The classic technique, or "laparotomy," is performed by making a single incision. The indication for a laparotomy is to gain sufficient access to the abdominal cavity to perform the surgery safely.
In specialized centers in hepatobiliary surgery, it is not usually the first choice because it has a longer postoperative period.
With recent advances in technology, surgery has progressed into the era of laparoscopic surgery (LAPAROSCOPY LINK), which is minimally invasive for patients.
However, there are still many circumstances in which laparotomy is indicated, such as emergency situations where rapid abdominal access is needed to stabilize the patient. In the elective setting (i.e., for non-emergency elective procedures), a laparotomy may be necessary if laparoscopic surgery is not sufficient to gain the necessary access to the viscera.
- blunt abdominal trauma
- hemorrhage (also called hemoperitoneum)
- viscera perforation
- peritonitis
- intestinal obstruction with extremely distended loops of bowel, making successful laparoscopic surgery impossible.
- removal of large pieces, such as duodenocephalopancreatectomy (LINK DCP).
- multiple previous abdominal operations, which cause the formation of extensive adhesions, that is, fibrin and collagen bridges that stick the viscera to each other and to the abdominal wall.
- Occult gastrointestinal bleeding that is not controlled with laparoscopic surgery.
Preparation
Preparedness varies depending on the nature of the operation and whether it is an emergency procedure or a planned (elective) operation. Depending on the patient's BMI (body mass index), preoperative weight loss may be required to improve suitability for anesthesia and facilitate surgery.
In the presence of scars or deformations due to previous operations in the abdominal wall, the presence of adhesions or hernias of the abdominal wall on previous incisions (incisional hernias) must be taken into account.
To improve the patient's anesthetic profile and postoperative evolution, it is recommended to reduce or stop smoking and control blood glucose, in the case of diabetes, to improve subsequent wound healing.
Generally, a few hours before the operation, hair is removed from the abdominal wall (epilation).
Types of laparotomies
Depending on the disease, the patient's physical characteristics, and, in part, the surgeon's experience, the incisions might be of different sorts, lengths, and locations.
- Subcostal/subcostal approach: This incision begins below the xiphoid process and extends below and parallel to the costal margin. The incision should be at least two finger widths below the rib margin to reduce the risk of postoperative pain and poor wound healing. It is the most commonly chosen type of incision in hepatobiliary pancreatic surgery. It is used to access the gallbladder and liver when done on the right side, and the spleen when done on the left side. If the left and right subcostal incisions meet in the midline, they form a "roof" incision.
- Midline approach: The most common procedure is the midline laparotomy, in which an incision is made in the middle of the abdomen.
- Paramedian Incision: This is similar to the median approach, but the vertical incision is not made in the center of the abdomen but rather lateral to the midline to allow access to lateral or retroperitoneal structures such as the kidneys and adrenal glands.
- Transversal incision: made horizontally and lateral to the navel, it causes less damage to the innervation and abdominal muscles since the incised abdominal muscle heals, producing a new tendinous intersection. An example of the use of the transverse incision is the right hemicolectomy.
- Pfannenstiel incision: It is made about 5 cm above the pubis, transversely (i.e., horizontally), to access the pelvic cavity. This incision is commonly used in caesarean sections and when a large surgical piece must be removed (even after laparoscopic surgery), such as in the case of a hemicolectomy or after a major hepatectomy (removal of 3 or more liver segments).
Complications
Complications of a laparotomy can be specific to the surgical site or general and are influenced by factors that depend on the patient, the operator, and the operation itself.
They include:
- hemorrhage
- infections
- bruises
- seroma/subcutaneous hematoma
- wound dehiscence (that is, its partial opening or poor adhesion of the margins)
- necrosis
- eventration (called incisional hernia, it is a distant complication).
- chronic pain
- numbness of the skin, with changes in sensation, especially of the skin around the incision
- increased intra-abdominal pressure
- unsatisfactory cosmetic result