CSTStudy ← Ex Lap
Exploratory laparotomy · Whiteboard

Ex LapWhiteboard

The class whiteboard, heading by heading. The layers and anatomy, with their graphics, are below it.

Ex Lap

General ex lap: a bowel obstruction is found, resected and joined back together.

Procedure

  • Ex Lap: exploratory laparotomy

Definition

  • Explore the abdomen, for diagnosis

Purpose of procedure

  • Find a tumor and/or a pathological condition that needs to be corrected: remove or repair
  • In this checkoff: a bowel obstruction is found and resected

How the diagnosis is determined

  • Before surgery: CT, MRI, blood work, ultrasound, physical exam
  • In surgery: a piece of specimen is removed and sent to pathology for testing

Relevant anatomy

  • Abdomen → skin → subQ / adipose → fascia → muscle (rectus abdominis, linea alba) → peritoneum → omentum → mesentery → bowel
  • Colon: cecum → ascending → hepatic flexure → transverse → splenic flexure → descending → sigmoid → rectum
  • Bowel layers: serosa, muscularis, submucosa, mucosa

Meds

  • 0.9% saline, warm (irrigation)
  • 0.5% Marcaine with epi (hold)
  • Sterile water
  • State the meds on the field at the time out

Anesthesia

  • General anesthesia

Position

  • Supine, safety strap, egg crate foam
  • Pillows, head donut, warm blanket, SCDs

Prep

  • ChloraPrep (26 mL)
  • Swab the umbilicus first with a cotton-tipped applicator
  • Circular, inside to out: incision site to the periphery
  • Nipple line to top of thighs, to the table on both sides

Equipment

  • ESU, suction, Harmonic, Ligasure
  • OR bed, back table, suction carousel
  • Fluid warmer, SCD, Bair Hugger, cell saver

Instruments

  • Major tray, Balfour tray
  • Deep (long) tray, Harmonic tray
  • Poole suction, Glassman bowel clamps

Supplies

  • Major pack, back table pack, double basin, gowns and gloves
  • Foley kit, GIA stapler and reloads, skin stapler
  • Sutures (Vicryl, silk, chromic gut, PDS), ties
  • Extra blades, extra suction, extra Bovie, extended Bovie tip, Yankauer, peanuts, extra laps
  • Drains (JP), grounding pad
  • Dressings: Telfa, drain sponge, island bandage

Steps

  • 1Mark the incision
  • 2Hand the blade
  • 3Pass the Bovie for the deeper incision
  • 4Use Metz, Bovie, #15 blade and peanuts for further dissection
  • 5Retraction: Army-Navy
  • 6Further dissection: Bovie, Metz, curved Mayo, 6″ DeBakey
  • 7#10 blade, blunt dissection with laps, sponge stick, curved Mayo
  • 8Bovie → peritoneum
  • 9Ligasure + 8″ DeBakey → peel back the omentum
  • 10Retracting: Balfour, 2 moist laps
  • 11Mobilize the bowel with the Ligasure
  • 12Towel off the surgical site; bring up the instruments and supplies needed; towel over the Mayo stand
  • 13Use Glassman clamps to occlude on both sides (E. coli, feces)
  • 14Use the GIA stapler to close off and cut on each side of the obstruction
  • 15Side-to-side anastomosis: cut a slit with the Bovie on the corners of each side
  • 163rd load on the GIA for the side-to-side anastomosis
  • 17Take the sponge stick and check the integrity of the lumen
  • 18Use four Allis to close, and the doctor uses the stapler (GIA)
  • 19Check for tears before closing
  • 20Transition to clean: dirty towels, instruments and suction go in the basin
Say it out loud:“Meds on the field: saline”“Count is correct”“Changing gloves”

Layers & anatomy

Hover a part (or tap it) to see its label.

1. Abdominal wall layers

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1SKIN2SUBCUT. FAT3FASCIA4MUSCLE5PERITONEUM·CAVITY

The wall goes from the diaphragm to the pubis. Outside to inside, the layers are:

  • 1Skin
  • 2Subcutaneous adipose: lobulated fat, from ¼ inch to over 8 inches thick
  • 3Fascia
  • 4Muscle
  • 5Peritoneum (the parietal peritoneum)

2. Abdomen anatomy

RUQLUQRLQLLQ 123 456 789
Nine regions: 1 right hypochondrium, 2 epigastric, 3 left hypochondrium, 4 right flank, 5 umbilical, 6 left flank, 7 right iliac, 8 suprapubic, 9 left iliac.

Nine regions: left and right hypochondrium, epigastric, left and right flank, umbilical, left and right groin (inguinal), pubic.

Four quadrants, and what sits in each:

  • Right upper: liver, gallbladder, colon, portions of the small intestine
  • Left upper: stomach, pancreas, spleen, colon, portions of the small intestine, kidneys, adrenal glands, descending aorta, ureter
  • Pelvic cavity: ureters, uterus and adnexa (female), prostate (male), urethra, urinary bladder, sigmoid colon, rectum

Abdominal wall muscles: the two rectus abdominis, attached from the pubis to the 5th to 7th costal cartilages, and the three flank muscles (external oblique, internal oblique, transversus abdominis). The linea alba is the midline band where the muscles meet.

Peritoneum: the parietal peritoneum lines the cavity. The mesentery attaches the bowel to the posterior wall. The greater omentum covers the stomach, duodenum and part of the colon.

3. Bowel anatomy

FRONT VIEW, SCHEMATIC PATIENT RIGHT ON THE LEFT OF THE PICTURE BOWEL WALL, CROSS-SECTION OUTER SEROSA SUBMUCOSA MUCOSA LUMEN
Top: the GI tract laid into the abdomen, from the stomach down to the rectum. Bottom: a cut through the bowel wall, outside in.

Three layers of the bowel wall:

  • aMucosa, the inner lining
  • bSubmucosa, closed with the mucosa in suture closure
  • cOuter serosa, the outside layer, closed with fine interrupted sutures

The bowel is held by the mesentery, which fans out to cover the small intestine.

Say it out loud:“Five layers, skin to peritoneum”“Nine regions, four quadrants”