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A laparotomy is a
surgical Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
procedure involving a surgical incision through the
abdominal wall In anatomy, the abdominal wall represents the boundaries of the abdominal cavity. The abdominal wall is split into the anterolateral and posterior walls. There is a common set of layers covering and forming all the walls: the deepest being the ...
to gain access into the
abdominal cavity The abdominal cavity is a large body cavity in humans and many other animals that contains many organs. It is a part of the abdominopelvic cavity. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roof is th ...
. It is also known as a celiotomy.


Origins and history

The first successful laparotomy was performed without anesthesia by
Ephraim McDowell Ephraim McDowell (November 11, 1771 – June 25, 1830) was an American physician and pioneer surgeon. The first person to successfully remove an ovarian tumor, he has been called "the father of ovariotomy" as well as founding father of abdomina ...
in 1809 in
Danville, Kentucky Danville is a home rule-class city in Boyle County, Kentucky, United States. It is the seat of its county. The population was 17,236 at the 2020 Census. Danville is the principal city of the Danville Micropolitan Statistical Area, which include ...
. On July 13, 1881,
George E. Goodfellow George Emory Goodfellow (December 23, 1855 – December 7, 1910) was a physician and naturalist in the 19th- and early 20th-century American Old West who developed a reputation as the United States' foremost expert in treating ...
treated a miner outside Tombstone, Arizona Territory, who had been shot in the abdomen with a .32-caliber Colt revolver. Goodfellow was able to operate on the man nine days after he was shot, when he performed the first laparotomy to treat a bullet wound.


Terminology

The term comes from the Greek word λᾰπάρᾱ (lapara) 'the soft part of the body between the ribs and hip, flank' and the suffix ''-tomy'', from the Greek word τομή (tome) '(surgical) cut'. In diagnostic laparotomy (most often referred to as an exploratory laparotomy and abbreviated ex-lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause. In therapeutic laparotomy, a cause has been identified (e.g.
colon cancer Colorectal cancer (CRC), also known as bowel cancer, colon cancer, or rectal cancer, is the development of cancer from the colon or rectum (parts of the large intestine). Signs and symptoms may include blood in the stool, a change in bowe ...
) and the operation is required for its therapy. Usually, only exploratory laparotomy is considered a stand-alone surgical operation. When a specific operation is already planned, laparotomy is considered merely the first step of the procedure.


Spaces accessed

Depending on incision placement, laparotomy may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include: * the
digestive tract The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organs of the digestive system, in humans and ...
(the
stomach The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital organ in the digestive system. The stomach i ...
,
duodenum The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear, and the terms anterior intestine or proximal intestine m ...
,
jejunum The jejunum is the second part of the small intestine in humans and most higher vertebrates, including mammals, reptiles, and birds. Its lining is specialised for the absorption by enterocytes of small nutrient molecules which have been previou ...
,
ileum The ileum () is the final section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms posterior intestine or distal intestine m ...
and colon) * the
liver The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it i ...
,
pancreas The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an ...
,
gallbladder In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although ...
, and
spleen The spleen is an organ found in almost all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The word spleen comes .
* the
bladder The urinary bladder, or simply bladder, is a hollow organ in humans and other vertebrates that stores urine from the kidneys before disposal by urination. In humans the bladder is a distensible organ that sits on the pelvic floor. Urine en ...
* the male
prostate The prostate is both an accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found only in some mammals. It differs between species anatomically, chemically, and phys ...
* the female reproductive organs (the
uterus The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The ...
and
ovaries The ovary is an organ in the female reproductive system that produces an ovum. When released, this travels down the fallopian tube into the uterus, where it may become fertilized by a sperm. There is an ovary () found on each side of the body. T ...
) * the
retroperitoneum The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on their ...
(the
kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blo ...
s, the
aorta The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes o ...
, abdominal
lymph node A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that includ ...
s)


Types of incisions


Midline

The most common incision for laparotomy is a vertical incision in the middle of the abdomen which follows the linea alba. * The ''upper midline incision'' usually extends from the
xiphoid process The xiphoid process , or xiphisternum or metasternum, is a small cartilaginous process (extension) of the inferior (lower) part of the sternum, which is usually ossified in the adult human. It may also be referred to as the ensiform process. Bo ...
to the umbilicus. * A typical ''lower midline incision'' is limited by the umbilicus superiorly and by the
pubic symphysis The pubic symphysis is a secondary cartilaginous joint between the left and right superior rami of the pubis of the hip bones. It is in front of and below the urinary bladder. In males, the suspensory ligament of the penis attaches to the pubi ...
inferiorly. * Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in
trauma surgery Trauma surgery is a surgical specialty that utilizes both operative and non-operative management to treat traumatic injuries, typically in an acute setting. Trauma surgeons generally complete residency training in general surgery and often fe ...
. Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity.


Midline incision

# Cut (incise) the skin in midline # Cut (incise) subcutaneous tissue # Divide the linea alba (white line of the abdomen) # Pick up peritoneum, confirm that there is no bowel adhesion (intestinal adhesion) # Nick peritoneum # Insert finger beneath the wound to make sure that there is no adhesion # Cut the peritoneum with scissors


Other

Other common laparotomy incisions include: * Kocher (right subcostal) incision (after
Emil Theodor Kocher Emil Theodor Kocher (25 August 1841 – 27 July 1917) was a Swiss physician and medical researcher who received the 1909 Nobel Prize in Physiology or Medicine for his work in the physiology, pathology and surgery of the thyroid. Among his many ...
); appropriate for certain operations on the
liver The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it i ...
,
gallbladder In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although ...
and
biliary tract The biliary tract, (biliary tree or biliary system) refers to the liver, gallbladder and bile ducts, and how they work together to make, store and secrete bile. Bile consists of water, electrolytes, bile acids, cholesterol, phospholipids and ...
. This shares a name with the Kocher incision used for thyroid surgery: a transverse, slightly curved incision about 2 cm above the sternoclavicular joints. * Davis or Rockey–Davis "muscle-splitting" right lower quadrant incision for
appendectomy An appendectomy, also termed appendicectomy, is a surgical operation in which the vermiform appendix (a portion of the intestine) is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acute appe ...
, named for the Oregon surgeon Alpha Eugene Rockey (1857–1927) and the Philadelphia surgeon Gwilym George Davis (1857–1918), who devised such incision style in 1905. *
Pfannenstiel incision A Pfannenstiel incision , Kerr incision, Pfannenstiel-Kerr incision or pubic incision is a type of abdominal surgical incision that allows access to the abdomen. It is used for gynecologic and orthopedics surgeries, and it is the most common me ...
, a transverse incision below the umbilicus and just above the pubic symphysis. In the classic Pfannenstiel incision, the skin and subcutaneous tissue are incised transversally, but the linea alba is opened vertically. It is the incision of choice for
Cesarean section Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen, often performed because vaginal delivery would put the baby or ...
and for abdominal
hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries ( oophorectomy), Fallopian tubes ( salpingectomy), and other surrounding structures. Usually performed by a gynecologist, a hysterectomy may b ...
for benign disease. A variation of this incision is the
Maylard incision Maylard incision is a surgical incision in which a transverse cut is made on rectus abdominis muscle to allow wider access to the pelvic cavity. It is also called Mackenrodt incision. For gynaecological surgery, the skin incision is made 5-8 cm a ...
in which the
rectus abdominis The rectus abdominis muscle, ( la, straight abdominal) also known as the "abdominal muscle" or simply the "abs", is a paired straight muscle. It is a paired muscle, separated by a midline band of connective tissue called the linea alba. It exte ...
muscle Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of mus ...
s are sectioned transversally to permit wider access to the pelvis. This was pioneered by the Scottish surgeon Alfred Ernest Maylard (1855–1947) in 1920. * Lumbotomy consists of a
lumbar In tetrapod Tetrapods (; ) are four-limbed vertebrate animals constituting the superclass Tetrapoda (). It includes extant and extinct amphibians, sauropsids ( reptiles, including dinosaurs and therefore birds) and synapsids ( pelycosa ...
incision which permits access to the
kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blo ...
s (which are
retroperitoneal The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on thei ...
) without entering the
peritoneal cavity The peritoneal cavity is a potential space between the parietal peritoneum (the peritoneum that surrounds the abdominal wall) and visceral peritoneum (the peritoneum that surrounds the internal organs). The parietal and visceral peritonea are la ...
. It is typically used only for benign renal lesions. It has also been proposed for surgery of the upper urological tract. * Cherney Incision – developed in 1941 by the American uro-gynecologic surgeon Leonid Sergius Cherney (1908–1963).


Complications following laparotomy

Globally, there are few studies comparing perioperative mortality following laparotomy across different health systems. One major prospective study of 10,745 adult patients undergoing emergency laparotomy from 357 centres in 58 high-, middle-, and low-income countries found that mortality is three times higher in low- compared with high-
HDI The Human Development Index (HDI) is a statistic composite index of life expectancy, education (mean years of schooling completed and expected years of schooling upon entering the education system), and per capita income indicators, wh ...
countries even when adjusted for prognostic factors. In this study the overall global mortality rate was 1.6 percent at 24 hours (high 1.1 percent, middle 1.9 percent, low 3.4 percent; P < 0.001), increasing to 5.4 percent by 30 days (high 4.5 percent, middle 6.0 percent, low 8.6 percent; P < 0.001). Of the 578 patients who died, 404 (69.9 percent) did so between 24 h and 30 days following surgery (high 74.2 percent, middle 68.8 percent, low 60.5 percent). Patient safety factors were suggested to play an important role, with use of the
WHO Surgical Safety Checklist The World Health Organization (WHO) published the WHO Surgical Safety Checklist in 2008 in order to increase the safety of patients undergoing surgery. The checklist serves to remind the surgical team of important items to be performed before an ...
associated with reduced mortality at 30 days. Taking a similar approach, a unique global study of 1,409 children undergoing emergency laparotomy from 253 centres in 43 countries showed that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed in these settings. Internationally, the most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries. Absorption of drugs administered orally was shown to be significantly affected following abdominal surgery.


Related procedures

A related procedure is
laparoscopy Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...
, where cameras and other instruments are inserted into the
peritoneal cavity The peritoneal cavity is a potential space between the parietal peritoneum (the peritoneum that surrounds the abdominal wall) and visceral peritoneum (the peritoneum that surrounds the internal organs). The parietal and visceral peritonea are la ...
via small holes in the abdomen. For example, an
appendectomy An appendectomy, also termed appendicectomy, is a surgical operation in which the vermiform appendix (a portion of the intestine) is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acute appe ...
can be done either by a laparotomy or by a laparoscopic approach. There is no evidence of short-term or long-term advantages for peritoneal closure during laparotomy.


See also

*
Spaying Neutering, from the Latin ''neuter'' ('of neither sex'), is the removal of an animal's reproductive organ, either all of it or a considerably large part. The male-specific term is castration, while spaying is usually reserved for female animals. ...
, veterinary surgery often done via laparotomy *
Perioperative mortality Perioperative mortality has been defined as any death, regardless of cause, occurring within 30 days after surgery in or out of the hospital. Globally, 4.2 million people are estimated to die within 30 days of surgery each year. An important consi ...


References


External links


Article about exploratory Laparotomy


{{Digestive system surgical procedures Digestive system surgery Surgical incisions