Main objectives and primary examination
Surgical intervention begins with a midline incision. The main objectives of the exploration are to detect traumatic injuries, search for the source of acute inflammation (the so-called "acute abdomen"), and decide on tumor resection in oncological diseases.
If blood is present in the abdominal cavity, the parenchymatous organs—the liver, spleen, and pancreas—are examined first.
- Liver: the anterior edge and inferior surface are visually assessed. To do this, the transverse colon is displaced inferiorly and the edge of the liver superiorly, simultaneously inspecting the gallbladder and lig. hepatoduodenale. The diaphragmatic surface is checked by palpation. In complex situations, lig. falciforme hepatis is incised.
- Spleen: the stomach is retracted to the right and flexura coli sinistra inferiorly, after which the lower pole is inspected and the remaining areas are palpated through the left hypochondrium.
- Pancreas: access to its injuries is achieved exclusively after incision of lig. gastrocolicum.
Examination of the hollow organs of the gastrointestinal tract
Examination of hollow organs is performed in a strict sequence, especially if stomach or intestinal contents have spilled into the abdominal cavity.
- Stomach and duodenum: first, the anterior wall of the stomach, pylorus, and superior horizontal part of the duodenum are examined. The posterior wall of the stomach is examined after incision of the gastrocolic ligament.
- Small intestine: the examination begins from the flexura duodenojejunalis using the Gubarev maneuver. Each loop is sequentially checked along the mesenteric and antimesenteric borders. Wounds are not sutured immediately to avoid unnecessary trauma before potential resection; the loop is covered with a wipe and clamped with a soft non-crushing clamp.
- Large intestine: the examination begins at the ileocecal junction, carefully tracing the right and left colic flexures. If retroperitoneal hematomas are detected due to bowel rupture, the peritoneum is opened via the paracolic gutters.
Completion of exploration and surgery
After completing the examination of all intestinal divisions, as well as mandatory inspection of the pelvic organs (urinary bladder, uterus with appendages) and the contours of both kidneys, the surgical intervention proceeds to its final stage.
- Peritoneal lavage (Sanation): the abdominal cavity is thoroughly dried using surgical sponges or an electric suction device, removing pathological contents.
- Blockade: to reduce reflex responses, a 0.25% novocaine solution is injected into the celiac, superior, and inferior mesenteric plexuses.
- Suturing: the wound is closed tightly or drainage tubes are placed based on current indications.
Briefly: answers to topical questions
How is the Gubarev maneuver technically performed to locate the flexura duodenojejunalis?
The Gubarev maneuver to locate the flexura duodenojejunalis is performed by retracting the greater omentum and palpating the mesentery. The technique includes the following steps:
- Retraction — the greater omentum with the transverse colon is grasped with the left hand, put on tension, and retracted superiorly.
- Mesenteric search — the fingers of the right hand glide along the mesentery of the transverse colon toward the spine.
- Bowel grasping — the fingers slide to the left and grasp the loop located there, which is the first fixed loop of the small intestine.
Which liver ligaments must be incised for its complete mobilization and detailed examination of the diaphragmatic surface?
Sources indicate incising the falciform ligament to improve liver visualization: in doubtful cases, it is incised to improve exposure. During Nissen transabdominal fundoplication, the left triangular ligament is transected to mobilize the liver, and the left lobe is retracted to the right. A complete list of ligaments for total liver mobilization is not provided in the sources.
Which peritoneal fossae, spaces, and recesses must be sequentially examined to rule out the accumulation of pus or blood?
The sources do not provide a strict sequence for examining peritoneal compartments, spaces, and recesses. The following spaces and areas are indicated: right subdiaphragmatic space; left subdiaphragmatic space, including the left hepatic and pregastric bursae; subhepatic space; omental bursa (lesser sac); right and left paracolic gutters; greater and lesser omentum, small and large intestines with their mesenteries, parietal and visceral peritoneum, retroperitoneal space.
Trauma sequence: first solid organs (liver, spleen, pancreas), then hollow organs (stomach, small and large intestines) starting from fixed points (flexura duodenojejunalis, ileocecal junction).
Class and exam questions
Which organs are explored first when blood is present in the abdominal cavity?
Parenchymatous organs—the liver, spleen, and pancreas—are examined first, as they are most often the source of massive hemorrhage.
How is the small intestine examined and what should be done if a wound is found?
The examination begins from the flexura duodenojejunalis (Gubarev maneuver), sequentially inspecting each loop along the free and mesenteric borders. The discovered wound is not sutured immediately, but wrapped in a sponge, secured with a soft clamp, and general exploration is continued.
What does the Petrov-Khundadze maneuver entail?
The maneuver is used to detect injuries to the posterior wall of the descending parts of the duodenum. It consists of incising the parietal peritoneum along the lateral border of the ascending colon followed by mobilization of the bowel.
What else to study on this topic
- Technique of the Gubarev maneuver during small intestine examination
- Anatomical landmarks during mobilization of the duodenum (Petrov-Khundadze maneuver)
- Rules for sanitation and drainage of the abdominal cavity
- Performance of novocaine blockades of mesenteric reflexogenic zones
- Surgeon's tactics when detecting retroperitoneal hematomas of the large intestine
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