Laparotomy: midline

• Access to abdominal (also potentially thoracic and pelvic) cavity.

• Treatment of various lesions (almost all abdominal organs can be exposed optimally).
• Investigation when other options are unavailable or inconclusive.

Advantages

• Access to pelvic organs: extension via pubic symphysiotomy.
• Access to thoracic organs: extension via sternotomy or diaphragmatic incision.
• Allows full assessment of entire abdomen.
• Fast and usually avascular approach.
• Can improve access to craniodorsal abdomen with paracostal extension (rarely indicated).

• Flank: left or right flank Laparotomy: flank.
• Paracostal Laparotomy: paracostal.
• Paramedian Laparotomy: paramedian.

Criteria for choosing test

• Always briefly discuss specific surgical risks before surgery with the owner.
• Clear advice on possible adverse sequelae is more effective before surgery and if given in writing.

Minimum equipment

• Standard kit Surgical instruments.

Ideal equipment

• Self-restraining retractor, pediatric size (Balfour or Gossett)  . Laparotomy sponges (radio-opaque).

• Food withheld 12 h before to avoid reflux esophagitis Esophagitis. (If possible, ie not emergency procedure). Water should not be withheld, especially if fluid volume a concern.

• Place patient in dorsal recumbency.

Site

• Midline, ventral abdomen.

Preparation

• Clip and prepare sufficient area to allow extension incision if required .
• Drape to allow minimal skin exposure lateral to incision .
• Standard aseptic skin preparation .
• Can tilt surgery table so that hind limbs/tail lower than head   →   will reduce abdominal pressure on abdomen.

• General anesthetic General anesthesia: overview.

Step 1 - Incision

• Midline incision through skin and subcutis.
  Count sponges before cutting.

Step 2 - Identify linea alba

• Identify linea alba, which appears as trough between 2 rectus muscles, with minimum of blunt dissection/undermining.

Step 3 - Incise linea alba

• Raise linea alba, penetrate with stab incision .
  Use guarded scalpel blade.

Step 4 - Extend incision

• Using scissors extend cranial and caudal as required, incising linea and underlying peritoneum.
• Avoid underlying viscera by continuing to elevate linea alba and/or placing finger or grooved director within abdomen under line of incision.
• Ligate/cauterize small vessels.
  If using retractor protect exposed tissues with saline soaked sponges.

Step 5 - Further extension of incision

• Extend with sternotomy or pubic symphysiotomy if necessary, or with paracostal incision Laparotomy: paracostal.

Step 1 - Close body wall

• Count swabs before closure.
• Close body wall in single layer.
  Inclusion of peritoneum not critical.
• Include external rectus sheath - most important layer for strength (versus internal rectus sheath).

Step 2 - Suture body wall

• Continuous suture of monofilament nylon, polypropylene, polygalactin or polydioxanone is rapid and secure.
  Use simple interrupted technique if chromic catgut used.
• Use taper cut needle.
• Variable size suture material dependent on patient size.

Step 3 - Suture subcutis

• Simple continuous suture, with fine absorbable material, in subcutis .

Step 4 - Close skin

• Routine skin closure:
  • Close subcutaneous layer.
  • Simple interrupted or cruciate.
  • Appose skin edges.
  • Should be possible to lift knot easily, ie not too tight.
  • Alternative: subcuticular buried pattern.

Analgesia

• Essential Analgesia: overview.

Refereed papers

• Recent references from PubMed and VetMedResource.