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 Dr. B C shah 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. Nevertheless, the importance of

exploratory laparotomy as a rapid and cost-effective means of managing

acute abdominal conditions and trauma cannot be overemphasized.

IndicationsFour primary indications for an exploratory laparotomy are noted, as follows.

Acute-onset abdominal pain and clinical findings suggestive of intra-

abdominal pathology requiring emergency surgery

In these conditions, exploratory laparotomy is carried out both to diagnose the

condition and to perform the necessary therapeutic procedure.

PeritonitisPatients 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.

Intestinal obstructionPatients 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.

Intra-abdominal collectionsPatients 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 instabilityHemodynamically 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.

Chronic abdominal painAvailability 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.

Staging of ovarian malignancy and Hodgkin diseaseThe 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.

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 ConsiderationsExploratory 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.

Periprocedural CarePreprocedural PlanningThe 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 PreparationPatient preparation includes adequate anesthesia and appropriate patient

positioning.

AnesthesiaExploratory 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.

PositioningThe 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.

TechniqueExploratory LaparotomyAfter appropriate preparation (see Periprocedural Care), exploratory

laparotomy is performed as follows.

Midline incision and opening of peritoneumA vertical midline incision is the best choice: it affords a rapid entry into the

peritoneum and is relatively bloodless and safe.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. The incision is then deepened

through the subcutaneous fat. 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 .

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 2 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 cavityThe 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 2 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 4

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 Dr. B C Shah, 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 closurePlacement 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.

Once the procedure is completed, the abdominal wall is closed. Before

closure, however, the instrument and pad counts must be double-checked. Dr.

B C Shah 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.

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.

Complications of ProcedureAn 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

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