Heidi Hottinger Gulf Coast Veterinary Specialists, Houston, TX, USA A proper exploratory laparotomy requires appropriate surgical instruments and equipment. Important instruments and equipment that make an abdominal surgery most efficient include four‐pack of sterile Huck towels or sticky drapes for adequate quarter‐draping, Backhaus towel clamps (minimum 8), patient and table drape, laparotomy sponges, a variety of hemostats (e.g., mosquito, Kelly, and Rochester‐Carmalt), sterile bowl for warm saline lavage, curved Mayo scissors, curved Metzenbaum scissors, needle‐holders, suture‐cutting scissors, and a variety of thumb forceps (e.g., Brown‐Adson or Adson with teeth for closure and DeBakey or Semken forceps for handling delicate tissues). Proper suction tips to remove peritoneal fluid or lavage are also beneficial when working in the abdominal cavity. A Poole suction tip is very helpful in the abdomen and will allow fluid to be removed without suction attachment and trauma to abdominal organs. If a Poole suction tip is not available, a laparotomy sponge can be wrapped around a standard suction tip to dissipate the force of suction present at the tip and prevent tissue trauma. Abdominal retractors are also important for proper visualization and exposure. Balfour retractors are recommended for abdominal wall retraction and can be purchased in a variety of sizes. The clinician may wish to start with a single Balfour retractor, in which case a large size (10″ spread) would be recommended. This size can be used in medium‐ and large‐size dogs. For cats and small dogs, a small or medium Balfour retractor can be used, or a pair of Gelpi retractors with 7″ arms can be placed at either end of the incision. Other types of retractors that may be used if Balfours are not readily available include Weitlaner or Williams retractors. A proper abdominal explore requires that you fully open the abdomen. This does not mean a slightly extended spay incision, and it does not mean stopping in front of the prepuce; it means the abdomen should be opened from xiphoid to pubis. An adequate cranial extent of the incision is necessary to properly examine the liver and stomach, and it is also crucial to performing surgical procedures on those structures. An adequate caudal extension of the incision is equally important to open the abdominal space enough to work cranially and properly evaluate and work on the urinary bladder and prostate. When doing surgery on the urinary bladder, and especially when needing to evaluate the prostate, the midline incision must extend to the pubis for proper access and visualization. To create an abdominal incision of the appropriate length, the patient must be properly prepared for surgery. A surgical clip and scrub should begin 1–2 inches cranial to the xiphoid and 1–2 inches past the pubic brim. The lateral patient prep should be lateral to the mammary chains. In male dogs, the prepuce must also be clipped and then lavaged with a dilute iodine solution. If the prepuce is not to be included in the surgical field, it can be clamped to the left side (or the opposite side from where the clinician is standing) with a towel clamp, being sure to engage just the skin of the prepuce and not the penis, so the abdominal incision can be continued to the right (or left) side of the prepuce. Four quarter‐draping should be utilized with sterile Huck towels or sticky drapes secured with towel clamps. The quarter drapes should be placed just medial or lateral to the nipples of the mammary chain, proximal to the xiphoid cranially, and to the level of the pubis caudally. A large fluid impervious surgical drape is then placed, which covers the patient and instrument table. A fenestration is then cut in the drape to expose the proposed incision site. If spillage of free abdominal fluid is anticipated, an Ioban™ or similar adhesive drape may be adhered to the ventral abdomen over the exposed skin and patient drape immediately prior to incision. This will help the patient stay dry and may help maintain the patient’s temperature. Once the patient is properly prepped, a sponge and instrument count should be completed and recorded. These counts can be included as components of a surgical checklist, which is now utilized by many hospitals. The benefits of surgical checklists have been well documented,1 and numerous examples of veterinary‐specific lists are available online. When making the incision, the skin should be incised, followed by a direct incision through the subcutaneous tissues to the linea alba (i.e., aponeurosis of the rectus abdominis muscles or external rectus sheath). Do not remove the subcutaneous tissue in search of the linea, as this creates dead space that can lead to seromas and surgical site infections. Judicious undermining can be utilized as needed to ensure that the external rectus sheath is easily visualized for purposes of incision closure. To help identify the midline/linea, approach the umbilicus, which is usually easy to identify (Figure 20.1). Tent the body wall with thumb forceps at the umbilicus and use a #10 or #15 scalpel blade with the sharp blade facing away from the abdomen to make a stab incision at the umbilicus. A #11 blade can also be used but requires more caution and precision to prevent the sharp tip from impaling organs next to the body wall. Mayo scissors, or the technique of your choosing, can then be used to extend the incision in both directions (Figure 20.2). Prior to extending the incision, be sure to see or feel the internal side of the linea, which may be done easily by sweeping the finger in advance of sharp transection on the linea alba. This “digital sweeping” is performed to avoid damage to abdominal viscera that may be close to, or adherent to, the body wall. The falciform ligament should be removed next. Removal of the falciform ligament allows for better inspection of the viscera, facilitates easier closure of the abdomen, and prevents postoperative steatitis from trauma to the adipose tissue during the procedure. It can be excised with electrosurgery, scissors, or blunt traction with hemostats from its attachments to the midline of the body wall. There will be a blood vessel at the level of the xiphoid process and one or two small blood vessels laterally that may require ligation. The incision should extend to, but not cranial to, the xiphoid process due to the close proximity of the diaphragm and risk of iatrogenic pneumothorax if the diaphragm is punctured. Should the diaphragm be accidentally opened, management is easily accomplished. The clinician should first request manual ventilation of the patient, and then ask for suture material to close the defect. The defect can be closed in a continuous pattern with long‐term monofilament absorbable suture, and then free air within the thorax can be removed with a syringe and needle. The patient can then be gradually weaned from manual ventilation to ensure they are appropriately oxygenating without assistance. Figure 20.1 Location of the umbilicus to establish midline of the incision. Note that the quarter‐draping is just outside of the nipple line. Cranial is to the bottom of the image. Source: © Heidi Hottinger. Figure 20.2 An approach to the abdomen for an explore should extend from the xiphoid process to the pubis. In a male dog, a right‐handed surgeon standing on the patient’s right side will incise to the right of the prepuce, which is clamped to the opposite side of the sterile field. Cranial is to the bottom of the image. Source: © Kristin Coleman. Once the abdomen is open, the incision needs to be retracted open to improve visualization and working space. An appropriate abdominal incision without proper retraction (Figure 20.3a) limits visualization significantly. Following proper retraction (Figure 20.3b), the liver and stomach in the cranial abdomen, as well as a large left renal cyst, can now be easily visualized and accessed. Moistened laparotomy sponges should be placed along the exposed subcutaneous tissues prior to placing the abdominal retractors. The laparotomy sponges will help to prevent direct contact of abdominal viscera with exposed skin, and they will also prevent desiccation and contamination of the subcutaneous tissues, both of which can contribute to postoperative incisional infections. Once the laparotomy sponges are in place, abdominal retractors can be placed and expanded (Balfour retractors are advised, but Gelpi, Weitlaner, or Williams retractors placed at either end of the incision can be used in cats and small dogs). Once the abdomen is properly opened and retractors are in place, the abdominal explore can begin. It is very important to develop a systematic approach that is followed every time. This ensures all structures are evaluated without getting distracted by an abnormal finding. Once abnormal findings are noted, it becomes very easy to focus on the abnormality and forget to perform the rest of the exploratory. Resist this temptation and complete the explore before beginning any projects or procedures. There are a few times when you may wish to ignore this guideline, such as when an active source of hemorrhage is present, or a gastric dilatation‐volvulus (GDV) needs to be decompressed for the viability of the stomach and to allow room for an adequate explore. Similarly, an extremely large mass may prevent appropriate exploratory surgery until it has been removed. Aside from these exceptions, the full exploratory should be completed, then abnormalities can biopsied or definitively managed. For a systematic approach, the abdomen can be divided into five regions, with each region evaluated in an orderly fashion. These five regions are the cranial abdomen, the right and left gutters, the caudal abdomen/pelvic region, and the central abdomen.
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The Art of the Abdominal Explore
Instruments and Equipment
Proper Abdominal Incision
Proper Retraction
The Systematic Exploratory Laparotomy
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