Exploratory laparotomy is the exploration of the peritoneal cavity, routinely through a ventral midline incision. Strictly speaking, laparotomy refers to an abdominal incision through the flank. Coeliotomy is the more correct term to refer to a midline approach; however, both terms have come to be used interchangeably.

Indications

An exploratory laparotomy is indicated for diagnostic purposes when direct inspection or palpation of abdominal contents is required to achieve a diagnosis or samples collected at laparotomy are required for cytology, histopathology or culture. An exploratory laparotomy may be necessary for therapeutic purposes if there is intra-abdominal haemorrhage, visceral obstruction, a mass lesion, unusual accumulations of fluid or peritoneal contamination.

The surgery is exploratory and therefore it may not be possible to predict further management preoperatively. It is however essential that a thorough history taking, patient evaluation, blood work and appropriate diagnostic imaging have been performed prior to surgery. Information should have been gained preoperatively through thorough investigations, therefore allowing formulation of a provisional surgical plan.

Preparation

Appropriate client communication regarding the reason for exploratory laparotomy, implications of differential diagnoses and postoperative care is essential before proceeding.

Other than in emergency situations the patient should be starved overnight prior to the procedure. In patients that are young a minimum period of starvation of 6 hours is adequate. Unless specifically contraindicated, e.g., protracted vomiting, water should be freely available until the time of premedication. It is essential that thorough patient evaluation is conducted prior to induction of general anaesthesia and that appropriate intravenous fluid therapy has been provided to achieve timely correction of dehydration or hypovolaemia.

Surgical preparation of a wide area of the abdomen is performed to allow an adequate surgical incision, routinely from xiphisternum to pubis, to be performed. Performing the exploratory laparotomy through this length of incision will provide an adequate exposure, therefore making the surgical procedure more straightforward, and should also improve patient comfort by reducing stretching at the ends of the incision, which increases bruising and postoperative discomfort. The necessary clipped area extends from the caudal thorax to the inguinal area and to 5-10 centimeters laterally, usually up to one-third of the way up the costal arch. Surgical cases in which you may anticipate the incision extending cranially via a median sternotomy include diaphragmatic ruptures, portosystemic shunt ligation and chylothorax. For male patients, the prepuce is generally clipped but not flushed, unless it is anticipated that a urethral catheter should be passed during surgery, for example during the removal of urethral and cystic calculi. Clipping and initial preparation are performed in a separate preparation room before moving the patient into the sterile theatre.

The layout of the theatre (position of anaesthesia equipment, surgical trolley, theatre table, patient warming equipment and electrical extension leads) should be planned and set up prior to the procedure to ensure smooth running of the case. The patient should be positioned in dorsal recumbency with the head towards the top of the table. The patient is secured using troughs, sand bags or leg ties. Tilting the table at an angle of approximately 30 degrees with the head end up encourages the viscera of the cranial abdomen to move caudally, therefore improving access to structures of the cranial abdomen. Standard four-corner draping should always be employed; if the prepuce does not need to be accessed during surgery it should be clipped to one side using a towel clamp. It is usual for a right-handed surgeon to stand on the patient's right side and for a left-handed surgeon to stand on the left.

Equipment

Self-retaining retractors (e.g., Balfour or Gossett retractors) are essential to allow a thorough exploratory laparotomy to be performed. Suction apparatus is invaluable during a laparotomy to allow removal of fluid, blood, exudates and lavage fluid and to control intraoperative contamination. The use of a Poole suction tip, which has a sheath with multiple small holes covering the inner suction tip, is advantageous to allow efficient removal of fluid without disruption through blockage with omentum. It is wise to monitor the volume of fluid collected in the reservoir of the suction apparatus, in particular if there are intraoperative concerns regarding haemorrhage. All swabs should contain radio-opaque markers and the numbers should be accounted for before they enter the surgical field. Large saline-soaked laparotomy swabs are particularly useful to protect the edges of the incision, avoid desiccation and to pack-off viscera and avoid peritoneal contamination. Atraumatic intestinal forceps (e.g., Doyen intestinal forceps) are used when an enterotomy or enterectomy is performed. Warm sterile saline, sometimes in copious volumes, may be necessary during an exploratory laparotomy; the use of a water bath containing a stock of sterile saline bottles can help to anticipate this need.

Performing the Exploratory Laparotomy

As mentioned above, the standard approach for an exploratory laparotomy is through a ventral midline incision extending from xiphisternum to pubis. A paracostal incision, extending from the midline dorsally running parallel to the last rib, may occasionally be used to improve visualisation of the craniodorsal abdomen. Upon entering the peritoneal cavity samples of peritoneal fluid, if present, are collected and saved for bacterial culture and cytology. The wound edges are protected using moistened swabs prior to insertion of the abdominal retractors. In all cases a thorough exploratory laparotomy must be performed.

The surgeon should develop a systematic technique that ensures every part of the peritoneal cavity and the organs within it are thoroughly inspected. Some may choose to do this by dividing the abdomen into separate regions (cranial quadrant, intestinal tract, caudal quadrant, structures in the right paravertebral region and structures in the left paravertebral region), others may prefer to develop their own particular system. The important point is to have a system and to always stick to it, therefore avoiding mistakes and omissions. The abdominal contents are assessed for size, shape, location, surface colour and consistency. Once a thorough assessment has been performed, those abnormalities identified are addressed. Collection of tissue for histopathological analysis is performed from any tissue that is abnormal and also from organs that appear grossly normal if the clinical condition of the patient dictates it. Careful collection, accurate labeling and handling of these samples are essential. If the objective prior to exploratory laparotomy was to gain biopsy samples of specific tissues it is wise to form a checklist to ensure nothing is missed.

At the end of the procedure, lavage of the peritoneal cavity may be performed prior to closure. This is specifically indicated in cases of peritonitis, if peritoneal contamination has occurred pre- or intraoperatively and also if the patient is hypothermic. Removal of all lavage fluid is important prior to closure, since remaining fluid will serve as a nidus for infection. All instruments and swabs should be accounted for before closure.

Postoperative Care

This will need to be tailored to each and every patient; some will need more intensive care than others. Postoperative care requires careful attention to analgesia, maintenance of normal body temperature, adequate provision of nutrition, monitoring of the abdominal wound and prevention of patient interference. Providing appropriate advice to the client for ongoing patient care and monitoring at home are also of great importance.