Laparotomy

Question 1

Laparotomy

Answer 1

. Surgical opening through the skin layer and into abdominal cavity
. Under GA
. Patient in supine position
. Midline incision
. Skin prep boundaries: Midchest to midthighs and bilaterally

Question 2

Anatomy & Pathology: Layers of the abdominal wall:

Answer 2

. Subcutaneous fat.
. Scarpa’s fascia
. External oblique muscle
. Internal oblique muscle
. Transversus abdominus muscle
. Transversalis fascia
. Peritoneum

Pathology according to procedure to be performed

Question 3

Equipment & Instrument Sets Unique to Procedure:

Answer 3

. Major Laparotomy Set
. Self-retaining retractor according to surgeon’s preference

Question 4

Supplies Unique to Procedure:

Answer 4

. Laparotomy back table pack

Question 5

Preoperative Preparation:

Answer 5

. Position: Supine
. Anesthesia: General
. Skin Prep: Mid-chest to symphysis pubis and laterally as far as possible; may be extended to mid-thigh for extensive procedures
. Draping: Towels to square off; laparotomy drape

Question 6

Practical Considerations:

Answer 6

. Have Yankauer and Poole suction tips available.
. When using the Poole suction tip w/in the abdominal cavity, the surgeon may want to wrap a wet lap sponge around the tip to prevent tissue attaching to the tip and being damaged.
. Depending on the procedure, the surgeon may irrigate the abdominal cavity with an antibiotic solution that is mixed by the ST at the back table in a graduated pitcher or bowl
. A variety of retractors will be needed (handheld & self-retaining) according to surgeon’s preference

Question 7

1. Opening (hint: incision)

Answer 7

Midline skin incision is made & extended around the umbilicus

Considerations: Place 2 lap sponges on each side of the incision. Skin knife used. Have ESU (?) pencil & forceps ready.

Question 8

2. Opening (hint: Incision is deeper)

Answer 8

The incision is deepened.

Consideration: Deep knife used. As the surgeon goes deeper into the abdominal cavity, the larger, deeper retractors will be used.

Question 9

3. Opening (hint: encountering vessels)

Answer 9

Bleeding vessels are clamped with small hemostats & either ligated with non absorbable ties or cauterized.

Consideration: Keep ESU (?) cautery blade clean using Teflon cautery tip wipe clean with a sponge

Question 10

4. Opening (hint: external oblique muscles)

Answer 10

Using curved mayo scissors, electrosurgery, or scalpel, the external oblique muscle is opened the length of the skin incision. This is referred to as a muscle splitting incision because the incision is in the direction of the muscle fibers. Bleeding vessels are controlled through methods listed in #3 (Bleeding vessels are clamped with small hemostats & either ligated with non absorbable ties or cauterized.)

Consideration: Keep clean lap sponges on the field

Question 11

5. Opening (hint: retraction needed)

Answer 11

Medium retractors are placed to retract the external oblique muscle

Consideration: Richardson retractors are often used

Question 12

6. Opening (hint: replacement of retractors)

Answer 12

The internal oblique muscle, transverse muscle and transversals fascia are split in the direction of the muscle fibers up to the rectus sheath using a scalpel or curved mayo scissors.
The medium retracts are replaced with large Richardson retracts that have longer blades in order to retract the internal oblique and transverse muscle.

Question 13

7. Opening (hint: The peritoneum is now exposed. )

Answer 13

The peritoneum is now exposed.
A small incision is made in the peritoneum using the smooth forceps to grasp the peritoneum to elevate to prevent the underlying bowel from being injured, and the scalpel.

Consideration: Surgeon may prefer using a small hemostat to elevate the peritoneum.

Question 14

8 Opening (hint: what may be encountered after the peritoneum)

Answer 14

If abnormal fluid is encountered, sponges and suction are used as needed.
Cultures will also be taken at this time if necessary.

Consideration: Instruments & suction tips that come into contact with the infectious fluid are considered contaminated and should not be used when the wound is being closed.

Question 15

9 Opening

Answer 15

The edges of the peritoneum and transversalis fascia are grasped with a Kocher on each lateral edge and slight traction is placed on the Kochers laterally.

Question 16

10 Opening

Answer 16

Using metzenbaum scissors, curved Mayo scissors, or scalpel, the peritoneal incision is lengthened.
The surgeon may insert the index and middle finger beneath the peritoneum to aid in elevating it and carefully cut the tissue between the 2 fingers in the direction of the pelvis.

Question 17

11 Opening

Answer 17

Be prepared to encounter one or two blood vessels in the fatty layer between the fascia and peritoneum in the region of the umbilicus. These vessel(s) will need to be quickly clamped and ligated.

Consideration: Surgeon may use ties or cautery

Question 18

12 Opening

Answer 18

The Richardson retractors are repositioned to allow the surgeon to conduct an initial exploration of the abdominal cavity.

Question 19

13 Opening

Answer 19

Once the affected & non-affected organs have been identified, and anatomical landmarks are also identified, the Richardson retractors will be replaced with a large self-retaining retractor such as the Balfour or Bookwalter.

Question 20

1 Closure

Answer 20

The peritoneum may be closed separately or as a single unit with the internal oblique fascia.

Consideration: Sponge, sharp, and instrument counts must be completed before the abdominal cavity is closed.

Question 21

1a Closure (Peritoneum Closed Separately)

Answer 21

Peritoneum closed separately : Edges of transversals fascia grasped with toothed forceps to expose the peritoneum. The edges of the peritoneum are grasped with clamps and the clamps are crossed to bring the edges together.
The peritoneum may be closed with synthetic absorbable suture in continuous fashion or interrupted non-absorbable sutures. A medium width malleable (ribbon) retractor may be placed under the peritoneal layer to keep the underlying organs pushed away from the suture line to avoid being sutured to the peritoneum. The internal oblique fascia is the closed with absorbable or non-absorbable sutures in continuous or interrupted fashion.

Question 22

1b Closure (Single Unit)

Answer 22

Single-unit closure: The peritoneum and internal oblique fascia are closed together as a single unit. A heavy lopped synthetic absorbable or non-absorbable suture is used, #0 or #1 size; it is usually placed in continuous fashion.

Question 23

2. Closure

Answer 23

The muscle tissue may or may not be sutured. Because the incision is in the direction of the muscle fibers, the edges approximate in a natural fashion.

Question 24

3 Closure

Answer 24

The external oblique fascia and Scarpa’s fascia are separately closed with a few interrupted 3-0 absorbable sutures. Some surgeons may not close Scarpa’s fascia and proceed directly to the skin.
However, other surgeons are of the opinion that closure of Scarpa’s fascia lessens the incidence of dead space in the subcuticular layer.

Consideration: Use of retractors is easy to remember because it is opposite of the order used when opening the abdomen. As the surgeon closes a layer, the wound cavity becomes shallower; therefore, deeper retractors are replaced with smaller retractors. Similarly, needle holders and thumb forceps become shorter as the wound is closed.

Question 25

4 Closure

Answer 25

A few 3-0 or 4-0 absorbable sutures are placed in interrupted fashion to close the subcuticular layer.

Question 26

5 Closure (hint skin closure options)

Answer 26

The skin is closed in one of the following 3 most frequently employed methods:
Consideration: Last count must be completed before the skin closure is completed.
a. Skin edges are grasped on both sides w/ toothed forceps, preferably Adsons. The skin edges are brought together & approximated with interrupted 3-0 or 4-0 silk or nylon on a cutting needle
b. Subcuticular closure is achieved using interrupted or continuous 3-0, 4-0, 5-0 synthetic absorbable or non-absorbable sutures.
c. Skin staples are often used to approximate the skin edges. The skin edges are grasped and everted using the toothed Adsons. The skin staples are then placed.

Question 27

Postoperative Considerations

Answer 27

According to the procedure that was performed, the patient is transported to PACU. Complications, wound healing/classification, and prognosis depends on the patient’s condition, pathology that required surgical intervention, and the surgical procedure performed.