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03 / General Surgery · open

Emergency laparotomy

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.

Part of General Surgery →4 stages5 complications to knowopen
Free air under the diaphragm: the film that books the laparotomy
Cerevisae · CC BY-SA 4.0

Read the imaging first

Practice before you scrub

Read the obstructed abdomen

Colicky central pain, distension, bilious vomiting, and an appendicectomy scar. Abdominal radiograph. (Fictional educational case.)

  • Adhesional SBO earns a genuine trial of conservative management, with written exit criteria: deterioration, peritonism or a failed contrast transit means theatre.
  • Strangulation rewrites the tempo: constant pain, tenderness and lactate turn tonight's plan from a drip into an operation.
Practice this image View the anatomy

On the tray for this operation

Test yourself on the tray

Stage

1 / 4

Midline entry

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

🔧 Scalpel🔧 Electrosurgical pencil🔧 Richardson retractor

Watch for: Bowel injury on entry, highest with previous surgery and adhesions

Why are we operating?

The emergency laparotomy is not one operation but a doorway: a midline incision made because the abdomen holds an undiagnosed or uncontrolled catastrophe, perforation, ischaemia, bleeding, obstruction beyond salvage, and the plan will be finished inside. Its mortality is among the highest of any common operation, which is why the decision, the resuscitation and the seniority in the room matter as much as the incision.

Pulls toward surgery

Generalised peritonitisPerforated viscus with free gasIschaemic bowel suspected on clinical groundsUncontrolled intra-abdominal bleedingObstruction with peritonism or failed conservative care

Gives the team pause

Physiology not yet resuscitated (minutes spent here are repaid)Goals of care: the operation some patients should be protected fromThe frail patient whose mortality risk reshapes the conversation

Shared foundations

The acute abdomen method

Every general surgical emergency passes through the same funnel. Learn the funnel once and appendicitis, obstruction and perforation become variations, not separate subjects.

Understand it once, in the specialty hub

The anastomosis & why it leaks

Joining bowel is the specialty's signature act, and the leak is its signature fear. The principles are shared by every resection, so they are taught once here.

Understand it once, in the specialty hub

Damage control surgery

The idea that separates trauma surgery from elective surgery: when physiology is failing, the operation is abbreviated to haemorrhage and contamination control, and completeness waits. Taught once here; the laparotomy and thoracotomy pages assume it.

Understand it once, in the specialty hub

Balanced resuscitation

Every bleeding patient in every specialty is resuscitated on these principles; trauma is where they were learned.

Understand it once, in the specialty hub

What the surgeon is thinking

  • Midline entry

    Why midline, when smaller incisions exist?

    The midline is the abdomen's master key: bloodless (the linea alba is a tendon), extensile from xiphoid to pubis, and committed to no diagnosis. When you do not know what you will find, you choose the incision that can handle anything you find.

  • Systematic exploration

    How do you search an abdomen systematically?

    By trajectory and by tour: free gas and bile point upstream to the foregut, faeculent fluid downstream, blood to the mesentery and solid organs. Then the formal tour, stomach to rectum, both paracolic gutters, the lesser sac when the story demands it, because the second pathology is found by the surgeon who kept looking after the first.

  • Definitive repair or damage control

    What actually decides definitive surgery versus damage control?

    The physiology, read honestly: temperature, pH, coagulation and pressor requirement. A stable patient gets the full operation; a patient in the lethal triad gets control of bleeding and contamination and a planned return. The abdomen is closed when the patient can afford it, and saying 'we stop here' is a senior decision made early, not a concession made late.

  • Washout and closure

    What does the washout achieve, and what does it not?

    Lavage removes gross contamination, the inoculum the peritoneum must then handle, but it does not sterilise: source control did the curing, antibiotics cover the remainder, and the washout is the cleanup crew, not the fix. Closure then chooses between fascia today and a laparostomy when swelling or a relook forbids it.

Decision points

  • Perforated sigmoid found, patient stable-ish on low-dose pressors: resect and join, Hartmann's, or damage control?

    • Hartmann's procedure

      Resection plus end colostomy: the contaminated abdomen's default, no join to leak.

    • Resection with primary anastomosis

      For the genuinely stable patient with limited contamination, often defunctioned: the reversal-mountain avoided, the leak risk accepted.

    • Damage control: resect, staple, return

      For deteriorating physiology: continuity is a decision for a warmer, better-resuscitated tomorrow.

    Three right answers exist for the same finding in three different patients: the physiology and the contamination pick between them. What is always wrong is a heroic join in a patient whose body cannot fund its healing.

  • The operation is done but the bowel is oedematous and the wall will not close without tension.

    • Laparostomy with negative-pressure dressing

      Leave the fascia open by plan: abdominal compartment syndrome is deadlier than a delayed closure.

    • Close under tension

      The wrong economy: tension ischaemia buys dehiscence and compartment pressure with interest.

    Closure is a physiologic decision like every other in this operation: intra-abdominal pressure, ventilation pressures and the relook plan all vote, and the open abdomen is a strategy with a schedule, not an admission of defeat.

Leaving the OR

The handoff

Procedure
Emergency laparotomy: perforated duodenal ulcer, omental patch, washout
Physiology
Lactate 3.2 falling; noradrenaline weaning; extubation deferred
Abdomen
Fascia closed; no drains; NG on free drainage
Plan
Antibiotics per micro; Helicobacter and ulcer therapy started; relook only if trajectory fails
Watch for
Pressors re-climbing, abdominal pressure, day 5-7 collection window

A fictional educational patient, handed over the way real ones are.

The postoperative course

  1. ICU, first 24hThe operation is judged by trajectory: lactate clearing and pressors weaning say source control worked; the reverse says it did not, and earns imaging or a return.
  2. POD 1-3Extubation, lines rationalised, feeding started as the gut allows; the ileus is physiologic until it is not.
  3. POD 4-7The collection and leak window: swinging fevers or new organ dysfunction here mean a CT, not reassurance.
  4. Week 2+Rehabilitation measured honestly: this operation's survivors often need weeks, and the frailty conversation from before the operation continues after it.

Watch it done

Find Emergency laparotomy videos on YouTube

What can go wrong

Postoperative bleedingSurgical-site infectionIntra-abdominal abscessPostoperative ileusVenous thromboembolism
Live this operation as a case →Live this operation as a case →OR Prep this operationReview the instruments