Overview of Laparotomy
The term ‘laparotomy’ originated from the Greek words ‘lapara,’ which means side, and ‘tomy,’ which means to cut. This procedure refers to a significant cut or incision in the abdomen to reach the peritoneal cavity, which is the area inside your abdomen that contains your stomach, liver, and other digestive organs. So, when a doctor performs a laparotomy, they are typically making a cut along the middle of your belly along the linea alba, which is the line that runs down the middle of your abdomen.
In the United Kingdom, laparotomies are quite common, with roughly 30,000 to 50,000 of these procedures performed every year.
Anatomy and Physiology of Laparotomy
The abdominal wall holds in and protects the organs in your belly. The wall is made up of many different layers. These layers are, from the outside to the inside: skin, a layer of fat, two types of fascia (which is tough tissue connecting organs and muscles), there of different muscles (the external and internal oblique muscles, and the rectus abdominis muscle), another muscle called the pyramidalis muscle, the transversalis fascia (another type of tough tissue), and the peritoneum (lining of the abdominal cavity).
The rectus abdominis muscles are two long muscles that run up and down on either side of your belly button. These muscles are joined in the middle by the linea alba, a tough band of tissue that runs from the base of your sternum (breastbone) down to your pubic bone. The edges of these muscles, create an outline known as the linea semilunaris. The rectus abdominis muscles are divided by bands of connective tissue which give your stomach the well-known ‘six-pack’ appearance. These muscles help to squeeze and hold in your belly, as well as keep your pelvis steady while you walk. They are controlled by the thoracoabdominal nerve.
The pyramidalis, is a small, triangular muscle found under the rectus abdominis, running from your pubic bone to the linea alba.
The rectus abdominis and pyramidalis muscles are surrounded by the rectus sheath. This is a protective layer formed by the connective tissues (aponeuroses) of three other muscles – the external oblique, internal oblique, and transversus abdominis. The sheath has a front and back part – but does not have a back part below a certain point (the arcuate line), which allows another layer, the transversalis fascia, to come in direct contact with the muscles.
The blood for the abdominal wall comes from two main sources – the inferior and superior epigastric arteries, and the segmental arteries that come from the aorta, which is the main artery that carries blood from your heart to the rest of your body. These arteries supply blood to the rectus abdominis muscle and other tissues in the abdomen.
Along with the thoracoabdominal nerve, nerves such as the iliohypogastric, and ilioinguinal nerves, and branches from other nerves help to control the muscles in the abdominal wall.
Why do People Need Laparotomy
Surgery has come a long way and many operations that used to require large incisions can now be done using small cuts and a camera. This is known as minimal access surgery or ‘keyhole’ surgery. But there are still some cases where a larger incision or a traditional surgery known as a “laparotomy” is needed.
Your doctor might decide to do a laparotomy if keyhole surgery is too risky or challenging. This could be due to things like scarring from previous surgeries, severe inflammation, a bloated intestine, or a large amount of fluid in the belly from liver or heart disease. In situations where it’s a matter of life and death – to stop severe bleeding, to treat injuries from a physical impact or stabbing, or to deal with a serious whole-body infection from a leak in the gut – a laparotomy is often the first choice.
There are also specific situations where a laparotomy is still the preferred approach. For example, if a large specimen has to be removed, like for a Pancreaticoduodenectomy (that’s a name for a specific type of surgery that removes part of the pancreas), a laparotomy is more suitable. Additionally, certain types of organ transplants, for instance, of the pancreas or intestine, require a more traditional laparotomy.
It’s essential to understand that the decision between keyhole surgery and laparotomy depends on many things – the type of surgery, your health condition, the benefits and risks of each method. Your healthcare team will always consider what’s best for your health, safety, and recovery.
When a Person Should Avoid Laparotomy
There are certain conditions where it may not be safe for a person to go under general anesthesia. These could include other ongoing health issues, severe infections, issues with blood pressure stability, and advanced stage of cancer spread throughout the body. It’s also important to remember that everyone has the right to refuse a major surgery like a laparotomy (big cut in the belly), if they’re able to make that decision for themselves.
Before making a decision, your doctor will do a complete check-up and may also order some imaging tests. These are crucial because there are many health issues that could produce similar symptoms to a serious belly issue, leading to a potential wrongly suggested major surgery. These conditions could include things like a severe inflammation of the pancreas (acute pancreatitis), sudden high blood sugar crisis, gout, gastritis or a urinary tract infection.
Sometimes, the doctor might use a predictive tool called the P-POSSUM score. This helps them understand the risk of illness or death from the surgery, thereby making a more informed decision.
Equipment used for Laparotomy
The equipment used for a surgical procedure that opens the abdomen, known as a laparotomy, can differ depending on the reason for the surgery. However, to simply allow the surgeon access into the abdomen, the following tools are usually used:
- A scalpel (most often a 10 blade) – This is a small, sharp knife used for surgeries.
- Monopolar cautery – This is a medical device that uses heat to stop bleeding or to cut through tissue.
- Tooth forceps – These are a type of tweezers used by surgeons to hold tissue and skin safely.
- Abdominal packs/swabs – These are special materials used to absorb blood and fluids during surgery.
- Fraser-kelly clips – These are metal or plastic clamps used to hold tissue and skin open during surgery.
- McIndoe scissors – These are specialized surgical scissors used for cutting tissues.
- Retractor – This is a tool used to hold wounds open so that surgeons have better visibility and access to the area being operated on.
- Suction – This is a device that removes blood and body fluids during the operation to keep the area clean and visible.
The goal of these tools is to ensure the surgeon has a clear view and can perform the surgery safely and effectively.
Who is needed to perform Laparotomy?
During an operation known as a laparotomy, several medical professionals are usually present to ensure everything goes smoothly. These include the main doctor who performs the operation, known as a surgeon, and the surgeon’s assistant who provides help. You’ll also have a scrub nurse, who assists by ensuring surgical tools are clean and ready. An anesthetist is responsible for managing your pain and consciousness, while the anesthesist technician assists them.
Further assistance is provided by the operating department practitioner, who has a broad role in supporting the surgery process. Additionally, there are certain members of the hospital theater staff available. They help out by fetching more medical supplies or equipment if needed during your surgery.
Preparing for Laparotomy
Getting ready for surgery can vary greatly, depending on the reason for the operation. For example, if the surgery is related to cancer, it can be helpful to have a special nurse who works with cancer patients assist with preparation. If it’s an emergency situation, it’s important to keep the patient’s family or close ones informed, provided the patient agrees. Their support can be very helpful during this stressful time.
Patients and their families need to understand what will take place during the surgery and what the expected results are. This is known as informed consent. In cases where the patient can’t make decisions due to being unconscious or not mentally capable, the surgeon can use a Consent Form 4 to make decisions that are best for the patient. Before filling out the form, the surgeon must confirm the patient’s mental state and discuss the situation with a family member if possible. For children under the age of consent, a parent or guardian must provide legal consent using a Consent Form 2.
The way a patient physically prepares for surgery can change depending on the type of operation and whether it’s an emergency or pre-scheduled. Here are some things to consider:
- Removing hair from the belly area
- Checking the patient’s body mass index (BMI) – Patients planning to have an ileostomy might need to lose weight before surgery. This can make the anesthesia work better and make the surgery easier.
- Looking at any scars or abnormal shapes in the belly area – Previous surgeries can cause the tissue to stick together, making it harder to do the surgery.
- Checking for any hernias
- Considering patient’s smoking habits and how well their diabetes is controlled, as these can affect how wounds heal.
If a stoma is needed, the doctor will think carefully about where to place it. They’ll aim to choose a spot where the patient can easily see and reach it, and it won’t get in the way of things like belts or skin folds. They’ll also try to keep it away from certain body parts like the rib cage and belly button.
In certain cases where the patient is experiencing a blockage or tear in the digestive tract or might have issues with digestion after surgery, a nasogastric tube might be used. This is a tube inserted through the nose, down the throat, and into the stomach to remove air and fluids and keep the stomach empty.
Depending on the type of surgery, the patient may also need to have their fluid and electrolyte levels stabilized, a urinary catheter placed, receive intravenous (IV) antibiotics, determine their potential need for blood transfusion, and have certain imaging tests done, such as a CT (Computed Tomography) scan.
How is Laparotomy performed
Surgeons make incisions, or cuts, into the belly during an operation. These cuts allow surgeons to reach the organs that they need to treat. The belly, known as the abdominal cavity in medical terms, can be accessed in several ways, using different types of incisions. Here are the common types of cuts:
Midline/Median Approach
This procedure involves making a cut along the middle of the belly. The surgeon might make a small or a long cut depending on where the issue is inside your belly. For instance, for problems in the upper belly, the surgeon might not need to cut the lower part. However, if needed, they can make the cut longer for better access. After making the initial cut on the skin, the surgeon carefully cuts through layers of fat and fascia (tough tissue) to reach a layer called the rectus sheath. Here, the surgeon will make another incision to reach the peritoneal cavity, which is the space inside your belly where the organs are located. The surgeon is careful to not hurt other organs like your intestines.
Paramedian Approach
This involves a vertical cut done off-center on the belly to reach organs on the side or at the back of the belly, like kidneys or adrenal glands. This cut starts from a different landmark as compared to the midline approach. As this approach involves cutting through the muscles of the belly wall, there is a slightly higher chance of muscle damage, blood collection (hematoma), and nerve injury.
Transverse Approach
Unlike the previous two procedures that involve vertical cuts, this approach involves a horizontal or side-to-side cut near the belly button. This method generally causes less damage to the nerve supply to your abdominal muscles and heals well. This approach is usually used for an operation called an open right hemicolectomy, a kind of surgery that primarily deals with your colon.
Pfannenstiel Approach
With this technique, surgeons make a curved cut 5 cm (about 2 inches) above your pubic bone to reach the bottom of your belly, also known as the pelvic cavity. Surgeons use this incision in emergency cesarean sections or if they need to remove diseased tissue from elsewhere in your belly. When making this cut, the surgeon will take great care to not harm your bladder or intestines.
Subcostal Approach
In this approach, the cut starts below the small bone at the front of your rib cage (xiphoid process) extending below and parallel to your ribs. If your gallbladder or liver needs to be reached, the surgeon makes this cut on the right side. If the spleen is being targeted, the cut is made on the left side. Joining left and right subcostal incisions in the middle forms a rooftop incision.
Possible Complications of Laparotomy
Complications from a laparotomy, a surgical procedure where a large incision is made through the abdominal wall to gain access inside the abdominal cavity, can vary. They can be specific to the area where the operation took place or general complications that could happen after any surgery. These complications are often influenced by factors at the time of the operation and may depend on the patient’s health or the surgeon’s actions and decisions. Generally, they are also related to the surgical procedure itself. Here’s a list of potential complications:
- Bleeding – this is when you lose too much blood during or after the surgery.
- Infection – this happens when germs get into the wound and cause a problem.
- Bruising – this means discoloration and tenderness around the wound.
- Seroma/ hematoma – these are pockets of fluid or blood that can form under the skin.
- Wound dehiscence – this is when the surgical wound reopens after the operation.
- Necrosis – this is when some of the tissue in or near the surgical site dies.
- Incisional hernia – this is when part of your insides push out through the surgery wound.
- Chronic pain – this is long-term pain in the area of the surgery.
- Skin numbness – this happens when you lose feeling in the skin around your wound.
- Fistulation with underlying structures – this is when an abnormal connection forms between your wound and an organ or other structure inside your body.
- Raised intra-abdominal compartment pressure – this is when the pressure inside your belly area rises dangerously high.
- Damage to underlying structures – this is when some part deep inside you is hurt during the operation, like an organ or blood vessel.
- Poor cosmesis – this is when there is a dissatisfying appearance due to the surgery or resulting scar.
What Else Should I Know About Laparotomy?
Laparotomy is a type of surgery involving a large cut made in the abdomen. While the term doesn’t specify which operation will follow this initial cut, it generally implies a significant procedure. Over time, methods like minimally invasive surgery and robot-assisted surgery have caused laparotomies to be used less frequently. They are now typically reserved for emergencies or situations where other techniques wouldn’t be suitable.
For instance, if a patient needs immediate access to the abdomen, or the condition inside the abdomen is not responsive to other techniques, a laparotomy might be preferred. When preparing for such a surgery, the patient must be properly stabilized. Their electrolyte levels (chemicals in the body that help it function) must be balanced and any infection must be kept under control. The surgical cut must be done carefully to minimize its impact on the patient’s body functions.
