Management of the postoperative period in gynecological patients. Laparotomy in gynecology After laparotomy

On its organs it is called transection, or laparotomy (from the Greek lapara - belly, tomia - incision).

Incisions made to access the abdominal organs must be low-traumatic (not cross muscles, large vessels and nerves), ensure free manipulation of the operated organ, form a durable scar after surgery and not cause weakening of the anterior abdominal wall.

There are five types of laparotomy:

Longitudinal
Oblique
Transverse
Corner
Combined

Longitudinal laparotomies

Midline laparotomy(laparotomia mediana) is carried out along the white line of the abdomen in the direction from the xiphoid process to the pubic symphysis. Depending on the location of the incision relative to the navel, upper, middle and lower laparotomy are distinguished. During a middle laparotomy, the umbilicus must be bypassed to the left to prevent injury to the round ligament of the liver, which goes to the visceral surface of the liver to the right of the umbilicus and is an obliterated umbilical vein. With a midline incision, muscles, large vessels and nerves are not damaged; if necessary, it can be continued upward or downward. Since this incision provides good access to the abdominal organs, it is most often used in surgery. The disadvantage of a midline incision is that healing is somewhat delayed due to poor blood supply to the linea alba.

Paramedian laparotomy carried along the inner edge of the rectus abdominis muscle, cutting its vagina. The muscle is retracted outward and the other layers of the anterior abdominal wall are gradually dissected. In this case, a durable scar is formed, since the incisions of the anterior and posterior walls of the rectus abdominis sheath do not coincide: they are separated by an intact muscle.

Transrectal laparotomy pass through the rectus abdominis muscle. The anterior wall of the vagina of the specified muscle is dissected, separated along the fibers, and then the posterior wall is dissected. Separation of the fibers of the rectus abdominis muscle may be accompanied by bleeding, but good blood supply to the latter promotes rapid healing. This access is used mainly for fistula placement. The opening of the fistula is located inside the rectus abdominis muscle, due to the tone of which the stomach contents are prevented from escaping.

Pararectal laparotomy(Lennander) is carried out along the outer edge of the rectus abdominis muscle. After opening the anterior wall of her vagina, the muscle is pushed inward, the posterior wall of the vagina and the parietal peritoneum are dissected. This incision is sometimes used during appendectomy to clarify the diagnosis, since it can be continued downward to examine the pelvic organs.

Oblique laparotomy

Oblique incisions in the upper sections of the abdominal wall are made along the edge of the costal arches, in the lower sections - parallel to the inguinal ligaments. These incisions are used to provide access to the liver, gall bladder, spleen, and appendix (in particular, the Volkovich-Dyakonov oblique incision). The incision is made at the border of the outer and middle third of the line that connects the superior anterior iliac spine to the umbilicus (McBurney's point) almost parallel to the inguinal ligament. The directions of the incision are changed, taking into account the course of the fibers of the broad abdominal muscles. It is called a variable (slide) incision, which does not weaken the side wall of the abdomen. The disadvantage of the incision is limited access to the abdominal organs and the occurrence of difficulties during their examination.

Transverse laparotomies

Transverse incisions are made horizontally parallel to the nerve trunks and vessels, crossing one or both rectus abdominis muscles, which provide wide access to the internal organs. Most often, such laparotomies are used in the lower abdomen to access the pelvic organs. A serious disadvantage of transverse incisions is the weakening of the anterolateral abdominal wall (divergence of damaged recti).

Angled laparotomies

Corner cuts are made when necessary to continue the cut in a different direction, at an angle. For example, to provide access to the liver and extrahepatic bile ducts, a longitudinal incision along the linea alba of the abdomen is continued in an oblique manner, which is parallel to the costal arch.

Combined laparotomies

Combined (thoracoabdominal) incisions are performed during major operations on the organs of the upper floor of the abdominal cavity, when it is necessary to open the abdominal cavity and one of the pleural cavities or.

General rules of laparotomy

For any type of laparotomy, certain rules and sequence of technical techniques are followed. One of them is the correct position of the patient on the operating table. When making incisions on the anterolateral wall, the patient is placed on his back. If the operation is performed on organs located in the epigastric region, a bolster or an inflatable pillow is placed under the patient’s lower back.

Modern operating tables have special devices for changing the position of the patient. During surgical access to the organs of the hypogastric region, it is recommended to ensure a high position of the pelvic region of the patient's body. When performing laparotomy in the inguinal and lateral areas of the anterior abdominal wall in overweight patients, the operating table can be tilted to the right or left side. When choosing a surgical approach, you need to take into account the type of body structure of the patient, the possible location of the operated organ, and the expected volume of the operation.

For less trauma to the abdominal wall and the formation of a strong postoperative scar, it is recommended to adhere to the following general principles of laparotomy:

cross the muscle, not the aponeurosis;
mix the dissection lines of the anatomical layers relative to each other along the axis (variable access) or in the form of steps (staircase access);
preserve blood vessels and nerves.

When opening the parietal peritoneum during laparotomy, it is necessary to protect the surgical wound from possible infection by covering it with napkins and temporarily connecting the edges of the skin and peritoneum. The organ removed into the wound is isolated (protected) from the abdominal cavity using large wet wipes. During surgery, the abdominal organs are constantly moistened with warm isotonic sodium chloride solution. Moisturizing the mesothelium of the visceral peritoneum of organs prevents its destruction and reduces the risk of adhesions in the postoperative period. After laparotomy, the contents of the abdominal cavity are examined. If the diagnosis is established, during the operation the diseased organ is examined (to confirm it), as well as the place of possible leakage of contents in case of perforation of a hollow organ and regional lymph nodes if a neoplasm is suspected. In case of penetrating wounds and blunt trauma to the abdomen, all organs of the abdominal cavity must be examined in the following sequence: the entire length of the digestive canal, the liver and bile ducts, the spleen, the pancreas, and the organs of the retroperitoneal space. In case of bleeding, leakage of intestinal contents, bile, the bleeding is first stopped, intestinal sponges are applied and a complete inspection is carried out, after which the sequence of surgical procedures and their volume are determined.

At the end of the operation, carefully cover with peritoneum all places where the serous layer was damaged, and finally dry the abdominal cavity from blood, effusion, intestinal contents, and bile. In this case, pay attention to isolated areas of the abdominal cavity: bags, sinuses, pockets. The thoroughness of hemostasis is checked using a gauze swab attached to a long clamp in the most sloping places of the abdominal cavity. The number of instruments and wipes is checked and counted to prevent accidental leaving of them in the abdominal cavity.

Laparotomy wounds are sutured tightly in layers or using one, which is best removed through a separate small incision. The parietal peritoneum is usually sutured with a continuous suture. Interrupted sutures are placed on the muscles and aponeuroses. The skin is sutured with interrupted sutures with careful comparison of the edges of the wound.

A repeated incision in the abdominal cavity is called relaparotomy. Depending on the period that has passed since the first operation, early and late relaparotomy are distinguished. During early relaparotomy, sutures are removed to gain access to the abdominal cavity. The reasons for repeat laparotomy are most often bleeding, intestinal obstruction, and suppuration. Significant difficulties arise when closing a wound after relaparotomy: in inflamed tissues it is impossible to suture the wound layer by layer; the sutures applied are easy to cut through. In this case, a single-row suture is applied through all layers of the abdominal wall, the threads of which are tied on rubber tubes or gauze rolls. The sutures are reinforced with wide strips of plaster and removed no earlier than 14 days after surgery.

The article was prepared and edited by: surgeon

LAPAROTOMY(Greek, lapara groin, belly + tome cut; syn. transection) - opening of the abdominal cavity.

Mention of L. was found even before our era; in particular, it was produced in Ancient India. Caesarean section is considered the oldest operation of L. (see). Greek physician Praxagoras in the 4th century. BC e. produced L. for intestinal obstruction. In China, L. was performed by the surgeon Hua To (141 - 203). However, L. became widespread only in the 19th century. in connection with the introduction of antiseptics (see), and subsequently thanks to asepsis (see).

Laparotomy is a surgical intervention, the purpose of which is to perform an operation on the abdominal organs or free it from blood, pus and other pathols, accumulations.

Sometimes laparotomy is used for diagnostic purposes (diagnostic, trial, L.). In these cases, small incisions can be made (micro laparotomy); such laparotomy is rarely used due to the widespread use of other research methods, in particular laparoscopy (see Peritoneoscopy), laparocentesis (see). With L., the parietal layer of the peritoneum is always dissected. However, the term “extraperitoneal laparotomy” is conventionally used with dissection of the tissues of the posterior abdominal wall for access to the retroperitoneal space and its organs - the kidney, ureter, adrenal gland, abdominal aorta, inferior vena cava, trunk of the sympathetic part. n. With. In these cases, the peritoneum, as a rule, is not dissected. The conventionality of the concept of “laparotomy” can be traced in other operations. Thus, herniotomy is not called L., although it opens the hernial sac, which is the parietal layer of the peritoneum; only with a wide opening of the abdominal cavity by dissecting the posterior wall of the inguinal canal, for example, with an inguinal hernia, the operation is called herniolaparotomy.

Types of laparotomy

Depending on the anatomical location of the abdominal organ on which surgical intervention is performed, and the nature of the operation, various laparotomy incisions are used.

When L., longitudinal (Fig. 1), transverse and oblique incisions are used through the anterior abdominal wall, as well as the so-called. variable and angular cuts (Fig. 2). The number of cuts proposed for L. is very large. Thus, only during operations on the liver and extrahepatic bile ducts, according to A. N. Volkov, there are more than 70 approaches. In practical work, the surgeon uses 10-20 of the most common laparotomy incisions to create an optimal approach to one or another organ on which the operation is performed. It is necessary, if possible, to choose such incisions that spare the nerves of the abdominal wall (see), the intersection of which creates conditions for atrophy of the muscles of the abdominal wall and the development of its relaxation with the subsequent occurrence of hernial protrusions.

The most commonly used incision is access through the linea alba (see). Its advantage over others is determined by the speed of opening the abdominal cavity, the possibility of a wide examination, almost complete bloodlessness and ease of suturing the wound after the operation. It is customary to distinguish between upper median, lower median, central median and total median L.

The upper middle L. allows operations on the stomach, transverse colon, jejunum, and the left lobe of the liver. Some surgeons prefer to use an upper midline incision for cholecystectomy. Removal of the xiphoid process allows this incision to be extended upward (Fig. 3). If necessary, this incision can be extended downwards, bypassing the umbilicus on the left, in order to preserve the integrity of the round ligament of the liver. The tissues to be dissected in this case are the skin with subcutaneous tissue, the linea alba, preperitoneal tissue and parietal peritoneum (Fig. 4, a), the edges of the cut after its dissection are captured with clamps and fastened to the sheet delimiting the surgical field. If during the operation the need to expand access is revealed, the upper midline incision is supplemented with a transverse one, cutting the muscles transversely and turning the midline incision into an angular one. Suturing of the surgical wound in the upper middle L. is carried out in 3 layers: the peritoneum is sutured with a continuous suture, the aponeurosis and skin are sutured with interrupted silk or synthetic sutures (Fig. 4.6). If the subcutaneous tissue develops excessively, some surgeons sew it together with separate interrupted sutures.

When producing the lower median L. (Fig. 1), it must be borne in mind that below the line of Douglas there is no posterior wall of the rectus sheath and, in addition, the linea alba is very narrow here, so often the anterior layer of the rectus sheath is dissected into 1 - 2 mm to the right or left of the midline. The abdominal cavity is opened after spreading the rectus abdominis muscles to the sides with hooks. This access can be used for operations on the small intestine, uterus, tubes, ovaries, and rectum. When suturing this incision, the transverse fascia and parietal peritoneum are captured with one continuous suture, the rectus abdominis muscles are brought together with sparse interrupted sutures, over which the anterior layer of the aponeurosis, forming the sheath of the rectus abdominis muscle, is sutured with interrupted sutures. The skin is then sutured.

In case of an unclear diagnosis, especially in emergency surgery, a midline incision is used along the white line of the abdomen 8-10 cm long above and below the navel, bypassing the latter on the left (central midline). After orientation in the abdominal cavity and establishment of an accurate diagnosis, this incision can be extended upward or downward, depending on the need.

Sometimes the surgeon has to use a very wide opening of the abdominal cavity - from the xiphoid process to the pubic symphysis (total median L.). This incision significantly disrupts the subsequent function of the abdominal wall, and therefore it is used only when absolutely necessary, for example, for large tumors, during operations on the abdominal aorta.

The longitudinal sections include the so-called. Lennander's backstage incision (paramedian L.), the edges are made 2 cm to the right or left from the midline of the abdomen (Fig. 5). It is recommended for some operations on the stomach, duodenum, and biliary tract. After dissecting the anterior layer of the sheath of the rectus abdominis muscle, this muscle is retracted laterally with a hook, after which the peritoneum is dissected along with the posterior layer of the sheath of the rectus abdominis muscle. When closing the wound, the peritoneum is sutured together with the posterior layer of the vagina, usually with a continuous suture, after which the rectus abdominis muscle is placed in its place and the anterior layer of the rectus abdominis sheath is sutured with interrupted sutures, and then the skin with subcutaneous tissue. Some surgeons apply removable “holding” sutures to the anterior wall of the rectus sheath or use 8-shaped sutures according to Spasokukotsky.

When performing gastrostomy, transversostomy, and other operations in the upper half of the abdomen, transrectal L. is used (Fig. 1, 3). Its technique is close to Lennander’s, only the rectus muscle is not pushed to the side, but its fibers are bluntly pushed apart at the border between its inner and middle thirds. When suturing a laparotomy wound after transrectal L., a three-row suture is used, and the separated parts of the rectus muscle are not sutured.

The pararectal L. also belongs to the longitudinal L. The incision begins at the costal edge and is brought to the level of the navel at a distance of 2 cm medial to the outer edge of the rectus abdominis muscle (Fig. 1.4). Its advantage is that the rectus abdominis muscle at the end of the L. covers the line of sutures placed on the transverse fascia and peritoneum, but the disadvantage is that it is necessary to cross 3-4 motor nerves, which leads to muscle atrophy. The laparotomy incision along the semilunar (Spigelian) line suffers from the same drawback (Fig. 1, 5), which is why most surgeons avoid these incisions.

For a number of reasons, oblique and transverse incisions have some advantages over longitudinal incisions in L. In particular, these incisions cause little damage to the muscles of the abdominal wall if the incisions coincide with the direction of the fibers of the oblique abdominal muscles, and little or almost no intercostal nerves are crossed. When the wound suppurates, these incisions diverge less than vertical ones, and postoperative hernias are less likely to be observed with them. Disadvantages of some oblique and transverse incisions include less wide access than with vertical incisions.

The upper transverse L. (Fig. 2, 2) can be performed with the intersection of both rectus abdominis muscles or only one right or left, depending on the nature of the operation on the bile ducts or on the spleen. This incision is made above the umbilicus, extending beyond the lateral edges of the rectus abdominis muscles. The anterior and posterior layers of the sheath of the rectus abdominis muscles, rectus muscles, transverse fascia and peritoneum are dissected in the transverse direction, and after ligation the round ligament of the liver is also crossed. With good relaxation, you can limit yourself to dissecting only the anterior and posterior layers of the sheath of the rectus abdominis muscles, while the muscles themselves are pulled apart with hooks. If very wide access is necessary, the transverse incision is expanded in both directions to the anterior axillary line, and in this direction the external oblique muscle of the abdomen is cut, and the internal oblique and transverse muscles are pushed apart bluntly. During operations on the biliary tract, the incision can be made from the costal arch at the level of the eighth or ninth intercostal space to the linea alba with dissection of the oblique and transverse muscles, both layers of the sheath of the rectus abdominis muscle, retracting the latter to the side. Closing the upper transverse incision is carried out as shown in Figure 6. Transverse L. is very convenient for operations on the pancreas, transverse colon, and spleen.

The lower transverse L. is identical to the upper one, only it is performed several centimeters below the navel. It is convenient for hemicolectomy.

With this L., the surgeon must ligate the lower epigastric vessels.

Oblique incisions include the subcostal L. (Fig. 2, 7), which opens good access to the bile ducts on the right, to the spleen and to the upper half of the stomach on the left. There are many modifications of this L. (Courvoisier, Kocher, Fedorov, Pribram, etc.). At the suggestion of S.P. Fedorov, an oblique incision 10-12 cm long is made parallel to the right costal margin, 4-5 cm away from it. The outer two-thirds of the rectus abdominis muscle, sometimes part of the oblique and transverse abdominal muscles, are dissected. In patients with a flabby abdominal wall, they are limited to dissecting only the rectus muscle, and in more complex cases, this incision has to be bent upward along the linea alba (Fig. 7).

Oblique incisions include lateral transmuscular L. (Fig. 1.7). This incision is convenient for operations on the colon: on the right for right-sided hemicolectomy, on the left for left-sided hemicolectomy. Typically, the incision begins under the lower edge of the X rib and extends to the iliac crest, and then is made almost parallel to the outer edge of the rectus abdominis muscle. The external oblique abdominal muscle is cut along the fibers, and the internal oblique and transverse muscles are cut across. By dissecting the parietal peritoneum, wide access is created. Do not approach the area of the inguinal canal, damaging the semilunar line and the ilioinguinal nerve. Typically the length of this cut should be approx. 15 cm. When applying an ileostomy or sigmostoma, shorter incisions are used. The incision is sutured in 4 layers (Fig. 8).

With L. they often use the so-called. variable cuts. Their advantage is that the muscles move apart along the fibers and, therefore, when suturing these wounds, a more durable scar is obtained. The disadvantage of these incisions is the relatively small surgical field for examining organs and manipulating them, therefore, if it is necessary to expand the wound, it is necessary to cut the muscles across and, in the case of suppuration of the wound, it gapes wide, creating conditions for the formation of a postoperative hernia. The most commonly used variable incision is the incision for appendectomy (see) proposed by McBurney (S. McBurney) in the right iliac region (Fig. 2, 5). Obstetricians and gynecologists often use a lower variable suprapubic Pfannenstiel incision (see Pfannenstiel incision), made transversely along a skin fold 4-6 cm above the pubic symphysis (Fig. 2, 4).

In pediatric surgery, during operations performed for pyloric stenosis, an incision of only 3 cm long is used, parallel to the costal arch, outward from the rectus abdominis muscle. The muscles are moved apart along their fibers. Their layer-by-layer stitching subsequently produces a durable, inconspicuous scar.

In case of failure of the sutures of the duodenal stump, it is advantageous to use an incision 8-10 cm long, running 2-3 cm below the right costal arch and parallel to it (Fig. 9), and when dissecting the anterior layer of the sheath of the rectus abdominis muscle, it is moved medially without cutting the fibers .

When performing operations for stomach cancer, especially when the tumor is located high, the abdominal cavity must be opened wide. In these cases, the cut proposed by B.V. Petrovsky is very convenient (Fig. 10). It begins at the right costal arch and is led transversely to the left costal arch, and then parallel to it is brought to the anterior axillary line, crossing the white line of the abdomen 5-6 cm below the xiphoid process. To the left of the linea alba, the rectus, oblique and transverse abdominal muscles are dissected, while on the right, only the anterior and posterior layers of the aponeurosis that make up the sheath of the rectus abdominis muscle are dissected, moving the latter to the side with a hook. The transverse fascia along with the peritoneum is dissected along the entire length of the wound and the round ligament of the liver is ligated.

During operations performed simultaneously on the stomach and esophagus, as well as on the liver, it is often necessary to open the pleural cavity along with L. This type of surgery can be transthoracic or combined (abdominothoracic and thoracoabdominal), depending on the incision from which the surgeon begins the operation. With thoracolaparotomy, the operation begins with a thoracotomy (see) in the seventh intercostal space with an incision from the costal arch to the axillary line. Along the skin incision, the external oblique abdominal muscle, which covers the lower parts of the chest, and the latissimus dorsi muscle are dissected. The intercostal muscles and parietal pleura are cut along the upper edge of the VIII rib. The diaphragm is dissected from its costal edge to the esophageal opening without crossing the phrenic nerve. For resection of the lower thoracic esophagus, an incision is also used in the sixth intercostal space according to Peterson. For wider access, it is advisable to dissect the costal arch. If necessary, this transthoracic transdiaphragmatic L. can be converted into a thoracolaparotomy, for which the intercostal incision is continued onto the abdominal wall. If, during examination of the patient, the possibility of radical surgery on the stomach is questioned, it is better to start L. from the abdominal part of the incision and, only after making sure that there is no dissemination of the tumor process, open the pleural cavity - laparothoracotomy (Fig. 11). The right-sided approach is used for liver resection. M.A. Topchibashev recommends an incision starting at the outer edge of the right rectus abdominis muscle slightly above the navel, making this incision to the seventh intercostal space. After opening the abdominal cavity, the costal arch is dissected, the left hand is inserted into the wound, the diaphragm is pressed against the chest wall, the intercostal muscles and the diaphragm are gradually dissected, suturing its edges with the intercostal muscles after each section (Fig. 12).

Suturing the surgical wound after thoracolaparotomy (Fig. 13) begins from the dome of the diaphragm using interrupted silk sutures. The wound is closed with interrupted sutures drawn through the intercostal spaces. The parietal peritoneum is sutured with a continuous suture, capturing the dissected muscle, and then the muscles and skin are sutured in layers. Through a drainage inserted into the pleural cavity in the tenth intercostal space, air is removed at the end of the operation, and then constantly sucked out using active aspiration (see Aspiration drainage).

During gastrectomy, resection of the left lobe of the liver, another type of L. is used - sternomediastinolaparotomy. This operation begins with the middle upper leg, then soft tissues are dissected along the middle of the sternum for 6 - 7 cm, and the fibers of the diaphragm are bluntly separated under the xiphoid process after dissecting the peritoneum. The mediastinal pleura is peeled off with two fingers and the sternum is dissected for 4-6 cm in the longitudinal direction with maximum dilation of the wound using a powerful screw retractor. The diaphragm is cut during a technically very difficult resection of the left lobe of the liver. Sometimes in the lower corner of the wound it is advisable to additionally cross the rectus abdominis muscle (Fig. 14).

For gunshot wounds of the abdomen, the main incision used by surgeons during the Great Patriotic War was the median incision. Oblique transverse incisions were used for penetrating wounds with a horizontal direction of the wound channel in the upper floor of the abdomen. In case of through wounds with a short wound course and in case of tangential wounds of the abdomen, incisions such as widening the wounds were sometimes allowed. Pararectal incisions for L. are not recommended in military conditions.

Carrying out laparotomy

In modern conditions, the best type of pain relief for L. is endotracheal anesthesia with the use of relaxants (see Inhalation anesthesia), which allows you to relax the muscles of the abdominal wall and thereby expand the field of operation without lengthening the incision. However, when general anesthesia is contraindicated, local anesthesia is also used (see Local Anesthesia), and occasionally, during operations in the lower half of the abdominal cavity, epidural or spinal anesthesia is used.

The position of the patient on the operating table during L. depends on the nature of the planned operation.

Most surgical interventions are performed with the patient in a horizontal position on the operating table. During operations on the liver, bile ducts, spleen, pancreas, a cushion is placed under the XII thoracic vertebra, which brings these organs closer to the anterior abdominal wall (Fig. 15). For L. in the lower abdomen, especially during gynecology, operations on the rectum, etc., the Trendelenburg position is recommended (see Trendelenburg position).

The patient’s preparation for surgery can be different, depending on the state of hemodynamic parameters, the nature of the upcoming operation, its urgency and other conditions (see Preoperative period). During emergency operations, preparation for L. is carried out in a shortened time, but the patient needs to stabilize blood pressure before the operation, in case of bleeding, perform a blood transfusion, bring the patient out of shock, etc. The surgeon must always remember that preparation for surgery within 1 - 2 hour. patient with peritonitis and its removal from severe cardiovascular insufficiency makes it possible to more safely carry out L. In patients in Crimea, surgery is prescribed as planned, it is necessary to normalize the state of the cardiovascular system, respiratory organs, intestines, etc. The purpose of the diet depends on the nature upcoming surgery; in any case, 1-2 days before it, the patient is transferred to a more gentle diet with the exclusion of rough foods rich in toxins, the prescription of vitamins and, in the absence of diabetes, an increase in the amount of sugar. The patient is taken to the operating room on an empty stomach. with an empty bladder. The hair in the area of the intended operation is shaved the day before. If there are inflammatory diseases on the skin (folliculitis, boils, etc.), planned surgery should be postponed. Preparation of the surgical field (see) is carried out according to the usual rules of asepsis. In the production of L., some surgeons use special sterile films that are glued to the skin of the abdomen after treatment, which allows making a skin incision through the film and fastening the sheets that limit the surgical field directly to the parietal peritoneum. In cases where there is an accumulation of pus in the abdominal cavity, the abdominal cavity is fenced off with towels or large napkins, which must be fastened to the sheets delimiting the surgical field, in order to avoid accidental leaving of napkins in the abdominal cavity.

After opening the abdominal cavity, the surgeon carefully examines the affected organs. When removing intestinal heifers outside the laparotomy wound, after examining 2-3 loops, they should be tucked back into the abdominal cavity before removing the next loops. If it is necessary to leave the removed organs outside the paws and mouth of the ohmic wound during the operation, they should be wrapped in wet wipes soaked in hot physiol. r-rum. If it is necessary to examine the entire small intestine, 0.25% novocaine solution is injected into the root of the mesentery. If there is uninfected blood in the abdominal cavity, it is removed by electric suction into a sterile container for possible reinfusion.

In the absence of bleeding and good peritonization of the organs, the abdominal cavity is usually sutured tightly. If capillary or parenchymal bleeding is not stopped completely, then tampons are inserted into the abdominal cavity to the source of bleeding (see Tamponade), which are removed with caution a few days after they have mucused in order to avoid damage to adjacent organs. During operations on the biliary tract, pancreas, colon, etc., drains are often left in the abdominal cavity (see Drainage); they are usually removed after 3-4 days. It is better to introduce drainage not through a laparotomy wound, but through a separate incision 1 - 2 cm long in the abdominal steak, fixing the drainage to the skin. To introduce antibiotics into the abdominal cavity in the presence of peritonitis or other inflammatory focus, capillary microirrigators are used, left in the abdomen for 3-5 days. A glue sticker is applied to the sutured laparotomy wound or special glue is sprayed. For very large incisions, belts are placed on the abdomen. In patients with excessive development of subcutaneous tissue, when suturing a skin wound, it is recommended to either sew up the subcutaneous tissue with separate sutures, or use deep mattress sutures that capture the subcutaneous tissue to the aponeurosis, between which ordinary interrupted sutures are placed on the skin. To avoid hematomas in very obese patients, some surgeons use active aspiration of blood accumulating in the wound, using narrow drainage tubes placed under the tissue, at the ends of which balloons with rarefied air are placed, or special devices.

Removal of sutures in patients who have undergone L. is carried out at different times depending on the length of the incision, the general condition of the patient, his age, the nature of the main operation performed on a particular organ, the presence or absence of complications, etc. So, with median L. In the upper abdomen, sutures can be removed in the absence of complications on the 8th day; in weakened patients, this period can be extended to 10-14 days. For L. made through various other incisions, the period for removing skin sutures is determined individually.

Postoperative period

The postoperative period in patients who have undergone L. depends not so much on the access as on the nature of the main type of surgical intervention on a particular organ (see Postoperative period). Thus, operations on hollow organs (stomach, intestines), associated with the opening of cavities containing microbial flora, can create conditions unfavorable for the healing of the surgical wound of the abdominal wall, promoting infection of the abdominal cavity with the formation of abscesses (see Peritonitis) and other possible complications. In the postoperative period, L. is often accompanied by paresis of the stomach and intestines, creating stretching of the muscles of the abdominal wall, which causes tension in the sutures. In weakened, exhausted patients, complete divergence of the edges of the wound may occur with loss of viscera under the skin or even onto the surface of the skin (see Eventration). For the course of a postoperative laparotomy wound without complications, the access chosen by the surgeon is of considerable importance. Thus, long midline incisions along the white line of the abdomen (from the xiphoid process to the symphysis) create a great danger for the possible formation of postoperative hernias (see). Some oblique incisions, when intercostal nerves are intersected, create conditions for subsequent atrophy of the abdominal muscles with possible relaxation, which often ends in the formation of a hernia. To prevent complications from the cardiovascular and respiratory systems, it is very important to use breathing exercises, getting up early, if drains and tampons are not left in the abdominal cavity, hemodynamic parameters and the nature of the surgical intervention performed on one or another abdominal organ allow. This also applies to the prescription of diet, and various medications, cleansing enemas and other prescriptions, in particular parenteral administration of drugs, blood transfusions, etc.

If there are clear signs of any complications (bleeding, peritonitis, etc.) that have developed in the abdominal cavity, it is necessary to open the abdominal cavity again, i.e., a relaparotomy is performed, for which all sutures placed on the laparotomy wound are removed. Relaparotomy is performed in the operating room according to the same rules that are mandatory for L. If complications are suspected, but without obvious clinically expressed symptoms or lab. indicators indicating a catastrophe in the abdominal cavity, surgeons sometimes use control removal of 2-3 sutures and insertion of a catheter into the abdominal cavity; through it, the liquid accumulated in the abdominal cavity is sucked into the syringe, and depending on its nature, the issue of the need for relaparotomy is decided. If there is a significant amount of blood, bile or intestinal contents in the syringe, all sutures are removed and a relaparotomy is performed, the cause of the complication is identified and the possibility of eliminating it. In a patient with simultaneous suppuration of the surgical wound, if relaparotomy is necessary, it is better to open the abdominal cavity with another incision that is most convenient for eliminating the complication, in order to avoid infection of the abdominal cavity from the suppurating wound. When suturing a relaparotomy wound due to inflammatory changes in the abdominal wall, it is recommended to suture all layers of the wound with mattress sutures along with the skin, and in the intervals between these sutures, apply separate sutures to the skin. When the laparotomy wound suppurates, it must be opened wide. If only the subcutaneous tissue is suppurated, wound treatment is carried out according to the usual rules (see Wounds, wounds). If pus penetrates under the aponeurosis, the sutures are removed from it only in the area of necrotic tissue, since removing all sutures from the aponeurosis threatens eventration. When an intestinal loop falls into the wound, it is often soldered to the parietal peritoneum; in these cases, the wound is covered with a bandage heavily soaked in some oily liquid (Vishnevsky ointment, Vaseline, etc.). After all necrotic tissue has been removed and the wound is covered with granulations, its edges are tightened with strips of adhesive plaster or a secondary suture is applied (see).

Patients after L. and surgical interventions on the abdominal organs often experience pulmonary complications: pneumonia, pulmonary atelectasis, respiratory failure, more often observed in elderly and senile people. Complications from the cardiovascular system develop hl. arr. in patients with hypertension stages II and III, hron, coronary insufficiency, especially with post-infarction cardiosclerosis, etc. According to V. S. Mayat and N. S. Leontyeva, 3/4 of all complications from the cardiovascular and respiratory systems after L occurs in patients at significant and extreme risk. Under equal technical conditions of the operation, the postoperative period in elderly and senile patients is more difficult than in young patients. Thus, according to V.D. Fedorov, wound dehiscence and eventration of organs, intestinal fistulas and progression of peritonitis are observed at this age 2-3 times more often than in younger patients, and thrombosis and embolism are even 3-4 times more often. Therefore, before planned L., performed in elderly and senile patients, it is necessary to carefully carry out measures to normalize the functions of the cardiovascular system and respiratory organs, and if the coagulogram changes, prescribe anticoagulants immediately after L. (see), especially to persons who have had thrombophlebitis in the anamnesis.

In order to prevent thromboembolic complications after surgery, it is important to include movements of the lower extremities in the complex of breathing exercises. In the postoperative period, in all patients who have undergone L., it is also necessary to monitor bowel and bladder emptying.

Bibliography: Volkov A. N. Sternomediastinolaparotomy, Cheboksary, 1971, bibliogr.; Littmann I. Abdominal surgery, trans. from German, Budapest, 1970; MayatV. S. and Leontyeva N. S. Cardiovascular and pulmonary complications after abdominal operations in elderly and senile patients, Surgery, No. 6, p. 134, 1974; Mayat V.S. et al. Gastric resection and gastrectomy, M., 1975; Multi-volume guide to surgery, ed. B.V. Petrovsky, vol. 7, p. 82 and others, M., 1960; Petrovsky B.V. Surgical treatment of cancer of the esophagus and cardia, M., 1950, bibliogr.; Sozon-Yaroshevich A. 10. Anatomical justifications for surgical approaches to internal organs, L., 1954, bibliogr.; Fedorov V.D. Treatment of peritonitis, M., 1974, bibliogr.; Fedorov S.P. Gallstones and surgery of the biliary tract, M.-L., 1934; Bier A., Braun H. u. KiimmelH. Cliirur-gische Operationslehre, Bd 4, T. 1-2, Lpz., 1972-1975.

Laparotomy (Abdominal Exploration; Laparotomy, Exploratory)

Description

Laparotomy is an opening of the abdominal wall to examine the organs and tissues inside the abdomen.

Reasons for laparotomy

This procedure is performed to evaluate the condition of the abdominal cavity.

Problems for which laparotomy is indicated include:

A hole in the intestinal wall (ulcer);
Ectopic (ectopic) pregnancy;
Endometriosis;
Appendicitis;
Damage to internal organs due to trauma;
Infection in the abdominal cavity;

Possible complications during laparotomy

Complications are rare, but no operation guarantees the absence of complications. If laparotomy is planned, possible complications may include:

Bleeding;
Infection of the incision;
Blood clots;
Damage to internal organs;
Hernia formation;
Large scars;
Negative reaction to anesthesia.

Factors that may increase the risk of complications:

Previous surgical intervention in the abdominal cavity;
Diabetes;
Heart and lung diseases;
Weak immune system;
Disturbances in the circulatory system;
Taking certain medications;
Smoking, alcohol abuse, drug use.

The risk of complications must be considered before undergoing the procedure.

How is laparotomy performed?

Before surgery

Preparation for the procedure:

Before the operation, the following examinations must be performed:

Conduct a physical examination;
Do blood and urine tests;
Perform an ultrasound, a test that uses sound waves to see the inside of the body;
Conduct a computed tomography scan - an x-ray examination that uses a computer to take photographs of internal organs;
MRI is a test that uses magnetic waves to see internal organs.

You may need to stop taking certain medications one week before your procedure:

Do not take anti-inflammatory drugs (for example, aspirin);
Do not take blood thinners such as clopidogrel (Plavix) or warfarin.

Do not eat food the day before the procedure.

Anesthesia

The procedure is almost always performed under general anesthesia.
Spinal anesthesia is used for possible complications from the use of general anesthesia - the area from the chest down to the legs is anaesthetized.

Description of the laparotomy procedure

The doctor will make one long incision along the abdomen. Organs are examined for the presence of disease. The doctor may take a biopsy of the organ of interest. During laparotomy, the necessary surgical intervention can be performed. After laparotomy, the incision is sutured with threads or secured with staples.

How long does a laparotomy take?

Approximately 1-4 hours.

Will it hurt?

Anesthesia prevents pain during the procedure. To reduce pain after the procedure, you must take painkillers.

The average hospital stay is several days. If complications arise, the period increases.

Caring for the patient after surgery

In the hospital

You may need to wear special socks or shoes to prevent blood clots;
You may need to use a catheter to help you urinate;
You can use an incentive spirometer to help you breathe deeper.

At home

It may take several weeks for the body to fully recover.

Follow your doctor's orders;
Sutures or staples are removed after 7-10 days;
Avoid infection at the incision site;
You need to wash and bathe with caution so that water does not get into the wound;
For the first two weeks after surgery, do not lift objects;
Slowly increase the intensity of your movements. Start with light housework, short walks;
To help your incision heal faster, eat plenty of fruits and vegetables.

Try to avoid constipation:

Don't eat foods high in fiber;
Drink plenty of water;
Take laxatives if necessary.

You should immediately go to the hospital in the following cases:

The appearance of fever or chills;
Redness, swelling, severe pain, bleeding, or any discharge from the incision site;
Bloating;
Diarrhea or constipation that lasts more than 3 days;
Bright red or dark black stools;
Dizziness or fainting;
Nausea and vomiting;
cough, shortness of breath, or chest pain;
pain or difficulty urinating;
Swelling, redness, or pain in the legs.

Laparotomy– surgical opening of the abdominal cavity, the purpose of which is internal examination, diagnosis of gynecological and other pathological changes, including surgical intervention.

It should be emphasized laparotomy quite often indicates such pathological phenomena as appendicitis, inflammation and adhesions in the pelvic area, pregnancy outside the uterus, and malignant ovarian tumor.

Laparotomy used in the treatment of endometrosis, excision of adhesions, the possibility of surgical removal uterine fibroids, ovaries (oophorectomy), appendix, as well as the surgical actions of the surgeon to restore the patency of previously ligated uterine tubes.

Due to the fact that laparotomy- these are surgical actions of a surgeon associated with potential risks; medical specialists prefer to first perform laparoscopy, which is the least traumatic diagnostic method and treatment of certain pathological disorders in the body.

How are laparotomies prepared?

Before the surgical actions of the surgeon, the following medical examination methods are performed:

Conduct a physical examination of the patient.
They do a general analysis.
Ultrasound examination.
A computed tomography scan is performed.

During the week before the procedure, stop taking the following medications:

Anti-inflammatory drugs (aspirin, etc.).
Medicines and blood thinners.

The day before laparotomy, they refuse to eat.

Diagnosis by laparotomy

In the diagnosis of emergency laparotomy, abdominal surgical procedures involve symptoms of acute diseases or damage to internal organs, taking into account that in previous diagnostics (invasive measures inclusive), they could not confidently exclude pathological changes in the body.

Similar diagnostic difficulties can be observed in cases of extraperitoneal trauma or perforation, for example:

Duodenum.
Pancreas.
Stomach.
Large blood vessel.

The reason for perforation of the septum of a hollow organ of the extraperitoneal cavity is:

Chronic peptic ulcer disease.
Acute peptic ulcer disease.
Tuberculosis.
Large foreign body.
Fecal stone, which causes bedsores of the wall.
Thromboembolism of branches in the mesethereal artery causing limited necrosis.

Indications for diagnosis by laparotomy, may also become an infectious problem after laparotomy inside the abdominal cavity.

The difficulty in detecting early peritonitis after surgical interventions is explained by the following circumstances:

The patient's serious condition.
Incorrect perception of the disease, resulting from a degenerative disorder of the receptors, as well as the abdominal nerve plexuses.
Leveling of clinical signs due to medicinal therapeutic effects (for example, analgesics).
An atypical course with minor symptoms is peritonitis after surgery in mature, anemic patients who have mental disorders.

Recognition of such a threat to the life of the human body, a complication, is based on a number of specific criteria:

Long-term postoperative paresis.
Reduced effectiveness of drug stimulation.
Increasing intoxication.
Fading of intestinal peristalsis after a restorative procedure.
Increased inflammation in the blood.
Paralytic variant of intestinal obstruction.

The above symptoms are observed in the terminal and also toxic stages of peritonitis, that is, they have a long period of development.

Urgent diagnosis by laparotomy optimizes detection of peritonitis after surgery by a surgeon in the initial development process.

The assumption of a cancerous tumor in the peritoneum, if it is impossible to exclude suspicion in other ways, also has a solid indication for diagnosis by laparotomy.

Complication

Bleeding.
Hernia formation.
Infection.
Injury to internal organs during surgery.
Big scar.
Negative response of the body to anesthesia.
Circumstances that increase the risk of complications:
Previous surgical actions of the surgeon in the peritoneal cavity.
Heart and lung diseases.
Diabetes.
Weak immune system.
Failure of the circulatory system.
Use of certain medications.
Abuse of habits negative for the body (alcohol, smoking, etc.).

Rehabilitation period

To prevent blood clots, use special clothing.
A catheter is used for difficulty urinating.
A spirometer is used to stimulate breathing.
Compliance with the instructions of medical specialists.
Staples and stitches are removed within ten days.
Limit physical activity.
Eat more vitamins.
Try to avoid constipation (take laxatives if necessary).
Drink plenty of water.

Laparotomy is a surgical procedure that involves making an incision in the anterior abdominal wall to examine and treat the abdominal organs and to diagnose the cause of lower abdominal pain.

In this article we will find out what laparotomy is, its features and possible risks.

Abdominal laparotomy and popular one have their advantages, but each operation also has a disadvantage. For those who do not know what laparoscopy is, it should be noted that it is a surgical procedure, but it does not require any incisions to be made in the abdomen. It is enough to make 2-3 minor punctures through which instruments and a video camera are inserted into the abdominal cavity. Under these conditions, the doctor performs microsurgical manipulations.

Despite the significant advantages of laparoscopy, patients are often prescribed laparotomy surgery. It has differences that are its advantage:

Technical simplicity of the operation.
No complex equipment required.
This surgical procedure is convenient for the surgeon.

Indications for laparotomy

Not everyone has indications for laparotomy. A similar operation is prescribed in the following situations:

ovarian cysts;
ectopic pregnancy;
purulent fallopian tubes or ovaries;
peritonitis;
development of tumors of the reproductive organs;
ovarian dysplasia;
tubo-peritoneal infertility.

As a rule, it is not difficult for women who go to the doctor with complaints about it to make a diagnosis. For this purpose, standard tests and ultrasound are prescribed. But sometimes a detailed examination is required to clarify the diagnosis. For example, the surgeon may need to determine the location of a sudden ulcer rupture or determine the cause of internal bleeding or find a node. Exploratory laparotomy is an opportunity to determine the exact cause of the patient’s complaints and prescribe appropriate treatment. Anesthesia is required for such an intervention.

Types of laparotomy

Laparotomy can be performed in several ways. Types of laparotomy:

Laparotomy according to Pfannenstiel

Laparotomy according to Cherny. This type involves making an incision along the line exactly between the pubic bone and the navel. The so-called Cherny laparotomy involves transverse interiliac transection. This method is used for tumor pathologies, for example, if uterine fibroids have developed. The advantage of this method is that the surgeon can expand the incision lines at any time convenient for him and access to organs and tissues will be increased.
Laparotomy according to Pfannenstiel. The preferred method used in gynecology. A transverse suprapubic transection is assumed. The incision will be along the lower line of the abdomen. The scar remaining along the incision line will not be noticeable.
Laparotomy according to Joel-Cohen. It involves making a transverse incision made 2-3 cm below the middle of the distance between the navel and pubis. Implementing such mini-access is very convenient.

Preparing for surgery

Surgery requires preparation. The doctor must collect as much necessary information about the patient as possible. That is why a woman should answer the doctor’s questions as accurately as possible. This applies, at a minimum, to lifestyle, harmful addictions, medication and diet.

After laparotomy, the doctor instructs the patient that certain procedures will definitely need to be completed, and also expresses his predictions regarding the period after surgery.

The anesthesiologist who will administer the anesthesia must also ensure that the patient is ready for surgery.

Laparotomy, features of the operation

To begin with, anesthesia is administered. As a rule, all abdominal operations, and laparotomy is no exception, are performed after general anesthesia has been administered.
The surgical technique is as follows:

As soon as the anesthesia wears off, the patient will regain consciousness.

Recovery after surgery

To ensure that a woman does not encounter complications or undesirable consequences after surgery, and that her recovery is faster, she needs to follow certain instructions prescribed by the doctor.

While in the hospital, the patient must:

follow all doctor's orders;
use special shoes to reduce the risk of blood clots;
Often (though not always) it is necessary to urinate through a special catheter.
in severe situations, a special incentive spirometer can be used to improve breathing.

Important! The patient is prohibited from independently examining the wound, removing bandages, or touching drains. There is a high chance that an infection may occur.

How long a woman will stay in the hospital depends on the characteristics of the disease for which the surgical intervention was performed. If the patient goes home soon after the operation, she must also adhere to certain rules:

follow all doctor’s instructions, including regarding the timing of hospital visits;
Maintain maximum hygiene in the wound area;
Water should not get into the postoperative suture site;
reduce the amount of physical activity to a minimum;
Do not lift heavy objects under any circumstances, as the seams may come apart;
A diet of predominantly fruits and vegetables must be followed.

Usually 5-7 days after surgery the sutures are removed. However, after this you need to be extremely careful about your condition. If you notice a number of symptoms, you should immediately consult a doctor:

in case of elevated temperature;
if inflammation or strange discharge appears in the operation area;
bowel dysfunction that continues for 2-3 days;
the chair has changed its properties (for example, color);
general condition worsened (weakness, dizziness appeared);
nausea, vomiting;
problems with urination;
swelling appeared, which is in no hurry to subside, redness, pain in the legs.

A laparotomy operation performed with the symptoms described above is evidence of complications.

Many patients are afraid that the stitches may come apart. They should not diverge if you follow all the doctor’s recommendations. However, every patient should know the answer to the question of what to do if the suture suddenly breaks after surgery.

In this case, the main thing is not to panic. Examine the wound, incision lines and call an ambulance immediately. While you wait, the edges of the wound can be covered with a bandage to stop further dehiscence.

Possible complications

Laparotomy in gynecology can result in complications under certain circumstances. For example, when performing an operation on the uterus, the possibility of damage to neighboring organs cannot be ruled out. The laparotomy procedure being performed increases the risk of adhesions. This happens due to the fact that in the process of performing surgical actions, the instruments have to touch the peritoneum, as a result a process can begin and adhesions appear on the peritoneum, “gluing” the organs together.

A serious complication is bleeding, which can be caused by various reasons.

Laparotomy with myomectomy

Laparotomy as a conservative myomectomy, otherwise known as enucleation, is carried out through a longitudinal cavity incision. Myomatous nodes are removed while preserving the uterus. Laparotomy with conservative myomectomy is prescribed in the same cases as laparoscopy, but only because the latter is not possible due to the lack of technical capabilities.

In modern gynecology, laparotomy through conservative myomectomy is recommended in the presence of large myomatous nodes that deform the uterine cavity, the presence of pelvic pain, discomfort in the abdominal area, uterine fibroids, bleeding, dysplasia and other pathologies.

Laparotomy with conservative myomectomy is performed if there are no more than 4 myomatous nodes.

Before laparotomy with conservative myomectomy is prescribed, the doctor conducts the necessary examination.

How is the operation performed? The patient is given anesthesia. After the incision, the uterus is brought out into the wound, where it is fixed, cut, and all the necessary manipulations are performed on it. The existing myomatous nodes are excised and desquamated.

In the postoperative period, the woman is prescribed pain relief. The patient requires care for some time. If there were no complications, then she is discharged in the second week, after 9-11 days. From this moment the rehabilitation period begins. The menstrual cycle is quickly restored after surgery. After rehabilitation, after 2 months. you will need to do an ultrasound.

Laparotomy, namely resection of the ovary, involves surgical intervention on this organ in order to remove part of it. Menstruation is not disrupted.