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Laparotomy and Laparoscopy

Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparoscopy is surgical exploration and interventions performed through ports placed in small incisions with a camera and long instruments. Laparoscopy offers the advantage of being minimally invasive, but it misses the tactile component of abdominal exploration for the surgeon. Both techniques have their applications, advantages, and disadvantages, and a surgeon should be familiar and comfortable with both techniques.

Last updated: Aug 11, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Abdominal Anatomy

The surgeon must be familiar with the anatomical landmarks and important corresponding structures of the abdomen to avoid iatrogenic Iatrogenic Any adverse condition in a patient occurring as the result of treatment by a physician, surgeon, or other health professional, especially infections acquired by a patient during the course of treatment. Anterior Cord Syndrome injury to these structures, especially in emergency situations.

Surface anatomy

Boundaries of the abdomen:

  • Superior:
    • Xiphoid process Xiphoid process Chest Wall: Anatomy
    • Costal cartilages of the 7th–10th ribs Ribs A set of twelve curved bones which connect to the vertebral column posteriorly, and terminate anteriorly as costal cartilage. Together, they form a protective cage around the internal thoracic organs. Chest Wall: Anatomy
  • Inferior:
  • Lateral: 
    • Superior: inferior aspect of the 10th rib
    • Inferior: iliac crest

Surface landmarks:

  • Umbilicus: “belly button”
  • Linea alba: medial edges of the rectus muscles; the longitudinal midline
  • Semilunar lines: lateral edges of the rectus muscles
  • Anterior superior iliac spines
  • Iliac crest
  • Pubic symphysis Pubic Symphysis A slightly movable cartilaginous joint which occurs between the pubic bones. Vagina, Vulva, and Pelvic Floor: Anatomy: where the halves of the pelvic girdle join together anteriorly in the midline
  • Inguinal grooves: “ groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination

The 4 quadrants of the abdomen: The abdomen is divided into 4 quadrants with the umbilicus in the center:

  • Divided into right and left halves 
  • Divided into upper and lower halves
  • Quadrants:
    • RUQ
    • LUQ
    • RLQ
    • LLQ

The 9 regions of the abdomen: The abdomen is divided into 9 regions by 3 lines/planes:

Layers of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen

Anterolateral: in order (from superficial to deep):

  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
  • Superficial fatty layer (Camper’s fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis
  • Deeper membranous layer (Scarpa’s fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis)
  • Investing fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis
  • External oblique External oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy muscle/aponeurosis
  • Internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy muscle/aponeurosis
  • Transverse abdominal muscle
  • Transversalis fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis
  • Extraperitoneal fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis
  • Parietal peritoneum Parietal peritoneum A membrane of squamous epithelial cells, the mesothelial cells, covered by apical microvilli that allow rapid absorption of fluid and particles in the peritoneal cavity. The peritoneum is divided into parietal and visceral components. The parietal peritoneum covers the inside of the abdominal wall. The visceral peritoneum covers the intraperitoneal organs. The double-layered peritoneum forms the mesentery that suspends these organs from the abdominal wall. Posterior Abdominal Wall: Anatomy

Differences above and below the arcuate line (located approximately ⅓ the distance from the umbilicus to the pubic crest):

  • Above the arcuate line, the fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis surrounding the rectus consists of:
    • Anterior to the rectus: 
      • Aponeurosis of the external oblique External oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy
      • Anterior lamina of the internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis
    • Posterior to the rectus:
      • Posterior lamina of the internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis
      • Aponeurosis of the transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy
      • Transversalis fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis
  • Below the arcuate line, the fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis surrounding the rectus consists of:
    • Anteriorly:
      • Aponeurosis of the external oblique External oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy
      • Aponeurosis of the internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy
      • Aponeurosis of the transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy
    • Posteriorly: transversalis fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis

Arterial supply of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen

  • Superior epigastric artery: branch of the internal thoracic, or mammary, artery
  • Inferior epigastric artery: branch of the external iliac artery
  • Both arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology run through the rectus sheath (deep to the rectus muscle) and anastomose.
  • Additional blood supply comes from:
    • The 10th and 11th posterior intercostal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology
    • Anterior branches of the subcostal vessels
    • Superficial epigastric artery (a branch of the femoral artery Femoral Artery The main artery of the thigh, a continuation of the external iliac artery. Femoral Region and Hernias: Anatomy)
    • Superficial circumflex iliac artery (a branch of the femoral artery Femoral Artery The main artery of the thigh, a continuation of the external iliac artery. Femoral Region and Hernias: Anatomy)
Arterial supply of the abdominal wall

Arterial supply of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen
a.: artery

Image by Lecturio. License: CC BY-NC-SA 4.0

Innervation of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen

Nerves running between the internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy and transverse abdominal layers:

  • Thoracoabdominal (T7–T11)
  • Subcostal (T12)
  • Iliohypogastric (L1)
  • Ilioinguinal (L1)

Abdominal dermatomes Dermatomes Spinal Cord: Anatomy:

Indications and Contraindications

Definitions

  • Laparotomy: surgical intervention consisting of a single incision performed to gain access to the abdominal cavity (open surgery)
  • Laparoscopy: surgical intervention designed to access the intraabdominal organs via various small (typically 5‒12 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma) portal incisions for the insertion of a laparoscope and other instruments
  • Exploratory: procedure that will aid the surgeon in determining definitive treatment for the patient based on intraoperative findings

The majority of abdominal procedures nowadays could be performed with either the open or the laparoscopic approach. Laparoscopic approaches are generally preferred when possible

Traditional indications for laparotomy

  • Abdominal trauma accompanied by:
    • Peritonitis Peritonitis Inflammation of the peritoneum lining the abdominal cavity as the result of infectious, autoimmune, or chemical processes. Primary peritonitis is due to infection of the peritoneal cavity via hematogenous or lymphatic spread and without intra-abdominal source. Secondary peritonitis arises from the abdominal cavity itself through rupture or abscess of intra-abdominal organs. Penetrating Abdominal Injury
    • Shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock
    • Evisceration Evisceration Surgical Complications: extrusion of the abdominal viscera through an opening in the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen
    • Hemoperitoneum
  • Acute abdomen Acute Abdomen Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain that may be caused by inflammation, infection, perforation, ischemia, or obstruction. The location of the pain, its characteristics, and associated symptoms (e.g., jaundice) are important tools that help narrow the differential diagnosis. Acute Abdomen/ peritonitis Peritonitis Inflammation of the peritoneum lining the abdominal cavity as the result of infectious, autoimmune, or chemical processes. Primary peritonitis is due to infection of the peritoneal cavity via hematogenous or lymphatic spread and without intra-abdominal source. Secondary peritonitis arises from the abdominal cavity itself through rupture or abscess of intra-abdominal organs. Penetrating Abdominal Injury caused by:
    • Perforated viscus Perforated Viscus Perforated viscus or GI perforation represents a condition in which the integrity of the GI wall is lost with subsequent leakage of enteric contents into the peritoneal cavity, resulting in peritonitis. The causes of perforated viscus include trauma, bowel ischemia, infections, or ulcerative conditions, all of which ultimately lead to a full-thickness disruption of the intestinal wall. Perforated Viscus
    • Intestinal ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage
    • Strangulated hernia Hernia Protrusion of tissue, structure, or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernia may involve tissues such as the abdominal wall or the respiratory diaphragm. Hernias may be internal, external, congenital, or acquired. Abdominal Hernias
    • Necrotic bowel
  • Uncontrolled GI hemorrhage
  • Obstetric cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery

Indications for laparoscopy

Laparoscopy has become the standard of care Standard of care The minimum acceptable patient care, based on statutes, court decisions, policies, or professional guidelines. Malpractice for many procedures because it consistently yields more favorable outcomes when it can be performed safely in place of laparotomy.

  • Procedures commonly performed laparoscopically include:
    • Cholecystectomy Cholecystectomy Cholecystectomy is a surgical procedure performed with the goal of resecting and extracting the gallbladder. It is one of the most common abdominal surgeries performed in the Western world. Cholecystectomy is performed for symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis and gallstone pancreatitis, and rarely, for gallbladder cancer. Cholecystectomy
    • Appendectomy Appendectomy Appendectomy is an invasive surgical procedure performed with the goal of resecting and extracting the vermiform appendix through either an open or a laparoscopic approach. The most common indication is acute appendicitis. Appendectomy
    • Inguinal and ventral hernia Hernia Protrusion of tissue, structure, or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernia may involve tissues such as the abdominal wall or the respiratory diaphragm. Hernias may be internal, external, congenital, or acquired. Abdominal Hernias repair
    • Colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy resections
    • Nissen fundoplication and hiatal hernia Hernia Protrusion of tissue, structure, or part of an organ through the bone, muscular tissue, or the membrane by which it is normally contained. Hernia may involve tissues such as the abdominal wall or the respiratory diaphragm. Hernias may be internal, external, congenital, or acquired. Abdominal Hernias repair
    • Heller myotomy Heller myotomy Surgical incision of the lower esophageal sphincter near the cardia often used to treat esophageal achalasia. Achalasia for achalasia Achalasia Achalasia is a primary esophageal motility disorder that develops from the degeneration of the myenteric plexus. This condition results in impaired lower esophageal sphincter relaxation and absence of normal esophageal peristalsis. Patients typically present with dysphagia to solids and liquids along with regurgitation. Achalasia
    • Bariatric procedures ( gastric bypass Gastric bypass Surgical procedure in which the stomach is transected high on the body. The resulting small proximal gastric pouch is joined to any parts of the small intestine by an end-to-side surgical anastomosis, depending on the amounts of intestinal surface being bypasses. This procedure is used frequently in the treatment of morbid obesity by limiting the size of functional stomach, food intake, and food absorption. Gastroesophageal Reflux Disease (GERD), sleeve gastrectomy)
    • Splenectomy Splenectomy Surgical procedure involving either partial or entire removal of the spleen. Rupture of the Spleen
    • Nephrectomy Nephrectomy Excision of kidney. Renal Cell Carcinoma
    • Adrenalectomy Adrenalectomy Excision of one or both adrenal glands. Cushing Syndrome
    • Gynecologic procedures:
      • Hysterectomy
      • Ovarian cystectomy and oophorectomy
      • Tubal occlusions
  • Diagnostic laparoscopy:
    • Can be performed for a stable patient with diagnostic uncertainty
    • Can be converted to an open procedure for a definitive surgery, if necessary

Choosing laparotomy versus laparoscopy

Factors to take into consideration:

  • Surgeon comfort with the procedures based on the clinical situation
  • Ensuring route will provide adequate visualization and surgical exposure 
  • Certainty of the diagnosis
  • Need for rapid/emergent entry into the abdomen (laparotomy is faster)
  • Prior surgical history
  • Generally improved outcomes associated with laparoscopy, which typically include:
    • Less blood loss
    • Less postoperative pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Shorter hospital stay
    • Reduced postoperative infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
    • Improved cosmetic outcomes

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

There are no absolute contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to exploratory laparotomy; it is commonly performed under emergent conditions.

  • Some relative contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to any abdominal surgery include:
    • Coagulopathy
    • Congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure
    • Ischemic heart disease Ischemic heart disease Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. Coronary Heart Disease
    • Severe pulmonary disease Pulmonary disease Diseases involving the respiratory system. Blastomyces/Blastomycosis
  • Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation specific to laparoscopy:
    • Inability to tolerate pneumoperitoneum Pneumoperitoneum A condition with trapped gas or air in the peritoneal cavity, usually secondary to perforation of the internal organs such as the lung and the gastrointestinal tract, or to recent surgery. Pneumoperitoneum may be purposely introduced to aid radiological examination. Perforated Viscus (e.g., hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, severe pulmonary disease Pulmonary disease Diseases involving the respiratory system. Blastomyces/Blastomycosis, heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR))
    • Hemodynamic instability

Procedure

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care

  • Adequate preparation may not be possible in emergency situations.
  • Previous fast (nothing by mouth) of 8 hours, if possible
  • Preoperative labs to consider:
    • Type and screen or type and cross-match depending on anticipated blood loss and potential need for transfusion
    • Baseline CBC
  • Blood products are made available for transfusion, if needed, after blood type is obtained.
  • Anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are withheld before the procedure.
  • Antibiotic prophylaxis Prophylaxis Cephalosporins against surgical site infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
  • Antitetanus prophylaxis Prophylaxis Cephalosporins is administered in cases of abdominal trauma involving the bowels.
  • Venous thromboembolism Venous thromboembolism Obstruction of a vein or veins (embolism) by a blood clot (thrombus) in the bloodstream. Hypercoagulable States ( VTE VTE Obstruction of a vein or veins (embolism) by a blood clot (thrombus) in the bloodstream. Hypercoagulable States) prophylaxis Prophylaxis Cephalosporins options:
  • Electrical grounding pad applied to the individual to ground electrosurgical instruments (e.g., Bovie) 
  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions preparation and surgical draping Draping Examination of the Breast:
    • Typically with chlorhexidine or povidone-iodine
    • Allow appropriate time for the prep to dry. 
    • Drape the individual based on anticipated incisions to keep the surgical site sterile Sterile Basic Procedures

Operative care

Laparotomy:

  • Allows quick access to the abdominal viscera, which is important in an emergency.
  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions incision is chosen based on planned procedure (see table).
  • Emergency surgery is usually done through a vertical midline incision, which could be extended from the xiphoid process Xiphoid process Chest Wall: Anatomy to the pubic symphysis Pubic Symphysis A slightly movable cartilaginous joint which occurs between the pubic bones. Vagina, Vulva, and Pelvic Floor: Anatomy, if needed
  • A vertical midline incision is carried through the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions, subcutaneous tissues, linea alba (rectus sheath), and peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy.
  • Retractors are placed to keep the incision open during the procedure.
  • At the completion of the procedure, the rectus fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis is closed with running or interrupted sutures (absorbable or nonabsorbable).
  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions can be closed, or it can be left open in case of gross contamination of the field with bowel contents or pus.
Incision sites for types of midline laparotomies

Types of midline laparotomies

Image by Lecturio. License: CC BY-NC-SA 4.0
Table: Other abdominal incisions commonly used for open abdominal procedures (examples)
Direction Incision Description Common example of use
Longitudinal Midline On the midline Trauma procedures, cancers
Paramedian 2–5 cm to the left or right of the midline Unilateral visceral procedures: kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys: Anatomy, adrenal glands Adrenal Glands The adrenal glands are a pair of retroperitoneal endocrine glands located above the kidneys. The outer parenchyma is called the adrenal cortex and has 3 distinct zones, each with its own secretory products. Beneath the cortex lies the adrenal medulla, which secretes catecholamines involved in the fight-or-flight response. Adrenal Glands: Anatomy, and spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen: Anatomy
Pararectus (Battle incision) On the lateral border of the rectus abdominis Rectus Abdominis A long flat muscle that extends along the whole length of both sides of the abdomen. It flexes the vertebral column, particularly the lumbar portion; it also tenses the anterior abdominal wall and assists in compressing the abdominal contents. It is frequently the site of hematomas. In reconstructive surgery it is often used for the creation of myocutaneous flaps. Anterior Abdominal Wall: Anatomy muscle Open appendectomy Appendectomy Appendectomy is an invasive surgical procedure performed with the goal of resecting and extracting the vermiform appendix through either an open or a laparoscopic approach. The most common indication is acute appendicitis. Appendectomy (uncommon)
Oblique McBurney’s incision McBurney’s Incision Appendectomy Obliquely, on McBurney’s point McBurney’s point Appendicitis Open appendectomy Appendectomy Appendectomy is an invasive surgical procedure performed with the goal of resecting and extracting the vermiform appendix through either an open or a laparoscopic approach. The most common indication is acute appendicitis. Appendectomy (most common)
Subcostal (Kocher) Below a costal margin Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy, gallbladder Gallbladder The gallbladder is a pear-shaped sac, located directly beneath the liver, that sits on top of the superior part of the duodenum. The primary functions of the gallbladder include concentrating and storing up to 50 mL of bile. Gallbladder and Biliary Tract: Anatomy, and duodenal procedures
Chevron (bilateral subcostal) Below both costal margins Large upper-abdominal surgeries
Transverse Rockey–Davis Transversely, centered on McBurney’s point McBurney’s point Appendicitis Open appendectomy Appendectomy Appendectomy is an invasive surgical procedure performed with the goal of resecting and extracting the vermiform appendix through either an open or a laparoscopic approach. The most common indication is acute appendicitis. Appendectomy
Pfannenstiel Gynecologic/pelvic procedures, cesarean deliveries
Location of surgical incisions

Location of surgical incisions

Image by Lecturio.

Laparoscopy: 

The main goal of the procedure is to achieve the same results as with an open approach, but less invasively. The quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of surgical intervention should never be sacrificed, though, and the procedure can be converted to an open one at any point, as necessary.

  1. Abdominal cavity can be accessed with a Veress needle or with a Hasson trocar through a small (usually 10‒12 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma) incision.
  2. CO2 is pumped into the cavity through the needle or trocar until an intraabdominal pressure of 12–15 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma Hg is reached (artificial pneumoperitoneum Pneumoperitoneum A condition with trapped gas or air in the peritoneal cavity, usually secondary to perforation of the internal organs such as the lung and the gastrointestinal tract, or to recent surgery. Pneumoperitoneum may be purposely introduced to aid radiological examination. Perforated Viscus).
    1. Insufflation is needed to establish a working space for the instruments and adequate organ visualization.
    2. Pressure should be low (usually < 5 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma Hg) upon entering the abdomen; if the pressure is higher, the needle/trocar may be preperitoneal or in a visceral organ → back out and replace the needle/trocar
  3. A laparoscopic camera is introduced through the trocar and is aimed at the area to be explored.
  4. Additional trocars are placed using the laparoscope for visualization, and the necessary instruments are introduced through these portals as needed.
  5. When the main intervention is complete, the instruments and trocars are extracted.
  6. The laparoscope is extracted and the abdomen is desufflated.
  7. The fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis needs to be closed at larger port sites.
  8. The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions at the trocar sites is closed with subcutaneous sutures or glue.
Laparoscopic intervention of the abdomen

Laparoscopic intervention of the abdomen:
Ports for the insertion of instruments are shown.

Image by Lecturio.

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care

  • The details of care depend on the particular intervention that was performed.
  • Common care includes:
    • Monitor vital signs, oxygen saturation Oxygen Saturation Basic Procedures, and urine output.
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics control
    • Assess surgical sites for bleeding/drainage.
    • Assess for signs of cardiovascular and/or pulmonary complications (e.g., chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, which may suggest myocardial ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage).
    • Deep vein thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus prophylaxis Prophylaxis Cephalosporins if staying in the hospital (may include early ambulation)
    • Discontinue drains and lines when safe (depends on the procedure and individual’s status).
    • Labwork (varies)
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship can commonly be discharged home within 24 hours after uncomplicated laparoscopic procedures.
  • Laparotomies commonly require longer hospitalizations owing to the need for pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways control
  • Common discharge requirements for most procedures include:
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is controlled with oral medications.
    • Tolerance Tolerance Pharmacokinetics and Pharmacodynamics of oral intake
    • Ability to empty the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess
    • Ambulatory, movement at baseline, or accommodations are arranged to assist the individual with activities of daily living.

Complications

Some complications are specific to the intervention performed (i.e., cholecystectomy Cholecystectomy Cholecystectomy is a surgical procedure performed with the goal of resecting and extracting the gallbladder. It is one of the most common abdominal surgeries performed in the Western world. Cholecystectomy is performed for symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis and gallstone pancreatitis, and rarely, for gallbladder cancer. Cholecystectomy or appendectomy Appendectomy Appendectomy is an invasive surgical procedure performed with the goal of resecting and extracting the vermiform appendix through either an open or a laparoscopic approach. The most common indication is acute appendicitis. Appendectomy). However, some complications are common to all procedures.

Complications associated with both laparoscopy and laparotomy

Common complications after laparoscopy

  • Injury to the epigastric vessels
  • Subcutaneous emphysema Emphysema Enlargement of air spaces distal to the terminal bronchioles where gas-exchange normally takes place. This is usually due to destruction of the alveolar wall. Pulmonary emphysema can be classified by the location and distribution of the lesions. Chronic Obstructive Pulmonary Disease (COPD) (due to CO2 pumping)
  • Hypercarbia and acidosis Acidosis A pathologic condition of acid accumulation or depletion of base in the body. The two main types are respiratory acidosis and metabolic acidosis, due to metabolic acid build up. Respiratory Acidosis (CO2 trapping and absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption)
  • Gas embolism

Complications associated with laparotomy

Laparotomy is associated with higher rates of:

  • Surgical site infection Surgical site infection Infection occurring at the site of a surgical incision. Surgical Complications
  • Wound dehiscence Wound dehiscence Pathologic process consisting of a partial or complete disruption of the layers of a surgical wound. Wound Healing
  • Postoperative ileus Ileus A condition caused by the lack of intestinal peristalsis or intestinal motility without any mechanical obstruction. This interference of the flow of intestinal contents often leads to intestinal obstruction. Ileus may be classified into postoperative, inflammatory, metabolic, neurogenic, and drug-induced. Small Bowel Obstruction
  • Small bowel obstruction Small Bowel Obstruction Small bowel obstruction (SBO) is an interruption of the flow of the intraluminal contents through the small intestine, and is classified as mechanical (due to physical blockage) or functional (due to disruption of normal motility). The most common cause of SBO in the Western countries is post-surgical adhesions. Small bowel obstruction typically presents with nausea, vomiting, abdominal pain, distention, constipation, and/or obstipation. Small Bowel Obstruction
  • Incisional hernias Incisional hernias Protrusion of tissue at or near the site of an incision from a previous surgery. Abdominal Hernias

References

  1. García, A. (Ed.), (2017). Procedimientos esenciales. Cirugía 1. Educación quirúrgica, 6e. McGraw-Hill. https://accessmedicina.mhmedical.com/content.aspx?bookid=2194&sectionid=167843688
  2. Blackbourne, L. (2015). Surgical recall. Philadelphia: Wolters Kluwer Health.

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