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Nursing tips for the exploratory laparotomy patient

From anaesthesia to post-operative monitoring, there are many considerations when approaching an exploratory laparotomy

03 September 2020, at 8:40am

Exploratory laparotomy is commonly performed but there are many tips to optimise its execution and ensure patient safety. Exploratory laparotomy is required for diagnostic, prognostic or therapeutic purposes. Sometimes this will be an emergency procedure, but it can also be indicated following extensive diagnostic work-up. For defined surgical procedures, such as routine cystotomy, the surgical approach can be more defined.

Patient assessment and stabilisation

Thorough physical examination, including recording body weight and body condition score, is essential. Baseline blood work includes a packed cell volume and serum total solids or haematology, alongside a serum biochemistry pro-file. Further specific blood tests may be indicated. If significant blood loss is anticipated, or a tendency for increased clotting times may be present, then determination of blood-type and assessment of clotting times may be required.

The optimum time for which food is withheld, for adult cats and dogs, has been a matter of discussion in the past 10 years. Overnight fasting has tended to be the approach for elective procedures, but this has been reconsidered as extended fasting can increase the incidence of regurgitation and increases gastric acidity (Savvas et al., 2009). The optimal time to withhold food is suggested to be around six hours. Free access to water should be provided at all times, unless there is protracted vomiting. Intravenous fluid therapy should be provided before anaesthesia to achieve timely correction of dehydration or hypovolaemia.

Anaesthesia considerations

Multimodal analgesia should be employed. Premedication is most appropriate with a pure opioid agonist, alongside a sedative agent depending upon the disposition of the patient. Non-steroidal anti-inflammatory medication may be avoided, for example if there is any concern that gastrointestinal tract ulceration or hypovolaemia are present or anticipated.

Equipment

Use of an equipment checklist ensures items are not missed. Many patients requiring an exploratory laparotomy are higher risk anaesthetic candidates. Specific preoperative preparation will ensure optimal and efficient care and decrease anaesthetic duration.

Self-retaining retractors (eg Balfour or Gossett retractors) are important to allow a thorough visualisation. A suction apparatus is invaluable to allow removal of fluid, blood, exudates and lavage fluid and to control intraoperative contamination. The use of a Poole suction tip, which has a sheath with multiple small holes covering the inner suction tip, is advantageous to allow efficient removal offluid without blockage with omentum. It is wise to monitor the volume of fluid collected in the reservoir of the suction apparatus, in particular if there are intraoperative concerns regarding haemorrhage.

Swabs with radio-opaque markers (Figure 1) are recommended for all procedures within a body cavity. Large saline-soaked laparotomy swabs are particularly useful to protect the edges of the incision, to avoid desiccation and to pack off viscera and avoid peritoneal contamination (Figure 2).

Atraumatic intestinal forceps (eg Doyen intestinal forceps) are used when an enterotomy or enterectomy is performed. Warm sterile saline may be necessary during an exploratory laparotomy; the use of a water bath containing a stock of sterile saline bottles can help to anticipate this need.

Swab counts must be done before and after surgery. If a swab count does not tally and the swab cannot be located by repeat inspection, radiographs can be used to locate it. It is also prudent to account for all instruments prior to closure of the abdomen.

Theatre checklist and time out

Introduction of a surgical checklist has been demonstrated to dramatically reduce mistakes (Tivers, 2015). The surgical checklist is read aloud at three time points in theatre:

  1. Before induction:
    1. Check patient identification, procedure to be performed and site of procedure, medication intolerances, plan regarding antibiosis (if indicated)
    2. Patient resuscitation code is stated
  2. Before first incision:
    1. Reiterating the procedure to be performed
    2. Detailing anticipated risks and adverse events (eg hypotension, regurgitation and bradycardia)
    3. If biopsies are required, they are listed
    4. The number of surgical swabs in the kit are checked and noted
    5. Each member of the team introduces themselves and states their role. This has been demonstrated to empower the whole team to speak up if they notice an error and improves patient safety
  3. Before leaving theatre:
    1. Ongoing plan for analgesia, intravenous fluids, blood products, antibiosis if indicated
    2. Ongoing monitoring plan (eg monitor temperature, pulse and respiration and arterial blood pressure every two to four hours for the first 12 hours post-operatively)
    3. Potential post-operative complications are noted

Performing the exploratory laparotomy

Patient aseptic preparation

Surgical preparation of a wide area of the abdomen is performed to allow an adequate surgical incision, routinely from xiphisternum to pubis, to be performed. The necessary clipped area extends from the caudal thorax to the inguinal area and to 5 to 10cm laterally, usually up to one-third of the way up the costal arch (Figure 3). For male patients, the prepuce is generally clipped but not flushed, unless it is anticipated that a urethral catheter should be passed during surgery, for example during the removal of urethral and cystic calculi. Clipping and initial preparation are performed in a separate preparation room before moving the patient into the sterile theatre.

FIGURE (3) This young cat is clipped for an exploratory laparotomy following suspicion of a gastrointestinal obstruction after three days of vomiting
FIGURE (3) This young cat is clipped for an exploratory laparotomy following suspicion of a gastrointestinal obstruction after three days of vomiting

Once moved to theatre, the patient is positioned on the operating table. Warming blankets and circulating warmed air can be used to avoid hypothermia. They should remain turned off until drapes are secured to reduce airflow which may cause particles to be blown on the prepared surgical site. Reusable air blankets are available that can be laundered, maintaining standards regarding infection control but avoiding single-use. Basic heat pads and warmed bean bags or fluid bags should be used with great care as they can cause burns, in particular if skin perfusion is reduced due to hypotension.

Four quadrant draping is performed and the drapes are secured using towel clamps. Reusable textile drapes or single-use woven plastic drapes are appropriate;
however, if significant lavage is required or peritoneal fluid is present, there may be strikethrough of the textile drapes and secondary draping may be indicated. The use of a plastic adherent drape affords a benefit to minimise strikethrough and wetting of the patient’s body, which would exacerbate hypothermia.

The surgery

The abdominal approach extends from xiphoid (the caudal-most cartilage of the sternum) to the pubis. It is important to note that the cranial extent of the approach can result in a defect being created in the diaphragm, resulting in a pneumothorax. The patient’s ventilation should be monitored and intermittent positive pressure ventilation initiated if problems arise; the veterinary surgeon should be alerted to this issue and can then drain the thoracic cavity and repair the defect, allowing spontaneous ventilation to resume.

Once the peritoneal cavity is opened, free peritoneal fluid may be noted and a sample should be obtained with a syringe for cytology and culture, if appropriate. Each veterinary surgeon may have a different approach to performing the exploratory laparotomy; what is important is that it is performed systematically and thoroughly so that no area is overlooked.

Often biopsy samples (fine needle aspirate or Tru-Cut biopsy) may have been obtained preoperatively as part of the diagnostic work-up; sometimes their results may have proved inconclusive or further information is required war-ranting an exploratory laparotomy. Obtaining biopsies at laparotomy allows direct visualisation of the organ and therefore allows representative samples to be taken from focal lesions, increasing the likelihood of a diagnosis. For vascular organs, there is also improved safety from improved management of haemorrhage. Biopsy of relevant organs should always be taken even if the organs appear grossly normal if the patient’s clinical condition dictates this.

It may be necessary for a feeding tube to be placed at the time of surgery. There are a number of options: oesophagostomy feeding tubes are simple to place and can be removed easily but are not suitable if the patient has been vomiting; gastrostomy feeding tubes are convenient to place when operating within the abdomen and have the added potential to allow gastric decompression to be achieved, but they need to remain in place for at least two weeks following placement. Placement of a surgical peritoneal drain may be indicated, for example if septic peritonitis is present (Figure 4). It is important to ensure that feeding tubes and drains are clearly labelled before the patient leaves theatre; inappropriate use of the drain to deliver liquid feed is a possible error that would be catastrophic.

FIGURE (4) A cross-breed dog developed a perforated gastroduodenal ulcer following extended non-steroidal anti-inflammatory administration, causing septic peritonitis. Following local debridement, biopsy and repair of the lesion, the peritoneal cavity was lavaged and a Jackson Pratt surgical drain was placed
FIGURE (4) A cross-breed dog developed a perforated gastroduodenal ulcer following extended non-steroidal anti-inflammatory administration, causing septic peritonitis. Following local debridement, biopsy and repair of the lesion, the peritoneal cavity was lavaged and a Jackson Pratt surgical drain was placed

Post-operative monitoring

Careful post-operative monitoring is important, as documented above. Provision of early oral nutrition is recommended and aids with gastrointestinal healing. Full-thickness gastrointestinal tract incisions carry a risk of septic peritonitis; incidence ranges from 2 percent for incisional biopsy to 10 percent for intestinal resection and anastomosis. It is important that the risks are communicated to the clients before and after surgery. Patients should be monitored for loss of appetite, vomiting, pain or depression and detailed examination by a veterinary surgeon prompted if any concerns arise.

References
Author Year Title
Savvas, I., Rallis, T. and Raptopoulos, D. 2009 The effect of pre-anaesthetic fasting time and type of food on gastric content volume and acidity in dogs. Veterinary Anaesthesia and Analgesia, 36, 539-546
Swinbourne, F., Jeffery, N., Tivers, M., Artingstall, R., Bird, F., Charlesworth, T., Doran, I., Freeman, A., Hall, J., Hattersley, R., Henken, J., Hughes, J., de la Puerta, B., Rutherford, L., Ryan, T., Williams, H., Woods, S. and Nicholson, I. 2017 The incidence of surgical site dehiscence following full-thickness gastrointestinal biopsy in dogs and cats and associated risk factors. Journal of Small Animal Practice, 58, 495-503
Tivers, M. 2015 Reducing error and improving patient safety. Veterinary Record, 177, 436-437

Zoë Halfacree, MA, VetMB, CertVDI, CertSAS, FHEA, DipECVS, MRCVS, qualified from Cambridge University Veterinary School and spent a couple of years in first opinion practice before moving to the RVC. Here she completed a rotating internship and surgery residency and became a Senior Lecturer in Surgery.

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