Secrets of a Successful Exploratory Laparotomy
Avoid a 'Peek and Shriek Nightmare.’
By Phil Zeltzman, DVM, Dipl. ACVS
A great modern philosopher (her name is Patty Khuly, VMD) wrote about her concerns when dealing with some laparotomy cases ("Surgery Peek and Shriek: My Worse Nightmare," November 2007). Some procedures are technical or specialized, but with any laparotomy, there are a few secrets worth sharing.
|Classic plication of the jejunum in a 3-year-old cat who ate a linear foreign body.
Three critical steps of an exploratory laparotomy include the amount of hair clipped, the length of the incision and how systematic you are.
The surgical site must be clipped adequately to allow a sufficient skin incision. This means that hair is generously clipped from cranial to the xiphoid region to the pubis. Laterally, the area extends to the inguinal folds.
Very few clients will object to that once they understand it is in the pet’s best interest— and that incisions heal side to side, not end to end. Therefore, a 10-inch incision heals at the same rate as a one-inch incision.
A celiotomy starts with a ventral midline skin incision, which must be long enough to access and visualize every abdominal organ from the liver to the bladder. In cats and female dogs, an incision from the xiphoid process to the pubis is recommended. This is one of the few cases where saying “Big surgeons make big incisions” is OK.
After dissecting the subcutaneous tissue, the linea alba is tented and incised carefully with a scalpel blade. The dorsal aspect of the linea is palpated, cranially and caudally, to ensure that no adhesion or distended organ could be lacerated. The incision is carefully extended with scissors.
Organs that could easily be damaged include a full bladder, a bloated stomach, a gravid uterus, an enlarged spleen or any other large abdominal mass.
In a male dog, it may be prudent to move the prepuce laterally and hold it in place with a towel clamp to prevent urine leakage into the surgical field. The skin incision is extended lateral to the prepuce. In order to approach the caudal linea, you will need to cut the preputialis muscle and ligate branches of the caudal superficial epigastric vein.
For fear of retained surgical sponges, some surgeons ban the use of 4-by-4 gauze squares once they enter the abdomen. It is a reasonable precaution, as a bowel loop could easily stick to a gauze square, which could then be inadvertently left behind.
|Adenocarcinoma in the colon of an 8-year-old male cat.
It is safer to use laparotomy sponges, which contain a radiopaque marker. When in doubt, a radiograph will show the marker. Performing a sponge count before and after skin closure is another important precaution.
Some kind of systematic exploration is the next step. The following system is just one example, but it has worked well for many surgeons. You can develop your own systematic approach: All that matters is consistency and thoroughness.
It is often helpful to remove the fat-laden falciform ligament to improve access to the peritoneal cavity. A combination of traction with a large hemostat, ligatures and electrocautery minimizes bleeding.
After a Balfour retractor is placed, the first organ investigated can be the liver. Elevate the xiphoid region to better visualize the diaphragm and carefully palpate each liver lobe. The gallbladder is observed and very gently expressed to assess patency of the common bile duct.
The stomach can then be observed and palpated, from the cardia to the pylorus. Elevating the duodenum allows you to see the right limb of the pancreas. Gently moving the duodenum and meso-duodenum toward the left of the patient allows you to see the right kidney, adrenal gland, ureter and ovary. Don’t forget to palpate these organs. Seeing the right adrenal gland can be tricky because of its cranial location.
Then you can run the bowel, inch by inch. The thickness of the entire small intestine is appreciated. The mesenteric lymph nodes can be observed and palpated. After reaching the cecum, the entire colon is then palpated. Gently retracting the colon and meso-colon toward the right of the patient lets you view and palpate the left kidney, adrenal gland, ureter and ovary.
|Fat-ladden falciform ligament, weighing 1-pound, removed from a 10-year-old female Schnauzer.
The spleen, omentum and left limb of the pancreas should be inspected closely. The bladder, prostate, uterus and a possible retained testicle can then be visualized and palpated, depending on the patient’s gender.
Using this systematic approach for exploring the abdomen allows a quick but thorough exam. After any biopsies or cultures are taken, lavage the abdomen with warm, sterile saline or LRS if needed, and close.
Just like developing your own thorough way of doing a physical exam took time and practice, performing a thorough exploratory laparotomy takes time and the same effort. It will become easier to spot what is normal and abnormal. Soon, your personal system will become second nature.
It is important to remember that there is no such thing as a negative exploratory--even if you don’t find anything, at least take biopsies of the GI tract and mesenteric lymph nodes, for example.
Knowing how to do a thorough laparotomy is just the beginning ... knowing why and when it is required is another challenge. <HOME>
Phil Zeltzman, DVM, Dipl. ACVS, is a board-certified small animal surgeon at Valley Central Veterinary Referral Center in Whitehall, Pa. His website is www.DrPhilZeltzman.com.
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