incisional hernias that commonly follow them. Make an incision which is big enough to allow you to get at the organs you want to operate on[md]a common mistake is to make it too short. Incisions heal from side-to-side, not from end-to-end, so don't be afraid of making a long one. The length of an incision has little relation to the incidence of operative shock. If an incision is too small: (1) you will not be able to dissect safely, and (2) your assistant will have to exert excessive traction on its edges, which will kill tissue, and increase the risk of wound sepsis and breakdown. A good surgeon makes incisions that are large enough to ensure safe dissection, and does not exhaust his assistants by requiring them to exert forceful traction.

If you separate muscle fibres instead of cutting across them, you help to make a patient's abdomen as strong afterwards as it was before. Avoid cutting his intercostal nerves, because a paralysed abdominal wall is more likely to herniate. Remember that they take an oblique downwards path between his internal oblique and transversus muscles.

Which incision? If possible, make a transverse incision in an infant because it heals better. In an adult a median or paramedian one will enable you to get at everything in the abdomen if you need to. You can make the middle part to begin with, and extend it from his xiphisternum to his pubis, if necessary. If exposure is particularly difficult, you can extend either incision laterally to make a ''T' incision.

A midline incision above the umbilicus is quick, simple, and bloodless, and is useful for emergency operations. But access to the organs at the sides of a patient's abdomen is not easy, and if you want to extend it around his umbilicus, you have to make a detour which is difficult to sew up nicely. Even so, midline incisions are usually best for trauma, for Caesarean sections, and for most pelvic operations. One contributor felt that they are so much the best, that we should not mention paramedian ones. If you wish, you can always make a midline incision. Above the umiblicus they heal well, as they do below it if you repair them with monofilament as a single layer.

The old type of paramedian incision, in which the rectus muscle was retracted laterally, too often dehisced. The newer rectus-splitting type is less likely to do this, especially if you repair it with monofilament in a single layer.

When you get inside, you will have to decide what to do. Here, only experience can tell you what is normal and what is not. For example, some Ascaris worms inside a child's gut may feel so abnormal as to convince you that they must be the cause of his symptoms, when in fact they are normal for his community.

Be gentle, gut is highly sensitive. If you handle it roughly, especially if it is obstructed, ileus may follow. Gut does not like being frequently drawn out of a wound. So, if you need to draw it out, do so only once, and hold it with a moist swab. While it rests on the abdominal wall, keep it covered with warm moist packs or towels, or place it in a large sterile plastic bag. If it is grossly distended, even the most gentle handling will burst it, so decompress it (10-9). Break down adhesions gently (10-11).

A COMMON ERROR IS TO MAKE THE INCISION TOO SHORT Fig. 9-2 OPENING THE PERITONEAL CAVITY. A, the skin has been incised and the rectus muscle split in the line of its fibres. The posterior rectus sheath and peritoneum form a single layer. Pick this up with a haemostat, and then apply another one 5 mm from it. Release the first haemostat (which might perhaps have picked up gut) and then reapply it. With the peritoneum still tented up, make a small incision between the two haemostats. Air will enter the patient's peritoneal cavity, and his viscera will fall away.

B, put your fingers into the incision to make sure that there are no adhesions to the under surface of his abdominal wall, and then extend it with scissors.

LAPAROTOMY RESUSCITATION. Make sure that the patient has a drip up with a large needle or a cannula. If necessary, splint his arm with an armboard, and tie this to the table. If bleeding is likely to be serious, have some blood cross-matched for him.

X-RAYS. Take these when necessary, and have his films in the theatre.

EQUIPMENT. A general set (4.12). A No. 22 scalpel blade. No. 1 (or 1/0 monofilament used double) for single layer closure. 2/0 monofilament for his skin. 2/0 silk or linen for ligatures. Fine half circle needles with a cutting edge for his skin, and round bodied ones for deeper structures. 2/0 catgut on atraumatic needles for intestinal anastomoses. Gallipots of some soapy solution and alcoholic iodine. Sterile towels and a sheet with a window in it.

ANAESTHESIA. (1) General anaesthesia, preferably with relaxants (A 14.3). (2) Local anaesthesia (6.9). (3) Subarachnoid (spinal) or epidural anaesthesia (A 7.1), provided he is not shocked.

Always pass a nasogastric tube (4.9). Aspirate his stomach contents before you take him to the theatre. If the operation is an emergency, put 30 ml of magnesium trisilicate down the tube to minimize the risk of the acid aspiration syndrome (A 16.3). Spigot it during induction, and aspirate it from time to time during the operation.

If he is gravely ill, from bleeding or infection, local anaesthesia may be safer than a general anaesthetic (A 5.4). Mix 20 ml of 2% lignocaine with 80 ml of saline to give 100 ml of 0.4% solution. To this add 0.5 ml of adrenalin 1:1000. Inject 10 ml of this solution into five sites in his rectus muscle on either side in quantities of 1 ml to block his segmental nerves. Use another 20 ml to infiltrate the midline incision. Use the remaining 10 ml to infiltrate the root of his mesentery if you need to resect his gut. If you have to do some extensive procedure, such as lavaging his abdominal cavity, inject ketamine 1 mg/kg intravenously. Alternatively, and with greater risk, inject pethidine intravenously in SMALL quantities of 5 mg. Patients who are old or shocked or sick, especially if they have been previously sedated, are very sensitive to even modest doses of pethidine, which may produce coma deep enough to need resuscitation. So be prepared to do this if necessary (A 3.4).

POSITION. For most abdominal operations, lie him on his back. If your table does not rotate from side to side, and you want him turned to one side, place pillows under his back on each side, or use a wedge block under the mattress.

If you are operating on his pelvic organs, you will find the Trendelenburg or head-down position helpful. It will allow his gut to fall towards his diaphragm, so that you get a better view into his pelvis. You will need well-padded shoulder rests to prevent him sliding downwards. Don't tip him too steeply, or the pressure on his diaphragm will impair his breathing. If he is in [mt]10[de] of Trendelenburg, you must intubate him, keep him on relaxants, and control his ventilation.

Use one arm for a blood pressure cuff and the other for an intravenous line. Keep his hands by his side, or out on arm boards, or folded on his chest with suitable ties; don't place them under his buttocks or under his head.

EXAMINATION. When he is anaesthetized and relaxed, feel his abdomen carefully. You may get a better appreciation of his abdominal pathology than you could when he was awake.

PREPARATION. See elsewhere for shaving and preparation (2.3). Drape his abdomen and fix the drapes with towel clips. Cover these with a large windowed sheet, and add additional sterile towels as necessary.

WHICH INCISION? (also see above) If you are doing a purely exploratory laparotomy, and don't know what you are going to find, make a midline or rectus-splitting incision in the correct half of his abdomen, upper or lower.

If you are reopening his abdomen, go through the old skin incision. Excise it and extend it so that you can enter his abdominal cavity above or below any adhesions to the under surface of his abdominal wall. Work your way up or down carefully, dividing any adhesions you find, so as not to injure any adherent gut.

CAUTION ! (1) If you are in doubt, make the ''incision of indecision' in the midline 5 cm above and below his umbilicus. Enter his abdomen and then extend it in the most useful direction. (2) Don't make a second incision parallel to an earlier one, because the tissues between them may necrose.

Before you make any abdominal incision, use the back of your scalpel to make some scratches across it. When you come to sew it up afterwards, these scratches will help you to bring the edges of the skin together accurately. Later, as you gain experience, stop doing this, as it may cause keloids.

MIDLINE INCISION UPPER MIDLINE INCISION. Use his xiphoid and umbilicus as landmarks, keep strictly to the midline, and don't cut into his rectus muscle on either side. It does not matter if you do, except that you may have difficulty approximating the wound edges later.

Cut down to his linea alba and then use the flat of the blade to clear 7 mm on either side, ready for closure later. Cut through his linea alba to expose his extraperitoneal fat. Use gauze dissection to move this to one side.

If necessary, extend the incision downwards. Cut 1.5 cm round his umbilicus[md]don't cut into it[md]it is full of bacteria! You can also get a little more length by incising between his xiphisternum and his costal cartilage.

LOWER MIDLINE INCISION. Make this in a similar way. You will see his pyramidalis muscle at the lower end of the wound. There is no posterior rectus sheath in the lower two-thirds of the wound, below his umbilicus.

Fig. 9-3 A MIDLINE INCISION. A, the site. B, cut down to the linea alba, and then carefully dissect the fat for a centimetre on either side, using the flat of the knife. C, incise the linea alba to expose the underlying fat and peritoneum. D, displace the fat and vessels laterally by blunt gauze dissection. E, pick up the peritoneum, incise it with a knife and split it with blunt- ended scissors. F, if you want to continue the incision downwards, go round the umbilicus. After Dudley HAF, ''Operative Sugery[md]the abdomen.' Butterworth, Permission requested.

PARAMEDIAN INCISION Make a paramedian incision 2.5 cm (not more) from the midline on the side where you expect to be working most, in the upper or lower abdomen, as required. If in doubt, centre it on his umbilicus, but carry the incision clear of it. If you expect to be working on a lateral structure, you will need good retraction to get adequate access, so make it at least 20 cm long.

Cut down to his rectus sheath, and then use the flat of the blade to clear 7 mm on either side, ready for closure later.

Divide his anterior rectus sheath, keeping well to its medial side. Above his umbilicus, where there are tendinous intersections, split it with a scalpel handle. The muscle medial to the split will be deprived of its nerve supply and atrophy, so don't split it more than than 2 cm from its medial edge. Put your two index fingers into the gap, and use them to split the rectus muscle in the length of the incision. Below his umbilicus split his rectus muscle or displace it laterally.

If necessary, tie his deep epigastric vessels before you divide his posterior rectus sheath. You probably won't see them because they lie laterally.

If his abdominal muscles bleed, clamp the bleeding vessels and tie them with catgut. Or, use pressure from a sponge. Or, transfix them with a ''figure of 8' catgut suture.

With his rectus muscle split, or out of the way, open his posterior rectus sheath and peritoneum as in Fig. 9.2, without injuring his gut! You can easily open it by mistake if: (1) it is obstructed, or (2) it has stuck to the a scar from a previous operation.

If you want to extend the incision, you can if necessary: (1) cut from his costal margin to his symphysis pubis, (2) extend the incision upwards between his xiphisternum and his costal cartilage, or (3) make a transverse cut in his left upper quadrant.

Fig. 9-4 A PARAMEDIAN INCISION. A, the site of the incision, which you can, if necessary, extend up to the inverted ''V' between the patient's xiphisternum and his costal cartilage, or down as far as his pubis. B, the way into his peritoneum. C, incising his anterior rectus sheath. D, incising his posterior rectus sheath after his rectus muscle has been split. E, the anatomy of the vessels to be tied. F, and G, incising his peritoneum. H, closing the muscles of his abdominal wall with a continuous monofilament single layer stitch. Alternatively, close the wound by Everett's method as in Section 9.8.

PFANNENSTEIL INCISION. See Section 23.15 and Fig. 23- 20.

ENTERING THE ABDOMEN Discovering what is wrong can be easy or very difficult. Be observant, learn to recognise what you see, and search thoroughly.

SMELL can tell you a lot. If a puff of gas greets you as you open his peritoneum, his gut has probably perforated. If there is an abnormal smell, it may be: acrid (a perforated peptic ulcer, or a typhoid perforation), faeculent (a ruptured caecum or sigmoid), the characteristic smell of E. coli (appendicitis with abscess formation or peritonitis), putrid (bacterioides or anaerobic streptococci), or urinary, as the result of an intraperitoneal rupture of his bladder.

LOOK FOR FLUID in his abdominal cavity, which may be: blood (an ectopic pregnancy or an injured liver, spleen, or mesentery); bile-tinged small gut contents (a perforated peptic or typhoid ulcer); a foul, turbid brown fluid (peritonitis from appendicitis); a watery, light-brown, odourless fluid (intestinal obstruction without strangulation); a watery, reddish-brown, offensive fluid (strangulation with incipient gangrene); or a pale straw-coloured fluid (ascites).

If there is any exudate, send it for culture, if you can.

If his peritoneum is fiery red with flakes of fibrinous exudate, he has peritonitis[md]see Section 6.2.

If there is bile-stained fluid in his paracolic gutter, he has probably perforated his gall bladder.

If he has an odourless greenish blood-stained effusion, he probably has pancreatitis (uncommon). Look behind his ileum at the peritoneum over his pancreas. Retroperitoneal oedema will help to confirm the diagnosis. Examine his omentum for flecks of fat necrosis.

If loops of his gut are distended, he has ileus, or his gut is obstructed. First find a loop of undistended gut. If there is one, then trace it proximally and you will find the obstruction. See Section 10.4.

If thickened oedematous omentum is adherent to something, it is a sign of acute inflammation, or strangulation (10.3), or abscess formation (6.3).

EXAMINE THE REST OF HIS ABDOMEN How extensively you should do this will vary. Limit your exploration to what is easily practicable if: (1) there is sepsis, or (2) you are operating for a known problem, or (3) your incision is a small one.

If there is infection, examine the infected area first. When you have dealt with it, consider whether you have done enough. Further exploration may spread the infection.

If there is carcinoma, start with the organs most distal to the diseased area, proceeding ''centripetally' towards the lesion.

If there is no obvious abnormality, search his abdomen in an orderly way. Examine his diaphragm and the upper surface of his liver, then examine his spleen, his stomach, his duodenum, and his intra-abdominal oesophagus. Examine his gall- bladder region. Then examine the whole of his small gut. Draw each loop out of the wound and then return it. Feel his major vessels. Feel his kidneys and look at his ureters. Examine the bladder, rectum, uterus, tubes, and ovaries. Finally look at his hernial orifices from inside. Don't forget to record your findings. Even negative ones can be most helpful later.

If you accidentally perforate a distended loop of gut, don't panic. Leave it there while someone gently clamps it with non-crushing clamps, and you surround the injured loop with packs to prevent the contents of his gut flooding into his peritoneal cavity. Have the sucker ready; repair the damage.

GET ADEQUATE EXPOSURE AND A GOOD LIGHT. You cannot do good work if loops of gut are always getting in the way, or if the light is bad, so adjust it as best you can. Make an adequate incision. If necessary extend it in one of the accepted directions. If you are working on a lateral organ through a midline incision, it will have to be a long one. Or, make a lateral T-shaped extension

Get good retraction. A self-retaining retractor will not be enough by itself. Use Deaver's retractor, or any large right-angled retractor, and make sure your assistant knows what you want him to do with it.

Get him into the best position You will never get adequate exposure in the pelvis unless his head is down in the Trendelenburg position. Similarly, if you are working on his upper abdomen (as when doing a vagotomy), tilt his head up a little. Extending his back by breaking the table or by putting a pillow under him will also help. If you want to draw his splenic flexure and small gut towards you, consider rolling him to the right, either by tilting the table or by using sandbags, or a wooden wedge under the mattress. If you are operating on his kidney, a kidney bridge or folded plastic-covered pillows will bring it forwards.

If loops of small gut (or anything else) get in your way, pack them away. This may save you much time, but don't forget to remove the packs afterwards! Anchor each pack by its tape or corner to a large haemostat hanging outside the abdomen.

MINIMIZE THE RISK OF SEPSIS. (1) If you have to open a hollow viscus, or an abscess, pack his abdominal cavity round it with packs or moist towels. Use clamps to prevent the contents of his gut escaping. (2) Handle an inflammatory mass carefully[md]don't let it burst and discharge pus everywhere. (3) Avoid any manipulation which might spread infection. (4) If an area does become contaminated, wash it out (6.2). (5) Insert drains when indicated (4.10).

BLEEDING can be difficult. You must know how to: (1) tie vessels in the depth of a wound (3.2), (2) tie them in continuity (3.2), (3) use curved and angled forceps, (4) secure temporary tape control over major vessels (55-4).

If a surface is merely oozing, consider applying haemostatic gauze (3.1).

If the bleeding is annoying, rather than brisk, you may be able to suck it away while you go on working.

If you have diathermy, consider applying it to the bleeding point with a fine-tipped dissecting forceps. You can do this with pin-point accuracy.

If bleeding becomes unmanageable, apply packs and pressure (3.1). You can even control bleeding from an avulsed renal artery like this. After 5 to 10 minutes, slowly remove the pack and clamp the bleeding point. If the vessel is a large one or deep, underrun it with a ''figure of 8' or a double mattress transfixion suture.

If there is a constant ooze during the operation: (1) the patient may have an excess of citrate, after the transfusion of many units of blood. This will not happen if you give him 10 ml of 10% calcium gluconate after every 4th (500 ml) unit of blood. (2) He may have DIC (disseminated intravascular coagulation), or some other clotting defect. If possible give him at least 2 units of fresh blood to replace clotting factors.

If you are absolutely desperate, as with bleeding from a ruptured uterus, try compressing the patient's aorta against her spine with your hand, until you have resuscitated her, and then tie her internal iliac arteries (3.5).

CAUTION ! (1) Don't stab blindly with a haemostat in a pool of blood! (2) Similarly, don't apply diathermy through a pool of blood[md]it won't work!

THE SPECIFIC CONDITIONS you might find when you do a laparotomy are described elsewhere[md]intestinal obstruction (10.3), peritonitis (6.2), intra-abdominal abscesses (6.3) etc.

THE SPECIMEN. If you have removed tissues from the patient and want to examine them, hand them to someone else and ask him to open them away from the patient, who will then not be contaminated by infection or malignancy.

To close his abdomen, go to Section 9.8. If you have operated for sepsis, delayed closure of his skin may be wiser.

DIFFICULTIES [s7]WITH A LAPAROTOMY If you CANNOT DO AN OPERATION THROUGH ONE INCISION, make another. Keep your original one open until you have finished[md]it may be useful!

If you want ACCESS TO A HUGE TUMOUR: (1) Start between his xiphisternum and his rib cage, and bring the incision outwards a little to become a standard upper rectus splitting paramedian incision. Continue horizontally just above his umbilicus for 5 cm. Then continue it down the other side of his lower abdomen to the brim of his pelvis as a muscle-splitting paramedian incision, as in B, Fig. 9-1. Or, (2) make a midline incision from top to bottom, skirting his umbilicus.

If you OPEN HIS PLEURA BY MISTAKE, there is a danger that his lung may collapse and cause marked hypoxaemia, not only because only one lung is being ventilated, but also because blood is passing through his collapsed lung unaltered.

If he is not intubated, stop operating to make it easier for the anaesthetist to pass a cuffed tracheal tube using suxamethonium (A 14.2). To do this you may have to move him. As soon as the tube has been inserted, close the hole in his pleura with a continuous multifilament suture. As you insert the last stitch ask the anaesthetist to blow up his lung so that it almost touches his pleura. At the end of the operation insert an intercostal water seal drain (65-5) and leave it in place for at least 48 hours. X-ray his chest, and if his lung is fully expanded, remove the drain, usually at 3 to 5 days.

If you are unable to intubate him, do the same. His lungs will usually expand postoperatively.

Fig. 9-6 SUTURING GUT. A, suturing gut with continuous Connell sutures, showing the principle of ''the loop on the mucosa' inverting the gut. Continuous Connell sutures like this are only used occasionally in the methods described here. Aa, gut anastomosed end-to-end with two layers of sutures: (1) an ''all coats' layer, (2) a layer of Lembert sutures through the serosa only.

B, the closed method of anastomosing gut end-to-end in Fig. 9-9 uses three Connell stitches. This is the first one on the antemesenteric border of the gut. C, the second Connell stitch, when the suture has reached the mesenteric border, and is about to turn round to close the anterior layer of the gut. D, the third and final Connell stitch closes the gut back at the antemesenteric border again.

E, the two layers of sutures: (1) the first continuous catgut ''all coats' layer and (2) the second or Lembert layer which can be interrupted or continuous; here it is continuous. F, a purse string suture for the appendix. G, Payr's crushing clamp, with firm, narrow blades. H, Lane's non-crushing clamp with springy, broad blades. I, correctly anastomosed gut. J, the gut has been cut obliquely in a way which reduces the blood supply to an area on the antemesenteric border of one loop. K, the gut has been partly deprived of its mesentery, and thus of its blood supply. L, the mesentery has been bunched together with a suture which occludes the vessels supplying the gut. M, gut which has been crushed by a crushing clamp has not been resected. N, the correct method; the gut is being held for suturing by a non-crushing clamp; crushed gut has been excised.