Lecture 21: Exploratory Celiotomy

What is a celiotomy?

incision into the abdominal cavity

What type of incision is a laparotomy?

flank incision

What does the phrase “acute abdomen” mean?

sudden onset of signs (distention, pain, vomiting) referable to the abdomen

What is abdominal evisceration?

herniation of peritoneal contents through the body wall with exposure of the abdominal viscera

What are the therapeutic reasons for abdominal exploratory surgery?

• Gastric dilatation and volvulus

• Severe hemorrhage

• Colonic perforation

• Foreign body removal

• Evisceration

What was the #1 cause of postoperative major abdominal evisceration in recent studies?

OHE

Why should trauma patients be observed for >8-12 hrs?

hemorrhage may not show up for 3-4 hours (splenic or liver lacerations)

True or false: surgeries less than 1 ½ hours, without opening a contaminated hollow viscus, do not usually warrant prophylactic antibiotics.

true

What supplies in instruments should be prepared for an exploratory celiotomy?

• Suction (Poole or Yankauer tip)

• Retractors (Balfour, malleable)

• Mixter (right-angle) forceps

• Laparotomy pads & 4x4s (with markers)

• Warm saline & bowl (copious amounts)

• Biopsy equipment/instrumentation

• Culture & Sensitivity

• Drains

Why is the linea alba easier to locate near the umbilicus?

it is wider and becomes thinner near the pubis

What is the site of insertion for the external abdominal oblique muscle (via the rectus sheath)?

linea alba

How long should an exploratory celiotomy incision be?

from xyphoid to pubis to explore all abdominal organs (can be adjusted by case)

What surgical prep step is unique to male patients?

flush the prepuce with antiseptic solution before the sterile prep and clamp the prepuce to one side with a towel clamp

How is an abdominal incision altered in male patients to account for the prepuce?

just cranial to prepuce, curve midline incision to side opposite the clamped prepuce

After incision xyphoid to pubis, what must be done before cutting through the linea alba?

• sharp/blunt dissection of SQ tissue to fascia

• ligate and cauterize small SQ bleeders

• avoid mammary tissue in lactating patients

• identify the linea alba

How is the incision through the linea alba created?

tent the abdominal wall and using a scalpel blade, incise the linea alba with a reverse-stab incision → extend incision with scissors (mayo) or use sliding incision with scalpel → digitally break down one side of falciform ligament or excise it

What is the general technique for the exploration part of the exploratory celiotomy?

1. explore cranial quadrant

2. explore caudal quadrant

3. explore intestinal tract

4. explore gutters

What is examined in the cranial quadrant of an exploratory celiotomy?

• diaphragm (including esophageal hiatus) and entire liver (palpate)

• gallbladder and biliary tree, then express gallbladder

• stomach, pylorus, proximal duodenum, and spleen

• examine both pancreatic limbs, portal v., hepatic aa., and caudal vena cava

What is examined in the caudal quadrant of an exploratory celiotomy?

• Descending colon

• Urinary bladder

• Urethra

• Uterine horns or prostate

• Inguinal rings

What is examined in the intestinal tract of an exploratory celiotomy?

• palpate and inspect duodenum to descending colon

• observe mesenteric vasculature and nodes (both sides)

• check entire length

What is examined in the “gutters” of an exploratory celiotomy?

right gutter:

• use mesoduodenum to retract intestines

• right kidney palpation

• examine right adrenal gland

• examine right ureter

• examine the right ovary or stump

left gutter:

• use descending colon to retract intestines

• palpate left kidney

• examine left adrenal gland

• examine left ureter

• examine left ovary or stump

Always use _____ lavage fluids to avoid hypothermia and decrease chances of post-op infection.

warm

What are the layers involved in abdominal wall closure?

1. Linea alba

2. Subcutaneous

3. Subcuticular

4. Skin

True or false: using a simple continuous closure increases the risk of dehiscence.

false

How many knots are using to secure the simple continuous closure of the linea alba?

6-8 at each end using strong absorbable suture

What ligament should NOT be incorporated between fascial edges when closing the abdomen?

falciform ligament

What is not included when closing the external rectus sheath?

muscle

When are sutures most likely to dehisce?

3-5 days post-op

What patient characteristics may cause an increased rate of dehiscence?

• Wound infection

• Fluid or electrolyte imbalances

• Anemia or Hypoproteinemia

• Metabolic disease or Immunosuppression

• Corticosteroids

• Radiation or chemotherapy patients

• Abdominal distention

• Improper surgical technique