An incision made through the abdominal wall into the peritoneal cavity,
preperitoneal space, or retroperitoneal space for the purpose of
exploration, diagnosis, and treatment.
Literally, laparotomy refers to an incision through the flank; however,
laparotomy usually refers to an incision through the anterior abdominal
wall into the peritoneal cavity. Laparotomy is performed for diagnostic
and/or therapeutic purposes.
The skin is incised with the “skin” knife. Subcutaneous tissue and
deeper structures are incised with the “deep” knife or electrosurgical
unit (ESU). Blood vessels may be clamped and ligated or cauterized
with electrosurgery. Fascia is incised, and the underlying muscles are
retracted or transected. The surgeon grasps the peritoneum (usually
with a smooth forceps) and incises it with the “deep” knife. The incision
is completed with a scissors (Metzenbaum or curved Mayo) or
electrosurgical pencil. Wound edges are retracted accordingly by
Deaver and/or Richardson retractors or by a self-retaining retractor
(e.g., Balfour). The abdomen is explored. The surgery is performed.
The wound/peritoneal cavity may be irrigated; the irrigation fluid is
removed by suction. Drains may be brought out through stab wound
incisions and sutured to the skin. A safety pin is often placed on the
exposed portion of the drain.The peritoneum is closed with a continuous
suture. Two toothed forceps or several Pean or Kocher clamps
may be used to grasp the peritoneum to assist in its exposure for closing.
The musculofascial tissues are closed in layers or, less often, in a
single layer.The skin is approximated with suture mounted on a small
cutting needle, skin strips/tapes, or skin staples.The skin may also be
closed using Dermabond™, a skin sealant. For infected cases (e.g.,
peritonitis), skin and subcutaneous tissues may be left open to drain
using appropriate wound packing and dressings. If a stoma is created
or a fluid-collecting catheter is placed, a collection device is applied to
the surrounding skin following the application of tincture of benzoin
or MastisolR to protect the skin.
Preparation of the Patient :
Antiembolitic hose are put on the legs, as requested. The patient is
supine; arms may be extended on padded armboards.A pillow may be
placed under the lumbar spine and/or knees (to avoid straining back
muscles). Pad all bony prominences and areas vulnerable to skin and
neurovascular pressure or trauma. A Foley catheter is not routinely
placed. An electrosurgical dispersive pad is applied.
Skin Preparation :
Determine the intended site of incision; begin at this “clean” site,
working outward. Never use the same used sponge to go back over an
area; instead, take a new sponge. Include skin surface area from nipples
to mid-thigh level and down to the table at the sides. For women, a
vaginal prep may be indicated; check with surgeon.
4 folded towels and a laparotomy sheet
Sequential compression device with leg wraps, as requested
Forced-air warming blanket, if ordered
Major procedures tray
Large self-retaining retractor (e.g., Balfour)
Ligating clip appliers, e.g., Hemoclip® appliers (various sizes and
Blades, (2) #10 and (1) #15
Needle magnet or counter
Electrosurgical pencil and cord with holder and scratch pad
Ligating clips, e.g., Hemoclips, variety of sizes
• The circulator must always use the Joint Commission (JC) (formerly
the Joint Commission on Accreditation of Healthcare
Organizations) Universal Protocol to identify that the patient is
the correct patient, anticipating the correct surgery on the correctly
marked side (laterality) and site.
• Before every surgery begins, an official “time out” must be
taken; it is a safety measure. A time out is required and must be
documented on the Perioperative Record for patient safety
in continuity of care and for medicolegal reasons
• The circulator adapts care to meet the individual
patient’s needs by implementing the nursing interventions that
result in the optimal desired outcomes. Use the Special Notes
to augment the plan of care to ensure that all reasonable considerations
have been taken into account.
• The circulator assists the anesthesia provider during the induction
of anesthesia, e.g., during endotracheal intubation (by
applying pressure to the cricoid cartilage), during the administration
of a block (e.g., by holding the patient in position for an
epidural anesthetic), or by injecting medications the anesthesia
provider has prepared (at his/her direction). For a description
of the circulator’s role during the administration of anesthesia.
• All patient care must be documented in the Perioperative
Record for continuity of care and for medicolegal reasons.
• The circulator conveys to the patient that he/she will act as the
patient’s advocate by speaking for him/her while the patient is
• It is important for the circulator to provide measures of emotional
support to the patient, e.g., maintain eye contact and
hold the patient’s hand during the administration of anesthesia.
• The patient may have fear and anxiety regarding the surgical
procedure and the unfamiliar environment; answer questions in
a knowledgeable manner.
• Provide emotional support regarding the patient’s feelings of
altered body image and permit an opportunity to express
• Provide emotional support to the patient by keeping the patient
adequately covered and exposing only those areas that are
involved in the procedure.
• Check chart for patient sensitivities and allergies, including to
latex products, e.g., gloves, drains, elasticized tape, etc. Note
that simple drains (e.g., Penrose) and pressure bandages (e.g.,
containing Elastoplast® tape) contain latex, as do many other
items in general use. Also, check for patient allergy to iodine
found in many prep solutions.
• The circulator should assess hemodynamic factors; he/she
should keep the patient’s legs uncrossed and apply antiembolitic
hose before positioning the patient for the procedure, (when
the hose have been requested by the surgeon).
• The surgeon may order a sequential compression device with
leg wraps (disposable) to be applied over the antiembolitic hose
(to prevent deep vein thrombosis).
• The circulator should take appropriate measures to maintain
the patient’s body temperature; when the patient is cold,
he/she should offer a warmed blanket and/or adjust the room
temperature accordingly.When ordered, a forced-air warming
blanket may be placed over legs and/or chest.
• The electrosurgical pad should be applied to skin that is relatively
hair-free (to obtain good contact); it may be necessary to
shave the area.The pad should be placed as close to the surgical
site as possible.
• The electrosurgical pencil tip should be kept free of debris and
eschar (by using the scratch pad) and kept in its holder when
not in use.
• Large amounts of noxious smoke and fumes resulting from
thermal destruction are a health hazard; smoke should be suctioned
away by the room suction with an in-line filter or with a
smoke evacuation system (e.g., Clear View® smoke evacuator).
• Masks with a filtering capacity of between 2 and 5 microns
should be worn by all personnel in the operating room (OR) during
an operative procedure to prevent inhalation of toxic matter.
• Only laparotomy pads (lap pads) are used once the abdminal
cavity has been entered. All lap pads must have a radio-opaque
strip incorporated in the fabric (making them x-ray detectable).
• After the abdominal cavity has been entered, “free” raytec
sponges (4′′ _ 4′′ sponges with a visible blue radio-opaque thread)
are never placed on the sterile field, except when
mounted on a sponge forceps (or other clamp).
• A raytec sponge, when mounted on a sponge forceps, is frequently
referred to as a “spongestick.”
• Most surgeons prefer that the lap pads be lightly moistened
with warm saline once the peritoneal cavity has been entered.
• The peritoneal cavity may be irrigated with copious amounts of
normal saline that may be suctioned with a Poole suction.
• A protective face shield is suggested for those scrubbed to avoid
inadvertent splashing of contaminated fluids onto mucous
membranes and eyes.
• Prior to leaving the OR, the circulator assures that the patient
is properly positioned on the gurney, that all tubings and lines
are not kinked, and that measures necessary to maintain the
patient’s body temperature have been taken.
• The circulator accompanies the anesthesia provider taking the
patient to the Post Anesthesia Care Unit (PACU); he/she gives
the PACU perioperative practitioner a detailed intraoperative
report regarding the course of events when the patient was in
• In the PACU, the perioperative practitioner observes that the
patient’s breathing is unobstructed, monitors the patient’s
blood pressure and vital signs, and documents all pertinent
information in the Perioperative Record in the Postoperative
Record. Documentation is vital for patient safety regarding
continuity of care and for medicolegal reasons.
• In the PACU, the perioperative practitioner assumes the role as
the patient’s advocate.
from : Pocket Guide to the Operating Room 3rd ed.