Exploratory Laparotomy

-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.

Indications

Four 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.

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 Considerations

Exploratory 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.

Preprocedural Planning
 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.
The 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

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 Preparation

Patient preparation includes adequate anesthesia and appropriate patient positioning.

Anesthesia

Exploratory 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.[8]

Positioning

The 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.

Technique

Exploratory Laparotomy
After appropriate preparation (see Periprocedural Care), exploratory laparotomy is
performed as follows.

Midline incision and opening of peritoneum

A vertical midline incision is the best choice: it affords a rapid entry into the peritoneum
and is relatively bloodless and safe.[9] 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. Electrocautery can be used instead of the
traditional scalpel for making the incision, as skin incisions made by cutting diathermy
are quicker, associated with less blood loss, and demonstrate no significant difference
in the rate of wound complications, scar cosmesis, or postoperative pain.[10, 11] The

incision is then deepened through the subcutaneous fat (see the image below).
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 (see the images below).
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 cavity

The steps of exploration depend on the initial findings and are governed by the
principles of systematic survey and priority for life-saving maneuvers.

Completion and closure

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.

Placement 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. The surgeon 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

Complications of Procedure

An 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

Exploratory Laporatomy

 It is an operation where a cut is made into the abdomen. It is a method of to explore

the abdomen, a diagnostic tool that allows physicians to examine the abdominal organs.

Purpose

 It may be recommended to a patient who has abdominal pain of unknown origin. In

addition, bleeding into the abdominal cavity is considered a medical emergency such as
in ectopic pregnancies. It is used to determine the source of pain and perform repairs if
needed. Exploratory laparotomy may be used to examine the abdominal and pelvic
organs (such as the ovaries, fallopian tubes, bladder, and rectum) for evidence of
endometriosis. Any growths found may then be removed.

Complications

 Bleeding
 Infection
 Failure to find the cause of the problem; more surgery or other treatments may be
needed
 Poor healing of the incision
 Damage, injury, or problems with the bowels
 Risks of anesthesia
Before the procedure

 Your doctor will do pre-operative evaluation in the clinic 1 week before the procedure
(if not an emergency case).
 You may need to undergo some routine tests before your operation e.g heart trace
(ECG), x-ray and blood tests for cardio-pulmonary clearance.

 You will be admitted a day before the scheduled procedure.

 Consents must be secured
 Nothing by mouth for 8 hours prior to the time of the procedure
 If ordered by the physician, cleaning or fleet enema will be given for further bowel
preparation.
 Insertion of Intravenous Line
 Diagnostic exams as ordered by the physician like Complete blood count, blood
typing, urinalysis and
ultrasound.
 Pre-operative medicines and antibiotics will be administered.
 Instructions regarding change of gown, removal of jewelries, dentures, contact
lenses, hair accessories,
nail polish and make up will be given.
 An hour before the scheduled operation, you will be wheeled down to the delivery
room.
 Abdominoperineal prep (shaving) will be done.

During the procedure

 Prior to the time of operation, you will be wheeled in to the operating room where a
surgical nurse will do the necessary preparations such as placement of cardiac leads,
hooking to the cardiac monitor, oxygen administration thru nasal cannula, and
placement of leggings.
 Your obstetrician will probably meet you in the operating room where an
anesthesiologist will be ready.
 Prior to the procedure, for verification that the right patient and right procedure will be
done, ”Signing in”
will be called, wherein you will be asked to state in your full name, date of birth, name of
your
surgeon and anesthesiologist, as well as the procedure to be done.
 After the introduction of anesthesia, a curtain will be raised over your mid section and
you arms will be
outstretched in order for the anesthesiologist and nurse to have access to your I.V.

 A Foley catheter will be inserted. This is not a painful procedure, and if you have an
anesthesia in you won't feel it at all. Then the surgical nurse will clean the incision site
with betadine.
 Once an adequate level of anesthesia has been reached, the initial cut into the skin
will be made. The surgeon will then explore the abdominal cavity for disease.
 Alternatively, samples of various tissues and/or fluids will be removed for further
analysis and will be sent to the laboratory for microscopic examination.
 The surgeon will then close the incision. What to expect after the procedure
 After the operation, you will be wheeled into recovery where you will be observed for
two hours as the anesthetic wears off.
 You will be hooked to the cardiac monitor to check your vital signs, and you will also
be hooked to the oxygen.
 Post-operative medicines will be given to you. Depending upon the nature of your
surgery and your doctor's assessment of your pain, you probably will be given a pain
drip to address the pain.
 The foley catheter will remain until further orders.
 After the recovery period, you will be transferred to your room if there are no
complications.
 Turning from side to side is advised. An abdominal binder is applied to support your
cut.
 Eat nothing per mouth or take only sips of water or clear liquids or as ordered by your
physician on the
first day of operation or until flatus passed out.

 Discharge instructions and wound care will be given to you by your bedside nurse.
At home:
 During the first two weeks, avoid tiring activities such as lifting heavy objects.
 Slowly increase your activities. Begin with light chores, short walks, and some driving.
Depending on
your job, you may be able to return to work.
 To promote healing, eat a diet rich in fruits and vegetables.
 Try to avoid constipation by:
o Eating high-fiber foods
o Drinking plenty of water
o Using stool softeners if needed
 Take proper care of the incision site. This will help to prevent an infection.
 Follow your doctor's instructions
When to call your doctor
After you leave the hospital, contact your doctor if any of the following occurs:
 Fever or chills
 Redness, swelling, increasing pain, excessive bleeding, or any discharge from the
incision site
 Increasing pain or pain that does not go away
 Your abdomen becomes swollen or hard to the touch
 Diarrhea or constipation that lasts more than 3 days
 Bright red or dark black stools
 Dizziness or fainting
 Nausea and vomiting
 Cough, shortness of breath, or chest pain
 Pain or difficulty with urination
 Swelling, redness, or pain in your leg
Postoperative Instructions for Exploratory Laparotomy

PLEASE READ THESE INSTRUCTIONS BEFORE YOUR SURGERY

DAY BEFORE SURGERY:

1. Please start a clear liquid diet at 12 pm the day prior to surgery. Only Jell-O, juice,
broth, coffee, tea, water, etc. should be consumed.
2. You will most likely need to clean your bowels prior to surgery. Your physician will
instruct you on the medication to take in order to complete this.
3. If you need to clean out your bowels, you will need a prescription for potassium
tablets. Please also pick up the prescription at your pharmacy and take them as
directed (one tablet at 4PM and another at 8PM). It is also suggested to purchase some
over the counter topical medication for rectal irritation (e.g. Balmex or barrier creams).
4. It is generally best not to plan to do too much the day of the bowel preparation. Most
patients should plan to take off work that day and stay near the bathroom.
6. In general you will be instructed to stop eating and drinking at midnight the day before
surgery.

DAY OF SURGERY:

Before Surgery

a. You will be escorted to the Pre-operative care unit and given instructions of what to
do with your belongings (leave all valuables at home)
b. A nurse will interview you
c. An IV will be started

During Surgery

a. Your family will wait in the Surgery Waiting Room

b. They will leave their cell phone number so that we can easily contact them during or
after surgery if necessary
c. After surgery, your physician will come to the waiting room to talk to the family to let
them know
that everything went well. If they are not present at that moment your physician will call
their cell phone.

After Surgery

a. You will wake up in the recovery room, where you will be checked frequently, and
then be transferred to a post surgical unit
b. You generally will have a tube in your bladder (foley catheter) to drain urine
c. You will have compression hose on your legs to help with circulation and prevent
blood clots
d. You may have an oxygen tube placed under your nose to help wake up
e. You may have a PCA (pain medicine pump) or you may be required to ask
for pain medicine as needed. Do not wait until you are in a lot of pain to ask for this.
f. Medications will be available for any nausea. Please ask for it as needed.
g. Your home medications may be restarted according to your doctor’s orders
h. Each day your nurse will:
i. Check your incision
ii. Check for vaginal discharge
iii. Check your temperature, blood pressure, and pulse
4. Activity
a. Immediately after the surgery your nurse will encourage you to turn, cough,
and take deep breaths frequently. The nurse will instruct you how to support your
incision during
these coughs to decrease the pain. This is to prevent lung problems like
pneumonia.
b. You will be asked to use an incentive spirometry device- this is a small bottle
that you slowly inhale as deep as possible to re-expand your lungs.

c. Use of incentive spirometry device and early ambulation will be VERY

IMPORTANT to prevent postoperative fevers, pneumonias, and also will help
with bowel functioning.
5. Diet
a. You may be asked to not eat anything for the first day or two if your surgery
was via a large incision.

FIRST DAY AFTER SURGERY:

1. The following will probably be removed

a. Dressing/bandage
b. Oxygen
c. Catheter (unless you had surgery on your bladder or had a radical
hysterectomy) d. Pain pump
e. Your IV fluids may be slowed down or stopped once you are taking fluids well
2. Treatments and Medications
a. Medications are available for gas pains and nausea
b. You will receive oral pain medication if you are tolerating fluids
c. Your nurse will continue to monitor:
i. Your incision
ii. Any vaginal discharge
iii. Your temperature, blood pressure, and pulse
iv. The amount of fluids you take in as well as the amount of urine you are
putting out
3. Activity
a. Continue to turn, cough, and take deep breaths
b. You will be assisted up to the bathroom and helped with deep breathing
exercises
 c. A pan will be provided to place over the toilet to measure your urine
d. You will be encouraged to get up to the chair and walk in the hall at least four
times every day (this helps your bowels to wake up and begin functioning).
An abdominal binder may also be given to you to help support your
incision during coughing or walking and to decrease the pain. If you had
particularly extensive surgery or if you have had difficulty with walking even prior
to surgery, physical therapy will be called to help with strengthening and walking.
4. Diet
a. You will start with sips of water or ice chips. Subsequently when your bowels
begin to make “sounds” and your nausea passes clear liquid diet (broth, jello,
juices) will be started. If after starting clear liquid diet you begin feeling very full or
nauseated, please stop drinking until your symptoms resolve and you talk to a
physician or a nurse. When you begin passing gas per rectum full liquid diet or
soft diet of your choice may be started. Passing gas per rectum is the first sign
that your intestines have begun to function. Bowel movement, however, may not
happen for up to five to seven days after the surgery.

SECOND DAY AFTER SURGERY UNTIL DISCHARGE:

1. Treatments and Medications

Your nurse will continue to monitor:
i. Your incision
ii. Any vaginal discharge
iii. Your temperature, blood pressure, and pulse
iv. The amount of fluids you take in as well as the amount of urine you are
putting out
b. Your IV will be capped or taken out if you are tolerating your diet
c. The bladder catheter will be removed (unless you had bladder surgery)
d. You may receive medications (pill or suppository) to help your bowel function recover
2. Activity
a. You should be up walking the halls as much as possible, but at least four times a day.
b. Your nurse will begin showing you how to care for your incision to prepare for going
home.
c. Generally you will be able to shower second day after surgery. You will be instructed
to let water and soap flow down the incision and then to pat it, not rub it dry. Until you
are able to take a shower nurses will assist you with sponge baths.
a. 3. Diet
b. a. Your diet will be advanced when you have passed gas or had a bowel movement.
Continue to drink plenty of liquids.
c. 4. Teaching
d. a. This is the time to ask questions about going home- please let your nurse know if
you do not have help at home.
e. b. Your nurse will instruct you on
f. i. Activity
g. ii. Driving
h. iii. Lifting
i. iv. Caring for your incision
j. 5. Discharge
k. a. You will be discharged from the hospital in general when:
l. i. You are tolerating soft diet
m. ii. You have either passed gas or had a bowel movement
n. iii. You have been without fever for >24 hours.

WHAT TO EXPECT AT HOME:

Pain

Pain is to be expected at home but will continue to decrease over time. You will be
given a prescription at discharge for oral pain medication. Use this as needed.

a. Unless your doctor has instructed otherwise, it is ok to take the following in addition to
your pain pills:
Motrin (ibuprofen, advil)- 400-600mg every 6 hours.

b. Narcotic pain prescriptions or refills will not be called in to a pharmacy on

weekends, or after 5pm during the week.

2. Routine Medications

a. Medications you were taking prior to surgery should generally be resumed as

directed on your discharge from the hospital.

3. Vitamins and Iron Supplements a. These can be purchased over the counter. Please
let your physician know if you are planning to start any new vitamin or herbal
supplementation.

4. Incision Staples

a. These should be removed 10-14 days after your surgery if you have a vertical skin
incision. For transverse skin incisions these are usually removed 3-4 days after surgery.
You should call our office to make an appointment with our nursing staff for staple
removal.
b. If you have sutures (stitches) these will generally dissolve on their own and do not
require removal. If you still have some that haven’t dissolved at your post-op checkup,
let your doctor or nurse know so that they can be removed.
5. Incision Care

Abdominal surgery, laparotomy, or abdominal hysterectomy:

a. Clean incision daily with clean cloth and soap and water
b. Staples will be removed 10-14 days after surgery
c. Steri-strips (small tapes) may wash off in the shower. If they are still present after 5-7
days, you may peel them off carefully.

Drainage or redness around your incision or a fever of >100.4 F should be reported to

your doctor or nurse

3. Postoperative check up
a. Unless instructed differently by your physician you should call our office to schedule
your first postoperative visit two weeks after your surgery.

4. Hygiene
a. Showers are acceptable
b. You may shampoo your hair.
c. It is ok to wash the incision gently with a clean cloth and soap and water.
5. Exercise (each procedure is different but these are general guidelines)
a. No lifting of heavy objects (10-15 lbs) until after your post-op checkup
b. Bending and stretching are ok unless it hurts (you may be putting too much strain on
your incision if this is the case)
c. Walking is encouraged, you will get fatigued faster than usual however
d. Stair climbing is ok, but use caution
e. Avoid vigorous exercise until after your post-op appointment
6. Activity
a. Driving after major surgery should be avoided for 2 weeks, until reflexes have
returned to normal, you can comfortably wear a seat-belt, and you are no longer taking
prescription pain medication.
b. Fatigue is common for 8-12 weeks after surgery; after all, your body has undergone
the equivalent of a marathon.
c. You should generally avoid sexual activity for at least 6 weeks and until after your
post-op checkup. d. Light vaginal bleeding or pink/brown discharge is common for 2-4
weeks following a
hysterectomy or vaginal procedure.
e. If it hurts, you probably shouldn’t do it

7. Bowel Function

a. Bowel function often takes several weeks to return to normal; due to anesthesia,
narcotic pain medications, and surgery on the intestines.
b. For constipation lasting a day or two:
i. Milk of Magnesia, or mild laxative of choice is ok.
c. For difficulty with gas pains: i. Walking
ii. Dulcolax (bisacodyl) suppository or glycerin suppository d. Diarrhea
i. Immodium or Pepto Bismol is ok
ii. If severe diarrhea (8-10 stools per day) then please contact your doctor
e. Stool softeners (colace, surfak, etc) may be used at your discretion
f. If any symptoms are lasting longer than 2 days, please call your doctor’s office.
8. Return To Work
 a. This will be discussed at your post-op visit. As a general guideline, allow 2 weeks
after laparoscopic or robotic surgery and 4-6 weeks after major abdominal surgery. If
you would like to return to work sooner, please call our office.
Complications

i. Fever greater than 100.4

ii. Unusually heavy bleeding
iii. Uncontrollable nausea, vomiting, or diarrhea
iv. Redness, tenderness, or swelling in one or both calves of your legs.
If you are calling after office hours, please leave a message and your phone number on
our emergency line and the physician on call will immediately contact you.
10. Home Nursing (Home Health Care)
a. Home nursing may be used in the following situations:
i. Open wounds
ii. Home IV antibiotics
iii. Unusual complications
iv. Hospice

ABDOMINAL LAPAROTOMY

Description: 

Laparotomy is a surgical incision (cut) into the abdominal cavity. This operation is performed to
examine the abdominal organs and aid diagnosis of any problems including abdominal pain. In many
cases, the problem – once identified – can be fixed during the laparotomy. In other cases, a second
operation is required. Another name for laparotomy is abdominal exploration.

Materials/ Equipments Needed:

         Abdominal laparotomy forceps supplies and surgical accessories

Procedures:

         The surgeon will make the incision. If the pain is in the lower right abdomen over the appendix, the
incision will be placed in that area.
         Two of the most common incisions are the midline incision, which is a vertical incision that is placed
between the pubic bone and below the sternum, and the transverse incision, which is placed
horizontally. In some cases, the incision may be small at the beginning of the surgery and then enlarged
as needed to complete procedures after a diagnosis is made.
         Once the incision is made, the organs and tissues will be inspected for signs of disease, infection or
inflammation. Biopsies may be taken of different tissues as needed. In some cases, the abdominal cavity
may be "washed," where sterile fluid is placed in the abdomen, and then collected for further study.
         Once the organs and tissues of the abdomen have been inspected, the laparotomy portion of the
procedure is over; however, in many cases an addition procedure will be performed. For example, a
laparotomy is performed to find the source of abdominal pain, and an inflamed appendix is found,
an appendectomy procedure would then be combined with the laparotomy.
         The incision may be closed in a variety of ways. Larger incisions are typically closed with sutures or
staples, smaller ones may be closed with adhesive strips called steri-strips or surgical glue. The incision is
then covered with a sterile surgical bandage. Anesthesia is stopped and a medication is given to wake
the patient, who is then taken to the recovery area.

Nursing Responsibilities:

BEFORE Procedure:
     Secure consent
     Give the prescribed pre-op medications
     Prepare the materials needed for the procedure.
     Shaved in the abdominal area.
DURING Procedure:
     Assist the doctor during the operation

AFTER Procedure:
     Clean the materials that were used aseptically.