Laparotomy- Indications, Contraindications, Procedure, and Recovery

Overview

Laparotomy (celiotomy) is a surgical procedure performed by incising the abdomen to gain access to the underlying organs. Primarily done to examine, diagnose, and treat abdominal health conditions. It is usually performed when other tests fail to diagnose or resolve the problem.

Laparotomy helps to diagnose abdominal conditions like :

• Unexplained severe abdominal pain.

• Unexplained internal bleeding.

• Abdominal infections.

• Abdominal trauma (accident cases).

• Peritonitis (inflammation of the inner lining of the abdomen).

• Organ perforation.

• Severe conditions like endometriosis or cancer (with undetermined spread).

• Hysterectomy (complete removal of the uterus).

What Are the Indications and Contraindications of Laparotomy?

Indications of Laparotomy

Indications for laparotomy have significantly been decreased, as minimal access procedures (keyhole surgeries) are preferred worldwide by doctors. But, in many conditions greater access to internal organs is essential to perform surgeries. Some of the indicative conditions are:

• Inflammatory conditions.

• Multiple dense adhesions due to previous surgeries.

• Intestinal obstruction or massive ascites.

• End-stage liver or cardiac diseases.

• Emergency Conditions: Acute intraperitoneal or gastrointestinal bleeding, penetrating abdominal injuries, perforated gastrointestinal tract, etc.

• Elective Procedures: Pancreaticoduodenectomy, pancreatic or intestinal transplants, etc.

Contraindications of Laparotomy

Laparotomy is avoided in the following cases-

• Patient unfit for general anesthesia.

• Comorbidities.

• Sepsis.

• Hemodynamic instability.

• Metastatic malignant diseases.

What Are the Different Types of Laparotomy?

There are different types of laparotomy depending on the position of the incision:

• Midline: As the name suggests, the incision is given in the middle of the abdomen. It is used for surgery of the upper abdomen.

• Paramedian: A vertical cut that runs to one side of the midline. It is used to treat the kidneys and adrenal glands.

• Transverse: A horizontal cut.

• Pfannenstiel: This is used to access the pelvic region, for example- in the case of an emergency cesarean delivery.

• Subcostal: This is a diagonal cut across one side of the upper abdomen. The subcostal incision is used to treat and diagnose the gallbladder, spleen, and liver.

• Rooftop (Chevron): Subcostal incision on both sides of the body, meet in the middle to make a rooftop incision.

How to be Prepared for a Laparotomy?

There is not much time to prepare for laparotomy in emergency cases like accidents. However, in case of a scheduled surgery:

• The Week Before Surgery- Basic preparations include:

  • Stop smoking or alcohol intake.

  • Well-managed health conditions (blood pressure, diabetes, etc.).

  • Inform doctors about pregnancy, any other supplements, prescriptions, and over-the-counter medications.

• On the Day of Surgery- Medications, and instructions given by doctors must be followed. Water intake should be minimum.

• Immediately Before the Operation-

  • The abdominal area is shaved.

  • Surgical scrub and dress are given.

  • An enema to empty the bowels.

  • The patient is checked for any possible allergies before administering anesthesia.

  • The principle of 'nil by mouth' (nothing to eat) is followed for a few hours before laparotomy.

  • Previous operative scars or deformities of the abdominal wall are checked.

  • Cross-matching of blood groups is done.

  • A urinary catheter is placed.

  • Intravenous antibiotics are given.

  • Maintain adequate fluid and electrolyte balance in the body.

  • A nasogastric tube might be placed (in cases of obstruction or perforation).

What Is the Procedure of Laparotomy?

General anesthesia is given to the patient for laparotomy.

The process is as follows:

• An incision is made through the skin and muscles of the abdomen to examine the underlying organs.

• Careful diagnosis and examination of the underlying organs are made.

• After diagnosis, doctors may fix the problem, or the patient may need a second operation.

• After completion, the wound is closed by placing sutures (stitches).

What to Expect After Laparotomy?

After the operation, the following procedures can be expected:

• Careful monitoring of temperature, pulse, respiration, blood pressure, and wound site.

• Insertion of a drain at the site of the wound.

• Placement of a nasal tube to help drain stomach secretions for a few days.

• A urinary catheter is placed.

• Intravenous fluids (directly into the vein) for providing nutrition.

• Painkillers are given.

• Patients are encouraged to perform deep breathing, leg exercises, and early walking (it reduces the risks of blood clots and chest infections).

• Daily wound care and regular observation is needed.

• Medication is given at the time of discharge.

How Is Recovery After Laparotomy?

Recovery time after laparotomy varies depending upon the case and cause of laparotomy. Factors that affect recovery time are the overall health and age of the person. A good self after-care by the patient aids in rapid recovery. Along with the doctor's guidance, the patient should follow:

• Taking sufficient rest for a few weeks as recommended by the doctor.

• Avoid any heavy lifting, pulling or pushing, sexual activities, and swimming for at least six weeks.

• Proper medication and exercise schedule.

• Proper diet.

• Contact the doctor immediately if:

  • Areas around the wound show increased pain or tenderness, redness, swelling, and discharge from the wound site.

  • Fever, vomiting, or nausea.

  • Symptoms of a blood clot like severe pain in the legs, chest pain, or difficulty breathing.

What Are the Risks Associated With Laparotomy?

Laparotomy is a major surgical procedure, so the general risk associated includes- bleeding, infection, bruising, hematoma, poor healing at the incision site, reaction to anesthesia, or skin numbness.

Other more specific complications include- lack of diagnosis (need for more procedures and tests), damage to bowels or abdominal organs, or hernia at the incision site.

• Scarring- Red, painful, raised scar across the abdomen may appear, which usually resolves in six weeks to eight weeks. Sometimes, the scars may become permanent.

• Abdominal Adhesions- Commonly seen after laparotomy, bands of scar tissues are formed inside the abdomen. Abdominal adhesion may cause symptoms like - pain, bloating, constipation, fever, nausea, and vomiting. Sometimes, it may lead to complications like a blockage in the intestines (small bowel obstruction) or infertility in females (reproductive system obstruction).

What Is Laparoscopy (Keyhole Surgery)?

Laparoscopy or keyhole surgery is quite similar to laparotomy. In this procedure, small keyhole incisions are made on the abdomen then a tiny tube with a light and camera at its end is inserted through it. Laparoscopy is less invasive and has better recovery as compared to laparotomy.

Conclusion

Laparotomy or celiotomy is a major surgical procedure. An incision is made over the abdomen to diagnose or treat the underlying organs. Proper after-care and following the prescribed medications aids in early recovery and better prognosis.