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 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 downsides, and a surgeon should be familiar and comfortable with both techniques.

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Abdominal Anatomy

The surgeon must be familiar with the anatomical landmarks and important corresponding structures of the abdomen to avoid iatrogenic injury to these structures, especially in emergency situations.

Surface anatomy

Boundaries of the abdomen:

  • Superior:
    • Xiphoid process
    • Costal cartilages of the 7th–10th ribs
  • Inferior:
    • Pubic bone and the pubic symphysis
    • Inguinal ligaments
  • Lateral: 
    • Superior: inferior aspect of the 10th rib
    • Inferior: iliac crest

Surface landmarks:

  • Umbilicus
  • Linea alba
  • Semilunar lines
  • Anterior superior iliac spines
  • Iliac crests 
  • Pubic symphysis
  • Inguinal grooves

Regions of the abdomen:

  • Abdomen divided into 9 regions by 3 lines/planes:
    • Right and left midclavicular lines
    • Subcostal plane
    • Transtrabecular, or intertrabecular, plane
  • Regions:
    • Right and left hypochondria
    • Epigastrium
    • Right and left lateral abdominal regions or flanks 
    • Umbilical region
    • Right and left inguinal regions or iliac fossae 
    • Hypogastrium

Layers of the abdominal wall

  • Skin
  • Superficial fatty layer (Camper’s fascia) 
  • Deeper membranous layer (Scarpa’s fascia)
  • Investing fascia
  • External oblique aponeurosis
  • Internal oblique muscle
  • Transversus abdominis muscle
  • Transversalis fascia
  • Extraperitoneal fascia
  • Parietal peritoneum

Arterial supply of the abdominal wall

  • Superior epigastric artery: branch of the internal thoracic, or mammary, artery
  • Inferior epigastric artery: branch of the external iliac artery
  • Both arteries run through the rectus sheath and anastomose.
Arterial supply of the abdominal wall

Arterial supply of the abdominal wall
a.: artery

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

Innervation of the abdominal wall

Nerves running between the internal oblique and transverse abdominal layers:

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

Abdominal dermatomes:

  • T7–L1
  • Visceral pain is referred to its respective dermatome. 
Abdominal dermatomes

Abdominal dermatomes

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

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 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. The choice of the approach depends on the surgeon’s skills and comfort level as well as the patient’s clinical picture.

Traditional indications for exploratory laparotomy

  • Abdominal trauma accompanied by:
    • Peritonitis
    • Shock
    • Evisceration: extrusion of the abdominal viscera through an opening in the abdominal wall
    • Hemoperitoneum
  • Acute abdomen/peritonitis caused by:
    • Perforated viscus
    • Intestinal ischemia
    • Strangulated hernia
    • Necrotic bowel
  • Uncontrolled GI hemorrhage

Indications for laparoscopy

Laparoscopy has become the standard of care for some procedures because it consistently yields more favorable outcomes, such as in laparoscopic cholecystectomy.

  • Other procedures commonly performed laparoscopically include:
    • Appendectomy
    • Inguinal and ventral hernia repair
    • Colon resections
    • Nissen fundoplication and hiatal hernia repair
    • Heller myotomy for achalasia
    • Bariatric procedures (gastric bypass, sleeve gastrectomy)
    • Splenectomy
    • Nephrectomy
    • Adrenalectomy
    • Gynecologic procedures
  • 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

Contraindications

There are no absolute contraindications to exploratory laparotomy because it is commonly performed under emergent conditions.

  • Some relative contraindications to any abdominal surgery include:
    • Coagulopathy
    • Congestive heart failure
    • Ischemic heart disease
    • Severe pulmonary disease
  • Contraindications specific to laparoscopy:
    • Inability to tolerate pneumoperitoneum (e.g., hypotension, severe pulmonary disease, heart failure)
    • Hemodynamic instability

Procedure

Preoperative care

  • Adequate preparation may not be possible in emergency situation.
  • Previous fast (nil per os (NPO; nothing by mouth)) of 8 hours, if possible
  • Blood products are made available for transfusion, if needed, after blood type is obtained.
  • Anticoagulants are withheld before the procedure.
  • Antibiotic prophylaxis: 
    • 1st-generation cephalosporin (cefazolin) 
    • Flagyl added for procedures involving bowel
  • Antitetanus prophylaxis is administered in cases of abdominal trauma involving the bowels.

Operative care

Laparotomy:

  • Allows quick access to the abdominal viscera, which is important in an emergency.
  • Usually done through vertical midline incision, which could be extended from the xiphoid process to the pubic symphysis, if needed
  • Incision is carried through the skin, subcutaneous tissues, linea alba (rectus sheath), and peritoneum.
  • At the completion of the procedure, the rectus fascia is closed with running or interrupted sutures (absorbable or nonabsorbable).
  • Skin 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)
DirectionIncisionDescription
LongitudinalMedianOn the midline
Paramedian2–5 cm to the left or right of the midline
Pararectus (Battle incision)On the lateral border of the rectus abdominis muscle
ObliqueMcBurney’s pointObliquely, on McBurney’s point
Kocher’sBelow a costal margin
Subcostal or Chevron’sBelow both costal margins
TransverseRockey–DavisTransversely, on McBurney’s point
Pfannenstiel
  • Curve incision
  • 2–5 cm above the pubic symphysis
  • 10–15 cm in length
Joel–Cohen
  • Straight, transverse
  • 3 cm below a line between the anterior superior iliac spines
  • 10–15 cm in length

Laparoscopy: 

The main goal of the procedure is to achieve the same results as with an open approach, but less invasively. The quality 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 an incision.
  2. CO2 is pumped into the cavity through the needle or trocar until an intraabdominal pressure of 12–15 mm Hg is reached (artificial pneumoperitoneum).
  3. Insufflation is needed to establish a working space for the instruments and adequate organ visualization.
  4. A laparoscopic camera is introduced through the trocar and is aimed at the area to be explored.
  5. Additional trocars are placed using the laparoscope for visualization, and the necessary instruments are introduced through these portals as needed.
  6. When the main intervention is complete, the instruments and trocars are extracted.
  7. The laparoscope is extracted and the abdomen is desufflated.
  8. The fascia needs to be closed at the access point if the abdomen was entered through the incision.
  9. The skin 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. License: CC BY-NC-SA 4.0

Postoperative care

  • The details of care depend on the particular intervention that was performed.
  • Patients can commonly be discharged home within 24 hours after uncomplicated laparoscopic procedures.
  • Laparotomies commonly require longer hospitalizations owing to the need for pain control and owing to postoperative ileus.

Complications

Some complications are specific to the intervention performed (i.e., cholecystectomy or appendectomy). However, some complications are common to all procedures.

Common complications after laparoscopy

  • Surgical site infection
  • Injury to the epigastric vessels
  • Subcutaneous emphysema (due to CO2 pumping)
  • Hypercapnia and respiratory acidosis (CO2 trapping and absorption)
  • Gas embolism
  • Trocar injuries:
    • Hollow viscus perforation 
    • Direct injury to solid abdominal viscera
  • Trocar site hernias

Complications associated with laparotomy

  • Surgical site infection
  • Wound dehiscence
  • Postoperative ileus
  • Small bowel obstruction
  • Incisional 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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