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extensible vertical incision, especially a midline one. Generally
speaking, the trans linea alba midline incision is swiftly effected and
relativelybloodless.Ontheotherhand,transverseincisionsarealittle
more time- and blood-consuming but are associated with a lower
incidenceofwound dehiscence and incisional herniaformation.In
addition,transverseincisionsareknowntobe‘easier’onthepatientand
hislungfunctionin thepostoperativeperiod,requirelessretraction,and
allow better exposure in the ‘wide and short’ patient. Vertical
paramedianincisionslargelybelongtohistory.
Keepingthisinmind,weshouldbepragmaticratherthandogmatic
and tailor the incision to the individual patient and his or her disease
process. We should take into consideration the urgency of the
situation,thesiteandnatureofthecondition,theconfidencein(or
uncertaintyabout)thepre-operativediagnosis,andthebuildofthe
patient.
Common sense dictates that the most direct access to the
specific intra-abdominal pathology is preferable. Thus, the biliary
systemis bestapproached througha rightsubcostal (‘Kocher’)incision.
Transverseincisionsareeasilyextended to offeradditionalexposure; a
rightsubcostalincisioncanbeextendedintotheleftside(asa‘chevron’),
offering an excellent view of the entire abdomen. When a normal
appendix is uncovered through a limited, transverse/oblique, musclesplitting, right lower quadrant incision, one can extend it by cuttingthe
musclesacrossthemidlinetodealwithanyintestinalorpelviccondition.
Alternatively, when an upperabdominal processis found,it isperfectly
reasonableto closethesmall rightiliac fossaincisionand placeanew,
more appropriate, one. Two good incisions are better than one,
poorlyplaced.
OldFinnishsurgicalproverb:“Surgeryiseasierwhentheincisionisplacedovertheorgantobe
operatedon.”Ari
The midline incision is bloodless, rapid, and easily extended,
affording superior exposure and versatility; it remains the classic
‘incisionofindecision’—whenthesiteoftheabdominalcatastropheis
unknown,andisthesafestapproachintrauma.Sometimesevenalong
midline incision is not enough, and you need to make an additional
transverse incision to gain exposure to the deep lateral or posterior
areas. If needed, don’t hesitate to do it. And conversely, a ‘chevron’
incision can be enlarged by a midline upper extension, creating a
‘Mercedes’ incision. (Ask your hepatic surgeon about his favourite
incision…andvehicle.)
Thisisthetimetomentionthatanemergencylaparotomywithout
adiagnosisisnotasin!Yes,apatientcanentertheoperatingtheater
withoutaticketfromtheCTscanner.Aclinicalacuteabdomen— when
other diagnoses have been ruled out (see Chapters 3 and 4) —
remainsanindicationforlaparotomywhentheabdominalwallistheonly
structureseparatingthesurgeonfromanaccuratediagnosis.Havingsaid
this—mainlytosatisfyandpacifythoseofyouwhoworkunderadverse
circumstances (e.g. we have visited a city hospital in Eastern Europe
where patients had to travel by ambulance for a CT!) — we have to
stressthatpre-operativeabdominalimaging(see Chapter 5) not
onlypinpoints the diagnosis butalso isofgreat help in choosing
thecorrectincision.Forexample,inapatientneedingsplenectomyfor
adelayedruptureofthespleenwewouldplacealeftsubcostalincision
ratherthana midlineone. TheCThasshownusthatthisis anisolated
splenicinjuryandthereisnoneedtoexploretherestoftheabdomen.
At what level must the midline incision start and how
longshoulditbe?( Figure10.1)
Figure10.1.“Whichincision?”
Themachosurgeonsofpreviousgenerationsoftenscreamed:“Makeit
long.Ithealsfromsidetoside,notfromendtoend.”Today,intheeraof
minimal access surgery,we are familiarwith the advantages of shorter
incisions.Intheabsenceofanyobviousurgency,entertheabdomen
through a shortincisionand then extendas necessary; butnever
accept less than adequateexposureor strive forkeyhole surgery.
Begin with an upper or lower midline incision, directed by your
clinical/imaging assessment; when in doubt, start near the level of the
umbilicus and ‘sniff’ around from there, then extend towards the
pathology. Just remember what the famous Swiss surgeon, Theodor
Kocher,saidmorethan100yearsago:“Theincisionmustbeaslong
as necessary and as short as possible.” Smart, eh? Before you
continue we want you to read a little about Herr Kocher (go to
http://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocherbio.html).
Whenshouldyouextendtheincisionintothethorax?
Veryrarely!Inthevastmajorityofcases,infra-diaphragmaticpathology
is approachable through abdominal incisions. The combination of a
subcostal and upper midline incision offers an excellent exposure for
almost all emergency hepatic procedures, with the exception of
retrohepatic venous injuries where insertion of a trans-atrial vena cava
shunt necessitates a median sternotomy — usually a futile exercise,
anyway. Thoracoabdominal incisions are mainly reserved for
combined thoracoabdominal trauma (and rarely for tumors at the
esophagogastric junction which ‘climb’ up the esophagus). If not
absolutely necessary, avoid extending the laparotomy incision to
thoracolaparotomythroughthecostalcartilage—ithealsverypoorly!In
most cases, it is sufficient to do a separate anterolateral
thoracotomyincision.Thiscaneasilybeextendedtotheothersidefor
a‘clamshell’incisionthat offersanexcellent viewof allanterior thoracic
structures.Ifyouneedtodividethediaphragm,doitlaterally,curve-
shaped to avoid damage to the proximal branches of the phrenic
nerve.Insomecases,rapidaccesstothepericardiumduringlaparotomy
(suspected cardiac tamponade forexample) is easily donethrough the
central tendon of the diaphragm by grasping the bare area of the
pericardiumwithaKocher’sclampandopeningthepericardium.Ifblood
is found, then extension of the laparotomy incision into a median
sternotomyisthebestoption.
Knifeordiathermy?
Afewstudiessuggestthatthelatterisafewminutesslowerwhilethe
former sheds a few more drops of blood; otherwise results are
comparable. We use either. In extreme urgency, gain immediate entry
withafewswiftstrokesoftheknife;otherwise,diathermyisconvenient,
especially when performing transverse muscle-cutting incisions.
Adequate hemostasis is acrucial surgical principlebut do notgo
overboard chasing individual erythrocytes and avoidreducing the
subcutaneousfatorskintocharcoal.Thehypothesisthat“Youcantell
howbad the surgeonisby the stink oftheBovie (electrocautery) inhis
OR”has notbeen provenby adouble-blindrandomizedtrialbutmakes
sensenonetheless.
Subcutaneoushemostaticligaturesbehavelikeaforeignbodyandare
almost never necessary. In practice, most incisional ‘oozers’ stop
spontaneouslyafterafewminutes,underthepressureofamoistlappad
oratemporaryhemostat.Ifnecessary,usewell-directeddiathermytokill
the bloody bleeder at the point where it emerges under the skin, and
avoidburningblindlyin apoolofblood.Itisalsounnecessaryto‘clean’
thefasciabysweepingthefatlaterally:themoreyoudissectand‘burn’,
the more inflammation and infection-generating dead tissue you
create!
Keepinmindspecialcircumstances:
•
If a stoma is anticipated then place the incision away from its
plannedlocation.Youdon’twantthetoiletinthekitchen!
•
Abdominal re-entry intothe ‘hostile abdomen’ of a previously
operated patient can be problematic. You may spend more time,
sweat and blood, but the real danger is creating inadvertent
enterotomies in intestine adherent to the previous incisional scar.
Thisisacommoncauseofpostoperativeexternalbowelfistula!(
Chapter 47). The prevailing opinion is to use the previous
incisionforre-entry,ifpossible.Whendoingso,however,starta
fewcentimetersbeloworabovetheoldincisionandgainentrytothe
abdomen through virgin territory. Then insert your finger into the
peritoneal cavity and navigate your way safely in, taking down
adhesions to the abdominal wall, which hamper the insertion of a
self-retainingretractor.Essentially,youarefinished‘gettingin’when
youareabletoplaceaself-retainingretractortoopentheabdomen
wide.In a dire emergencyorwhen you expecttheabdomen to be
exceptionallyscarred,itmaybeprudenttostayawayfromtrouble
and create an entirely fresh incision. In this situation beware of
parallel incisions in close proximity to one another because the
intervening skin may be at risk of necrosis, particularly if the first
incisionisrelativelyrecent.
Remember:Sometimes,spendinganhourto‘getintotheabdomen’inordertodo
a5-minuteprocedure(e.g. release of an obstructing adhesion) isnotasign of a timid
surgeonbutajudiciousone! Youmay wanttoconsider this mnemonic of abdominalentry
andexposure:‘the4Ps’:patience,preservation,persistence,prudence.(Somesurgeonsmay
needafifthp—Prozac®.)
Pitfalls
•
Wheninhaste,donotforgetthattheliverliesintheupperextremity
ofthelongmidlineincision,andtheurinarybladderatitslowermost.
Becarefulnottodamageeither.
•
Whenapproaching the upperabdomendivide and ligatetheround
hepatic ligament. Leave it long: it could be used to elevate and
retractthe liver or usedasa patch for perforatedduodenal ulcer if
the omentum is not available. Take the opportunity to divide the
bloodlessfalciformligament,whichrunsfromtheanteriorabdominal
wallandthediaphragmtotheliver.If leftintact itmay ‘tear’offthe
livercausingirritatingbleeding.
•
Whenperforminganytransverseincisionacrossthemidline,donot
forget to ligate or transfix the epigastric vessels just behind the
rectusabdominismuscles.They may retract, be difficult to control,
andcauseadelayedabdominalwallhematoma.
•
In the very obese patient, in the upright position, the umbilicus
commonly reaches the level of the pubis. After elevating the fat
panniculusyoucanplacealowermidlineincisionbetweenthepubis
and umbilicus but after the operation it will be macerated by the
sweaty (and smelly) panniculus. Thus, in the super-fat, a supraumbilical midline incision would provide a better access into the
lower abdomen. (By the way, be carefulwith the fatty omentum,it
tearseasilyifpulledtoohard,and bleedingfromthetornomentum
is difficult to control except by resecting that part of the omentum
altogether.)
“Praybefore surgery, but rememberGod willnot altera
faultyincision.”
ArthurH.Keeney
“When the doctor isin doubt and thepatient in danger,
makeanexploratoryincisionanddealwithwhatyoufind
asbestasyoucan.”
RobertLawsonTait
1
AsherHirshberg,MD,contributedtothischapterinthefirsteditionofthisbook.
Chapter11
Abdominalexploration:findingwhatiswrong
MosheSchein,PaulN.Rogers,AriLeppäniemi,DannyRosinand
JonathanE.Efron
1
In surgery, eyes first and most; fingers next and little;
tonguelastandleast.
SirGeorgeMurrayHumphry
Neverlettheskinstandbetweenyouandthediagnosis.
(We understand that this is anold andvenerated surgical
aphorismbutwethinkwedon’twishtoencouragereckless
pursuitofdiagnosis,dowe?)
Not uncommonly — especially with the increased use of diagnostic
imaging — when opening the abdomen, the surgeon knows what to
expectinside;theclinicalpicture and/or ancillary tests direct him to the
diseaseprocess.Insomeinstances,however,heexplorestheunknown,
led on only by the signs of peritoneal irritation, assuming that the
peritoneal cavity is flooded by blood or pus. Usually the surgeon
speculates about the predicteddiagnosis but always remainsready for
theunexpected (in some places ‘BigBrother’compares our pre-op and
post-op diagnoses — we are expected always to be ‘correct’ whereas
they are allowed to screw up the budget…). This is what makes
emergency abdominal surgery so exciting and demanding — the
everloomingcatastropheandtheanxietyaboutwhetherornotyou
areabletotackleitcompetently.Yes,eveninthedaysofCTandMRI
theabdomencan befull ofsurprises!Ifyoudon’t likesurprisesthengo
andbeadermatologist.
Abdominalexploration( Figure11.1)
Whilethespecificsequenceandextentofabdominalexplorationareto
betailored tothe clinicalcircumstances, thetwo principalstagesofany
explorationare:
•
Identification of the specific pathology which prompted the
laparotomy.
•
Routineexplorationoftheperitonealcavity.
Essentially,thereisasharpdistinctionbetweenalaparotomyfornontraumatic conditions such as bowel obstruction, inflammation or
peritonitis,and laparotomyfortrauma withintra-abdominalhemorrhage,
thelatterrarelybeingduetospontaneous,non-traumaticintra-abdominal
causes.
Figure11.1.“HeyDoc,didyoufindanything?”
Soyou incisetheperitoneum, whatnow?Your action dependson
theurgencyofthesituation(conditionof thepatient), themechanismof
the abdominal pathology (spontaneous versus trauma), and the initial
findings(blood,entericcontent,bileorpus).Whateveryoufind,followthe
mainpriorities:
•
Identifyandarrestactivebleeding.
•
Identifyandcontrolcontinuingcontamination.
At the same time — do not be distracted by trivia. Do not chase
isolatedredbloodcellsorbacteriainapatientwhoisbleedingtodeath.
For example, do not repair minor mesenteric tears in a patient who is
busyexsanguinatingfromatorninferiorvenacava.Thisisnotajoke—
surgeonsareeasilydistracted.
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