Abdominal Laparotomy

Definition :

An incision made through the abdominal wall into the peritoneal cavity,

preperitoneal space, or retroperitoneal space for the purpose of

exploration, diagnosis, and treatment.

Discussion :

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.

Procedure :

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.

Draping :

4 folded towels and a laparotomy sheet

Equipment :

Sequential compression device with leg wraps, as requested

Forced-air warming blanket, if ordered

Suction

ESU

Instrumentation :

Major procedures tray

Large self-retaining retractor (e.g., Balfour)

Ligating clip appliers, e.g., Hemoclip® appliers (various sizes and

lengths)

Supplies :

Antiembolitic hose

Basin set

Blades, (2) #10 and (1) #15

Needle magnet or counter

Suction tubing

Electrosurgical pencil and cord with holder and scratch pad

Ligating clips, e.g., Hemoclips, variety of sizes

Special Notes

• 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

in surgery.

• 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

his/her feelings.

• 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

surgery.

• 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.

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