What is a opening through the skin layer and abdominal wall into the peritoneal cavity
Laparotomy
What is an example of a laparotomy procedure
Bowel procedure
Subcutaneous fat
Scarpa’s fascia
External oblique muscle
Internal oblique muscle
Transversus abdominus muscle
Transversalis fascia
Peritoneum
Layers of the abdominal wall
ABC of close
Irrigate
Close
Dress
Suction tools used in a laparotomy procedure:
Yankauer and Poole suction tips; when using the Poole suction tip within the abdominal cavity the surgeon may want to wrap a wet lap sponge around the tip to prevent tissue attaching to the tip and being damaged
1. Midline Skin Incision (2 laps, ESU, forceps ready)
2. Incision is deepened with larger knife (deeper retractors needed)
3. Bleeding vessels are clamped with small hemostats and either ligated with nonabsorbable ties or cauterized
4. Using curved Mayo scissors, electrosurgery, or scalpel, the external oblique muscle is opened the length of the skin incision (muscle splitting incision in the direction of the muscle fibers) - keep laps on field
General surgery steps during an exploratory laparotomy procedure (opening) 1-4
5. Medium retractors are placed to retract the external oblique muscle (richardson) be prepared to quickly clamp and ligated blood vessels (ties or cautery)
6. The internal oblique muscle, transverse muscle, and transversalis fascia are split in the direction of the muscles fibers up to the rectus sheath using a scalpel or curved Mayo scissors. The medium retractors are replaced with large Richardson retractors that have longer blades in order to retract the internal oblique and transverse muscle.
7. The peritoneum is now exposed. A small incision is made - hemostat to elevate the peritoneum.
8. If abnormal fluid is encountered, sponges and suction are used as needed. Cultures will also be taken at this time
9. The edges of the peritoneum and transversalis fascia are grasped with a Kocher on each lateral edge and slight traction is placed on the Kochers laterally.
General surgery steps during an exploratory laparotomy procedure (opening) 5-9
10. The peritoneal incision is lengthened (Metz, curved Mayo or scalpel)
11. Tissue in the direction of the pelvis may be cut; blood vessels in the fatty layer between the fascia and the umbilicus could bleed (ties, clamps, or cautery)
12. Richardson retractors are repositioned to allow the surgeon to conduct an initial exploration of the abdomen
13. Affected and non affected organs are identified (Balfour or Bookwalter)
General surgery steps during an exploratory laparotomy procedure (opening) 10-13
1. The peritoneum and internal oblique fascia are closed
(Sponge, sharps and instruments counts are completed before the abdominal cavity is closed)
2. If peritoneum closed separately
-have toothed forceps and clamps ready
-Synthetic absorbable sutures or interrupted nonabsorbable sutures may be used
-A ribbon retractor may be used under the peritoneal later
the internal oblique fascia is closed with absorbable or nonabsorbable sutures
3. If single-unit closure:
-a heavy looped or synthetic absorbable or nonabsorbable suture is used e.g. #0 or #1
General surgery steps during an exploratory laparotomy procedure (closing) 1-3
4. The external oblique fascia and Scarpa's fascia are separately closed
-3-0 absorbable sutures are often used
-deeper retractor are replaced with smaller retractors
5. The subcuticular layer is closed
3-0 or 4-0 absorbable sutures are used
5. The skin is closed
-last count is completed
-toothed Adson forceps may be used to grasp the skin
-3-0 or 4-0 silk or nylon on a cutting needle may be used
6. Subcuticular closure
-3-0, 4-0, or 5-0 synthetic absorbable/nonabsorbable sutures may be used
-skin staples may be used to approximate skin edges
General surgery steps during an exploratory laparotomy procedure (closing) 4-6
What incision are used for laparotomy
Median or Paramedian