Emergency laparotomy

Why are we operating?

The midline answer to peritonitis, obstruction and bleeding: find the problem, control it, and decide how much surgery this patient can afford today.

Indication: Generalised peritonitis, perforated viscus, uncontrolled intra-abdominal bleeding, obstruction with compromise.

The operation in 4 steps

1. 01Midline entry

   A midline incision through the linea alba, extended as needed above or below the umbilicus.

   Why: The linea alba is bloodless and leads everywhere: the one incision that can reach all four quadrants and be extended in seconds when the diagnosis is wrong.

2. 02Systematic exploration

   Contamination is controlled by suction, then the abdomen is examined in a fixed order: small bowel run from DJ flexure to caecum, colon, stomach and duodenum, pelvis, and the lesser sac when the story points behind the stomach.

   Why: A fixed order is what stops the dramatic finding from hiding the second one; the operation treats what the exploration proves, not what the scan promised.

3. 03Definitive repair or damage control

   The source is dealt with at the level the physiology allows: patch of a perforation, resection with or without anastomosis, or pack-and-return when the patient is cold, acidotic and coagulopathic.

   Why: The most dangerous place for a marginal patient is under an anaesthetic having elegant surgery. Damage control trades completeness now for survival tonight; the abdomen can be revisited, the physiology cannot.

4. 04Washout and closure

   Warm saline lavage until clean, drains only for a reason, then mass closure of the midline; laparostomy if return is planned.

   Why: Dilution is the treatment for contamination that debridement cannot reach. The midline is closed with the slowly absorbable mass technique because dehiscence of an emergency laparotomy is a second emergency.

Anatomy you need

The whole abdomen, because a midline laparotomy owns all of it: run the bowel from ligament of Treitz to rectum.

What can go wrong

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.

• Intra-abdominal abscess

  Swinging fevers, malaise, and localized pain from day 5 onward, classically after perforated appendicitis.

• Postoperative ileus

  Distension, absent flatus, intolerance of diet, and quiet bowel sounds in the days after abdominal surgery.

• Venous thromboembolism

  Unilateral leg swelling, or sudden dyspnoea, pleuritic pain, tachycardia, sometimes the only sign is unexplained hypoxia.