Surgical approaches and general rules of laparotomy

Types and aims of laparotomy

In surgical practice, laparotomies are divided into two main categories depending on the ultimate goal of the intervention:

• Therapeutic (laparotomia vera). A full-scale operation that includes incision of the abdominal wall, organ exploration, and direct surgical elimination of the pathology.
• Diagnostic or exploratory (laparotomia probatoria). Performed in situations where non-invasive methods have failed to establish an accurate diagnosis. Most commonly used in oncology to assess the spread of the tumor process and determine the feasibility of its removal.

Longitudinal approaches: the gold standard

Longitudinal incisions are the most common group of approaches in abdominal surgery. They provide a good overview and are relatively easy to perform.

1. Midline laparotomy (laparotomia mediana). The incision runs strictly along the linea alba. A crucial technical rule is that the incision line must curve to the left of the umbilicus to prevent the surgeon from damaging the round ligament of the liver (lig. teres hepatis). The approach is divided into upper and lower. Its main advantages are the widest exposure of most organs, absence of trauma to muscle fibers, large vessels, and nerves, and the ability to easily extend the wound in any direction.
2. Paramedian incision. Performed along the inner edge of the rectus abdominis muscle. The surgeon incises the anterior rectus sheath, retracts the muscle itself laterally using a special retractor, and then opens the posterior sheath along with the peritoneum. Because the incision lines on the fascia do not coincide, an exceptionally strong postoperative scar is formed. The main disadvantage is the limited length of the approach.
3. Transrectal incision. A variant of the paramedian approach. The difference is that the rectus muscle is not retracted, but bluntly separated along the course of its fibers after incising both walls of the sheath. Muscle tissue is rich in blood vessels, so the wound heals quickly. However, long incisions here are hazardous: nerve branches running to the medial sections are severed, leading to atrophy of part of the muscle and a high risk of postoperative hernia formation.
4. Pararectal incision (Lenander approach). Runs parallel to the lateral edge of the rectus muscle, usually below the level of the umbilicus. Unlike the paramedian approach, here the muscle is retracted medially. A classic example of its use is an appendectomy.

Alternative incision options

In addition to longitudinal ones, other vectors of tissue incision are used depending on the localization of the pathological process:

• Oblique incisions. In the upper floor of the abdominal cavity, they are made parallel to the costal margin (for operations on the liver, gallbladder, or spleen). In the lower floor, they are made parallel or at a slight angle to the inguinal ligament (access to the vermiform appendix).
• Transverse incisions. Performed with the transverse transection of one or both rectus abdominis muscles simultaneously. They provide excellent and convenient access to organs, but are used less frequently due to technical difficulties in suturing muscle fibers and an increased risk of suture dehiscence.
• Combined (thoracoabdominal) incisions. Combine opening of the abdominal and thoracic cavities. Indispensable for large-scale interventions requiring maximum exposure: gastrectomy, splenectomy, or extensive liver resection.
• Angular incisions. Used in situations where it is necessary to urgently expand an existing approach at an angle to the initial line (often for liver or splenic trauma).

Basic rules for performing a celiotomy

Any operation on abdominal organs requires strict discipline and adherence to a clear algorithm of actions:

• Layer-by-layer technique. Incision and subsequent closure of the anterior abdominal wall are always performed strictly along anatomical layers.
• Safe opening of the peritoneum. Before incision, the peritoneum is bluntly separated from the transversalis fascia and preperitoneal fat. Opening is performed exclusively under visual control. The peritoneum is grasped with two anatomical forceps, lifted (to ensure that bowel loops or adhesions are not caught in the fold), and nicked. The edges are fixed with Mikulicz clamps to protective towels to isolate the wound from infection.
• Working with wound retractors. When placing blade retractors, the surgeon must carefully ensure that internal organs (intestines or omentum) are not trapped beneath the metal blades.
• Isolation and moistening. The affected organ is brought out of the wound if possible and covered with moist sponges to prevent drying of the serosa. If bringing the organ out is technically impossible, it is carefully isolated with sponges deep within the wound. It is advisable to operate on a previously emptied organ.
• Strict asepsis. When the lumen of a hollow organ is opened (e.g., during the placement of the first row of intestinal sutures), the surgical field becomes contaminated. After closing the lumen, it is mandatory to replace all draping towels, surgical instruments, and gloves (or thoroughly treat them).
• Gentle handling of the serosa. Any accidental trauma to the serous membrane must be sutured immediately.
• Completion and drainage. Before closing the wound, the surgeon checks hemostasis reliability, dries the cavity, and counts all instruments and sponges. All drains and tampons are brought out exclusively through a counter-incision (an additional small puncture), as bringing them out through the main wound sharply increases the risk of suture dehiscence.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Technique of layered closure of the anterior abdominal wall
• Features of intestinal suture placement and asepsis rules
• Topography of the nerves and blood vessels of the rectus abdominis muscle
• Indications for thoracoabdominal (combined) approaches
• Methodology for sequential revision of abdominal organs

Other topics in the "Abdominal Surgery" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.