Exploratory laparotomy

Exploratory laparotomy
ICD-10-PCS	0WJG0ZZ
ICD-9-CM	54.11
MeSH	= OPS301 =

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.^[1][2]

During an exploratory laparotomy, a large incision is made vertically in the middle of the abdomen to access the peritoneal cavity, then each of the quadrants of the abdomen is examined.^[1] Various other maneuvers, such as the Kocher maneuver, or other procedures may be performed concurrently. Overall operative mortality ranges between 10% and 20% worldwide for emergent exploratory laparotomies.^[3][4][5] Recovery typically involves a prolonged hospital stay, sometimes in the intensive care unit, and may include rehabilitation with one or more therapies.^[1]

Indications

A database that tracks exploratory laparotomies performed in the United Kingdom estimates that about 30,000 are done across England and Wales each year out of a population of 59.5 million people.^[6] Reasons why a patient may require an exploratory laparotomy include:

• Acute blunt or penetrating trauma with evidence of internal bleeding (a positive focused assessment with sonography for trauma, diagnostic peritoneal lavage, or CT scan), unstable blood pressure, or evisceration^[2][1]
• Acute abdomen with evidence of inflammation of the abdominal lining or the abdominal organs, gastrointestinal bleeding, or gastrointestinal perforation^[2][1]
• Cancer staging, especially ovarian cancer and Hodgkin and non-Hodgkin lymphoma^[7][8][9][1]
• Inability to access the part of the abdomen where a surgical disease is using a less invasive approach, or a lack of laparoscopic equipment, technology, or training^{[medical citation needed]}

Procedure

General technique

Scar from midline incision for exploratory laparotomy

A vertical cut, or incision, is made in the middle of the abdomen. This midline incision extends from the xiphoid process at the bottom of the chest to the pubic symphysis at the bottom of the pelvis. The fibrous tissue of the linea alba, which separates the right and the left abdominal muscles, serves as a guide for where to cut. After opening the fascia, the abdominal cavity, or peritoneum, is entered. The surgeon then looks for evidence of injury, infection, or disease. In trauma exploratory laparotomy, any immediate, life-threatening bleeding is first identified and controlled. In these cases, sponges are often packed in the spaces around the liver and the spleen to slow bleeding until a source can be found. This allows the surgeon to focus on one area at a time by removing the sponges from that quadrant.^[1]

A systematic approach is taken to examining the abdominal organs for disease. The small bowel is "run", or looked at segment by segment, along its entire length from the ligament of Treitz to the terminal ileum. The gastrocolic ligament is incised and the lesser sac is explored, including the posterior stomach and the anterior pancreas. The surfaces of the spleen and the liver also are examined for injury.^[1] If being performed for cancer staging, special attention will be paid during the exploratory laparotomy to the lymph nodes, which may be biopsied, or removed and assessed with a microscope or other special tests to see whether they contain cancerous cells indicative of cancer spread.^[7][9]

If necessary, several other surgical maneuvers or procedures may be performed.

Additional maneuvers

	Definition	Purpose	Structures mobilized	Structures exposed
Mattox maneuver ("left medial visceral rotation")[10][11]	surgical maneuver named for Dr. Kenneth Mattox in which left-sided abdominal organs are mobilized and moved temporarily out of the way	to provide access to deeper retroperitoneal left-sided abdominal structures	stomach, pancreatic tail, spleen, left kidney, left hemicolon	aorta, left iliac vessels, left renal vessels, pelvic vessels
Cattell-Braasch maneuver ("right medial visceral rotation")[10][12]	surgical maneuver named for Dr. Richard Cattell and Dr. John Braasch in which right-sided abdominal organs are mobilized and moved temporarily out of the way	to provide access to deeper retroperitoneal right-sided abdominal structures	duodenum, pancreatic head, right hemicolon	inferior vena cava, portal vein, right iliac vessels, right renal vessels
Kocher maneuver[10]	surgical maneuver named for Dr. Emil Theodor Kocher in which the duodenum and the head of the pancreas are mobilized and moved out of the way to the left	to fully inspect the duodenum and the pancreas and to access deeper structures behind them	duodenum, pancreatic head	aorta, inferior vena cava, posterior duodenum, posterior pancreas

Additional procedures

Based on where and what injury or disease is identified, one or more additional procedures may be performed during an exploratory laparotomy, including:

• splenectomy, or removal of all or part of the spleen^[13]
• hepatectomy, or removal of all or part of the liver^[13]
• pericardial window, in which an opening is made in the sac surrounding the heart^[13]
• repairs of the vena cava^[13]
• repairs of the aorta^[13]
• repairs of the common, external, or internal iliac arteries or common, external, or internal iliac veins^[13]
• distal pancreatectomy, or removal of the body or the tail of the pancreas^[13]
• enterotomy and bowel repair or bowel resection^[13]
• right or left hemicolectomy^[13]
• pyloric exclusion and gastric diversion, in which gastric secretions are diverted away from the duodenum by closing the pylorus and creating a new connection between the stomach and the small intestine^[14]
• nephrectomy, or removal of all or part of a kidney^[15]
• the "trauma Whipple"^[16]

Depending on the stability of the patient following an exploratory laparotomy, the abdomen may be sutured back together ("primary closure") or one or more tissue layers may be left open ("open abdomen") to facilitate further non-surgical resuscitation. In cases where the abdomen is left open, a vacuum dressing, a saline bag, or towel clips may be placed to protect the internal organs until the patient is stable enough to return to the operating room for definitive closure.^[1]

Outcomes

Postoperative mortality

The likelihood of death after an exploratory laparotomy depends on several factors including the age of the patient, injury or disease severity, other comorbid medical conditions, the skill of the surgeon, and what resources are available in the hospital.^[6][17] Overall, the mortality rate typically ranges between 10% and 20% worldwide for emergent exploratory laparotomies.^[3][4][5] It is lower for scheduled (elective) exploratory laparotomies, since patients are typically less sick and more optimized when procedures are able to be planned ahead of time.^[18]

Postoperative complications

Like with any major surgery, a variety of complications may occur during and after an exploratory laparotomy. These include minor problems, such as superficial skin infection or delayed bowel motility, and major problems, such as bleeding, blood clots in the legs or in the lungs, stroke, deep intraabdominal infection which can lead to sepsis, and reopening of the wound due to a failure to heal properly.^[17] A minority of patients will require reoperation for complications of exploratory laparotomy.^[1]

Recovery

Most patients spend at least several days in the hospital after having an exploratory laparotomy, sometimes in the intensive care unit, depending on the severity of the injury, infection, or disease. It can take weeks or months to heal completely. During the recovery period, there may be restrictions on activities such as driving, exercising, lifting, swimming, and showering. Depending on how long they were in the hospital, how severe their illness was, and whether they sustained other injuries or complications, some patients may require rehabilitation with physical therapy, occupational therapy, or speech-language pathology.^[1]

History

Exploratory laparotomy originated as a technique for the treatment of acute trauma. In 1881, Dr. George E. Goodfellow performed the first documented exploratory laparotomy for a ballistic injury, however the use of the procedure for blunt trauma has been described previously.^[19] In 1888, Dr. Henry O. Marcy first discussed using exploratory laparotomy as a means of diagnosing acute nontraumatic abdominal and pelvic problems at the 39th Annual Meeting of the American Medical Association, citing how improvements in safe surgical methods "so greatly increased the utility of the operation".^[20] Since the early 2000s, the opposite trend has been seen thanks to improvements in laboratory testing; CT, MRI, and other medical imaging; and less invasive laparoscopic surgical techniques, all of which have made exploratory laparotomy less common for diagnostic purposes outside of the severe trauma setting.^{[21][22][8][1]}

References

1. Townsed Jr CM, Beauchamp RD, Evers BM, Evers BM, Mattox K (2008). Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice (18th ed.). Saunders. pp. 488–492. ISBN 978-1-4160-3675-3.
2. Nichols JR, Puskarich MA (2018). Rosen's Emergency Medicine: Concepts and Clinical Practice (9th ed.). Elsevier, Inc. pp. 404–418. ISBN 978-0-323-39016-3.
3. Al-Temimi MH, Griffee M, Enniss TM, Preston R, Vargo D, Overton S, et al. (October 2012). "When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database". Journal of the American College of Surgeons. 215 (4): 503–11. doi:10.1016/j.jamcollsurg.2012.06.004. PMID 22789546.
4. Vester-Andersen M, Lundstrøm LH, Waldau T, Møler MH, Møller AM, et al. (The Danish Anaesthesia Database) (2013). "High mortality following emergency gastrointestinal surgery: a cohort study: ESAAP1-6". European Journal of Anaesthesiology. 30: 4–5. doi:10.1097/00003643-201306001-00012. ISSN 0265-0215.
5. Hendriksen BS, Keeney L, Morrell D, Candela X, Oh J, Hollenbeak CS, et al. (February 2020). "Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana". Annals of Global Health. 86 (1): 19. doi:10.5334/aogh.2586. PMC 7047759. PMID 32140429.
6. Boyd-Carson H, Gana T, Lockwood S, Murray D, Tierney GM (January 2020). "A review of surgical and peri-operative factors to consider in emergency laparotomy care". Anaesthesia. 75 (S1): e75 – e82. doi:10.1111/anae.14821. PMID 31903572. S2CID 209895469.
7. Armstrong DK (2020). "Gynecologic Cancers". In Goldman L, Schafer AI (eds.). Goldman-Cecil Medicine (26th ed.). Elsevier, Inc. pp. 1327–1335.e2. ISBN 978-0-323-53266-2.
8. Orazi A, Arber DA (2017). "Spleen: Normal Architecture and Neoplastic and Non-neoplastic Lesions". In Jaffe ES, Arber DA, Campo E, Quintanilla-Fend L, Harris NL (eds.). Hematopathology. Elsevier, Inc. pp. 1113–1131.e6. ISBN 978-0-323-38871-9.
9. Lester SC (2010). "Lymph Nodes, Spleen, and Bone Marrow". Manual of Surgical Pathology. Philadelphia PA: Saunders. pp. 513–524. ISBN 978-0-323-06516-0.
10. "Surgical Maneuvers". Archives of Surgery. 134 (8): 823. 1999. doi:10.1001/archsurg.134.8.823.
11. Gogna S, Saxena P, Tuma F (2020). "Mattox Maneuver". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 30335295. Retrieved 2020-11-10.
12. D'Cruz JR, Misra S, Shamsudeen S (2020). Pancreaticoduodenectomy. Treasure Island (FL): StatPearls Publishing. PMID 32809582. Retrieved 2020-11-10. {{cite book}}: |work= ignored (help)
13. American College of Surgeons Committee on Trauma (2018). ATLS Advanced Trauma Life Support Student Course Manual (Tenth ed.). American College of Surgeons. ISBN 978-0-9968262-3-5.
14. Ansari D, Toren W, Lindberg S, Pyrhonen H, Andersson R (2019). "Diagnosis and management of duodenal perforations: a narrative review". Scandinavian Journal of Gastroenterology. 54 (8): 939–944. doi:10.1080/00365521.2019.1647456. PMID 31353983. S2CID 198965786.
15. Singh S, Sookraj K (2020). "Kidney Trauma". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 30422491. Retrieved 2020-11-20.
16. Dave S, Toy FK, London S (2020). "Pancreatic Trauma". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 29083741. Retrieved 2020-11-20.
17. Ahmed M, Garry E, Moynihan A, Rehman W, Griffin J, Buggy DJ (October 2020). "Perioperative factors associated with postoperative morbidity after emergency laparotomy: a retrospective analysis in a university teaching hospital". Scientific Reports. 10 (1): 16999. Bibcode:2020NatSR..1016999A. doi:10.1038/s41598-020-73982-5. PMC 7550577. PMID 33046829.
18. Mallol M, Sabaté A, Dalmau A, Koo M (September 2013). "Risk factors and mortality after elective and emergent laparatomies for oncological procedures in 899 patients in the intensive care unit: a retrospective observational cohort study". Patient Safety in Surgery. 7 (1): 29. doi:10.1186/1754-9493-7-29. PMC 3847296. PMID 24007279.
19. Quebbeman FE (1966). "Medicine In Territorial Arizona" (PDF). University of Arizona. Archived (PDF) from the original on 10 December 2013. Retrieved 7 December 2013.
20. Marcy HO (1889-01-26). "EXPLORATORY LAPAROTOMY.: Read in the Section on Surgery, at the Thirty-ninth Annual Meeting of the American Medical Association, May, 1888". Journal of the American Medical Association. XII (4): 115–116. doi:10.1001/jama.1889.02400810007001a. ISSN 0002-9955.
21. Medeiros LR, Rosa DD, Bozzetti MC, Fachel JM, Furness S, Garry R, et al. (April 2009). "Laparoscopy versus laparotomy for benign ovarian tumour". The Cochrane Database of Systematic Reviews (2): CD004751. doi:10.1002/14651858.cd004751.pub3. hdl:10183/181311. PMID 19370607.
22. Galaal K, Donkers H, Bryant A, Lopes AD, et al. (Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group) (October 2018). "Laparoscopy versus laparotomy for the management of early stage endometrial cancer". The Cochrane Database of Systematic Reviews. 2018 (10): CD006655. doi:10.1002/14651858.CD006655.pub3. PMC 6517108. PMID 30379327.