A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.
Origins and history
The first successful laparotomy was performed without anesthesia by Ephraim McDowell in 1809 in Danville, Kentucky. On July 13, 1881, Dr. George E. Goodfellow treated a miner outside Tombstone, Arizona Territory, who had been shot in the abdomen with a.32-caliber Colt revolver. Goodfellow was able to operate on the man nine days after he was shot when he performed the first laparotomy to treat a bullet wound.
Terminology
The term arises from the Greek word λᾰπάρᾱ, meaning "the soft part of the body between the ribs and hip, flank," and the suffix "-tomy" arising from the Greek word "τομή" meaning "a cut." In diagnostic laparotomy, the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause. In therapeutic laparotomy, a cause has been identified and the operation is required for its therapy. Usually, only exploratory laparotomy is considered a stand-alone surgical operation. When a specific operation is already planned, laparotomy is considered merely the first step of the procedure.
Spaces accessed
Depending on incision placement, laparotomy may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include:
Pick up peritoneum, confirm that there is no bowel adhesion
Nick peritoneum
Insert finger beneath the wound to make sure that there is no adhesion
Cut the peritoneum with scissors
Other
Other common laparotomy incisions include:
Kocher incision ; appropriate for certain operations on the liver, gallbladder and biliary tract. This shares a name with the Kocher incision used for thyroid surgery: a transverse, slightly curved incision about 2 cm above the sternoclavicular joints;
Davis or Rockey-Davis "muscle-splitting" right lower quadrant incision for appendectomy, named for the Oregon surgeon Alpha Eugene Rockey and the Philadelphia surgeon Gwilym George Davis, who devised such incision style in 1905.
Pfannenstiel incision, a transverse incision below the umbilicus and just above the pubic symphysis. In the classic Pfannenstiel incision, the skin and subcutaneous tissue are incised transversally, but the linea alba is opened vertically. It is the incision of choice for Cesarean section and for abdominal hysterectomy for benign disease. A variation of this incision is the Maylard incision in which the rectus abdominis muscles are sectioned transversally to permit wider access to the pelvis. This was pioneered by the Scottish surgeon Alfred Ernest Maylard in 1920.
Lumbotomy consists of a lumbar incision which permits access to the kidneys without entering the peritoneal cavity. It is typically used only for benign renal lesions. It has also been proposed for surgery of the upper urological tract.
Cherney Incision - developed in 1941 by the American uro-gynecologic surgeon Leonid Sergius Cherney.
Complications following laparotomy
Globally, there are few studies comparing perioperative mortality following laparotomy across different health systems. One major prospective study of 10,745 adult patients undergoing emergency laparotomy from 357 centres in 58 high-, middle-, and low-income countries found that mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. In this study the overall global mortality rate was 1.6 percent at 24 hours, increasing to 5.4 percent by 30 days. Of the 578 patients who died, 404 did so between 24 h and 30 days following surgery. Patient safety factors were suggested to play an important role, with use of the WHO Surgical Safety Checklist associated with reduced mortality at 30 days. Taking a similar approach, a unique global study of 1,409 children undergoing emergency laparotomy from 253 centres in 43 countries showed that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed in these settings. Internationally, the most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI and middle-HDI countries compared with high-HDI countries. Absorption of drugs administered orally was shown to be significantly affected following abdominal surgery.
Related procedures
A related procedure is laparoscopy, where cameras and other instruments are inserted into the peritoneal cavity via small holes in the abdomen. For example, an appendectomy can be done either by a laparotomy or by a laparoscopic approach. There is no evidence of short-term or long-term advantages for peritoneal closure during laparotomy.
