Understanding Laparotomy and Laparoscopy Procedures

Laparotomy is the general medical term for a surgery performed on the abdomen using the traditional full-size incision, rather than a minimally invasive approach. Another name for this common surgery is a coeliotomy.

A laparotomy uses a full sized incision and the minimally invasive version of the procedure is called a laparoscopy and uses multiple small incisions.

The traditional procedure--laparotomy-- is often referred to as an "open" procedure, because the incision makes an opening that allows the surgeon to visualize the organs, blood vessels, and tissues in the abdominal cavity.  The laparotomy uses laparoscopic instruments including a camera inserted into very small incisions to allow the surgeon to visualize the internal structures and surgical instruments.

The decision to perform the procedure open or laparoscopically rests with the surgeon and what, if anything, he expects to find during surgery. If the surgery is being done as an emergency, the surgeon may perform a laparotomy versus a laparoscopic laparotomy because it provides a larger view and can be somewhat quicker than the minimally invasive approach.  When minutes count, the open approach procedure is typically much faster in the initial phase of surgery.

In the majority of cases the open technique is reserved for circumstances where time is of the essence, the patient is unstable or when the procedure requires a large incision, such as a surgery that requires that a large portion of the intestine be visible and accessible.

An exploratory laparotomy is the name given to an open abdominal surgery used to examine the organs and tissues of the abdomen when a diagnosis has not been made. If the source of an abdominal problem is not obvious, a visual examination of the abdominal cavity may help.

In the past, an exploratory laparotomy was commonly performed for “abdominal pain of unknown origin,” when testing was unsuccessful in determining the reason for the pain. It was also performed for many other reasons, including trauma, suspected cancer or other conditions that testing could not diagnose.

Today, the minimally invasive approach is used much more frequently than this open approach. When the procedure is done with minimally invasive techniques, it is called an exploratory laparoscopy

Exploratory surgery, in general, is less common than it was in the past due to the enhanced ability to obtain images of the body using Magnetic Resonance Imagine (MRI), Computer Tomography (CT Scans) and other techniques.  We can often diagnose things without having to look and see surgically, and many problems can be treated with medication rather than a scalpel.  

In some cases, the surgeon may find the cause of the abdominal problem and finish the exploratory procedure with no further treatment. The findings can then be discussed when the patient is fully awake and alert, and a treatment plan created. For example, if a woman was found to have severe ovarian cysts during a laparotomy, the surgeon might decide to discuss the procedure and the alternatives with the patient before going forward with surgical treatment.

During an exploratory laparotomy, tissue samples also may be taken in a procedure called a biopsy. This is done to help with a diagnosis of abdominal problems as the tissue can be examined under a microscope and the issue may be diagnosed in that way.

Reasons For a Laparotomy

A laparotomy is the general name for a surgical procedure performed on the abdomen. The term exploratory laparotomy is often used to describe a procedure that is being used to determine the nature of an illness. For example, if a patient is having abdominal pain and the source of that pain is not clear, the surgeon will schedule an exploratory laparotomy.

Common Reasons For a Laparotomy:

Large and Small Intestine: A perforation in the intestine, blockage of the intestine, cancer, 

Liver: Trauma, cirrhosis, liver enlargement, need for stenting.

Urinary System-Kidneys, Ureters and Bladder: Blockages such as kidney stones, cancer, trauma

Female Reproductive System: Endometriosis, cancer, ectopic pregnancy, inflammation

Gallbladder: Typically done using the minimally invasive approach, in rare circumstances it may be removed using the open technique

Spleen: Trauma, spleen enlargement, rupture

Pancreas: Inflammation of the pancreas, cancer

General abdominal complaints: Infections such as an abscess, cancer, trauma, inflammation of tissues, to determine the stage of a disease process, adhesions from previous procedures

A laparotomy may be performed emergently, meaning that the patient is experiencing a life-threatening condition and laparoscopy is needed to either determine the nature of the problem, to treat the problem or both. The problem may be bleeding from an unknown source, damage to an organ or even bleeding that cannot be controlled even though the cause is known.

A procedure that is frequently done after a traumatic injury resulting in abdominal pain is deep peritoneal lavage (DPL). This is where a small incision is made in the abdomen and the abdominal cavity is flushed with fluid. If the fluid comes out of the body with significant amounts of blood, a laparotomy may be indicated. The DPL does not diagnose the source of the injury but does indicate the bleeding is present. The laparotomy will diagnose the injury and the surgeon could potentially fix the problem as well.

Trauma, such as a car accident or a penetrating injury (stabbing or gunshot wound) is a frequent cause of abdominal injuries that must be diagnosed or treated with a laparotomy. In these cases it may be obvious that there is a major abdominal wound, however, the organs, vessels and tissues involved may not be as clear. In these cases, the surgeon can both visualize the injuries and diagnose the problem, and in most cases, treat the problem as well.

In addition to the general risks of surgery and the risks of anesthesia, both laparoscopy and  laparotomy pose their own risks. The risks vary based upon the underlying problem or disease that makes the procedure necessary, but the risks specific to the procedure are:

• Infection
• Incisional hernia
• Bleeding from the surgery site

A laparotomy or laparoscopy begins with the administration of general anesthesia. Once the anesthesia takes effect, the skin of the abdomen is prepared with an antibacterial solution to prevent infection at the surgical site.

The surgeon will make the incision. If the pain is in the lower right abdomen over the appendix, the incision will be placed in that area.

If a minimally invasive procedure laparoscopy is planned, several incisions less than an inch long will be made, if a laparotomy is planned, one large incision will be made. 

If the large incision will be used, it is likely to be either a midline incision, which is a vertical incision that is placed between the pubic bone and below the sternum, and the transverse incision, which is placed horizontally.

In some cases, the incision may be small at the beginning of the surgery and then enlarged as needed to complete procedures after a diagnosis is made.  In some case a minimally invasive procedure can become an open procedure if the surgeon needs more room to visualize the issue or work.

Once the incision is made, the organs and tissues will be inspected for signs of disease, infection or inflammation. Biopsies may be taken of different tissues as needed. In some cases, the abdominal cavity may be "washed," where sterile fluid is placed in the abdomen, then collected for further study.

Once the organs and tissues of the abdomen have been inspected, the "look and see" portion of the procedure is over; however, in many cases, an addition procedure will be performed. For example, a laparotomy is performed to find the source of abdominal pain, and an inflamed appendix is found, an appendectomy procedure would then be combined with the laparotomy.

The incision may be closed in a variety of ways. Larger incisions are typically closed with sutures or staples, smaller ones may be closed with adhesive strips called steri-strips or surgical glue. The incision is then covered with a sterile surgical bandage. Anesthesia is stopped and a medication is given to wake the patient, who is then taken to the recovery area.

The recovery from a laparotomy procedure varies widely from patient to patient. This is due to the vast number of problems that make the surgery necessary. Generally speaking, an uncomplicated procedure that is a laparotomy and no additional procedure requires 2 to 6 weeks of recovery time before returning to normal activities. This can be significantly lengthened by procedures that are necessary after a diagnosis is made.

Patients who have laparotomies and have more serious underlying conditions (a patient who was in a car accident with broken bones and internal bleeding that requires a laparotomy) may take much longer to heal from surgery. The body is working to heal multiple injuries at once, so the total healing time is extended. Some problems that make a laparotomy necessary may also delay healing. A patient who has cancer may have a more complicated recovery as the treatment for cancer may overlap with recovery. The same is true when having an additional surgical procedure with the laparotomy.

Once discharged from the hospital to recover at home, it is important that special care is taken to prevent infection and take proper care of the incision. Infection is one of the most common complications of this surgery, so knowing how to identify the signs of infection is essential. Plan to brace your incision when you are rising from sitting or any other activities that increase abdominal pressure to prevent pain, dehiscence and to decrease the risk of an incisional hernia.