A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal

cavity. It is also known as coeliotomy. Terminology In diagnostic laparotomy (most often referred to as an exploratory laparotomy and abbreviated Ex-Lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause. In therapeutic laparotomy, a cause has been identified (e.g. peptic ulcer, colon cancer) and laparotomy is required for its therapy. Usually, only exploratory laparotomy is considered a stand-alone surgical operation. When a specific operation is already planned, laparotomy is considered merely the first step of the procedure. Spaces accessed Depending on incision placement, laparotomy may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include:

the lower part of the digestive tract (the stomach, duodenum, jejunum, ileum and colon) the liver, pancreas and spleen the bladder the female reproductive organs (the uterus and ovaries) the retroperitoneum (the kidneys, the aorta, abdominal lymph nodes) the appendix

Types of incisions Midline The most common incision for laparotomy is the midline incision, a vertical incision which follows the lineaalba.

The upper midline incision usually extends from the xiphoid process to the umbilicus. A typical lower midline incision is limited by the umbilicus superiorly and by the pubic symphysis inferiorly.

Sometimes a single incision extending from xiphoid process to pubic symphysis is employed, especially in trauma surgery.

Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity. Other Other common laparotomy incisions include: TheKocher (right subcostal) incision (after Emil Theodor Kocher); appropriate for certain operations on the liver, gallbladder and biliary tract. This shares a name with the Kocher incision used for thyroid surgery: a transverse, slightly curved incision about 2 cm above the sternoclavicular joints; the Davis or Rockey-Davis "muscle-splitting" right lower quadrant incision for appendectomy; the Pfannenstiel incision, a transverse incision below the umbilicus and just above the pubic symphysis. In the classic Pfannenstiel incision, the skin and subcutaneous tissue are incised transversally, but the lineaalba is opened vertically. It is the incision of choice for Cesarean section and for abdominal hysterectomy for benign disease. A variation of this incision is the Maylard incision in which the rectus abdominis muscles are sectioned transversally to permit wider access to the pelvis.

Lumbotomy consists of a lumbar incision which permits access to the kidneys (which are retroperitoneal) without entering the peritoneal cavity. It is typically used only for benign renal lesions. It has also been proposed for surgery of the upper urological tract. Related procedures A related procedure is laparoscopy, where cameras and other instruments are inserted into the peritoneal cavity via small holes in the abdomen. For example, an appendectomy can be done either by a laparotomy or by a laparoscopic approach.

An appendectomy (sometimes called appendisectomy or appendicectomy) is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated perioperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix, causing transruptural flotation. This is a relative contraindication to surgery. Appendectomy may be performed laparoscopically (this is called minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy. There have been some cases of auto-appendectomies, i.e. operating on yourself. One was performed by Dr Kane in 1921, but the operation was completed by his assistants. Another case is Leonid Rogozov who had to perform the operation on himself as he was the only surgeon on a remote Arctic base.

Procedure
In general terms, the procedure for an open appendectomy is as follows. 1. Antibiotics are given immediately if there are signs of sepsis, otherwise a single dose of prophylactic intravenous antibiotics is given immediately prior to surgery. 2. General anaesthesia is induced, with endotracheal intubation and full muscle relaxation, and the patient is positioned supine. 3. The abdomen is prepared and draped and is examined under anesthesia.

4. If a mass is present, the incision is made over the mass; otherwise, the incision is made over McBurney's point, one third of the way from the anterior superior iliac spine (ASIS) and the umbilicus; this represents the position of the base of the appendix (the position of the tip is variable). 5. The various layers of the abdominal wall are then opened. 6. The effort is always to preserve the integrity of abdominal wall. Therefore, the External Oblique Aponeurosis is slitted along its fiber, and the internal oblique muscle is split along its length, not cut. As the two run at right angles to each other, this prevents later Incisional hernia. 7. On entering the peritoneum, the appendix is identified, mobilized and then ligated and divided at its base. 8. Some surgeons choose to bury the stump of the appendix by inverting it so it points into the caecum. 9. Each layer of the abdominal wall is then closed in turn. 10. The skin may be closed with staples or stitches. 11. The wound is dressed. 12. The patient will be brought to the recovery room.

NURSING MANAGEMENT: Assess the severity and location of pain. If client presents with board-like rigidity and severe pain, suspect for peritonitis. Administer analgesics after a diagnosis is made. Assess the effectiveness of the analgesic given. Position client in a supine position with thighs slightly flexed.

Preoperative care It is important to prepare a patient several hours pre-surgery. The patient may be dehydrated due to symptoms such as vomiting. It may be necessary to administer IV fluids. The patient's vital signs should be recorded every 2-4 hours. The nurse should not apply any heat over the area of pain while the patient is awaiting diagnosis as this could cause the appendix to rupture (Box 2). Analgesia should not be administered before examination because this can lead to an inaccurate diagnosis as the pain may subside and the examination will be ineffective. Aperients should also be avoided as induced peristalsis may cause perforation. If appendicitis has been diagnosed regular analgesia, usually an opioid depending on pain severity, should be given to make the patient comfortable before treatment. They may feel anxious so the nurse or surgical team should fully explain the procedure to them and answer any questions. The operation site will be washed and shaved before surgery, depending on local procedures. Postoperative care The severity of the patient's pain needs to be assessed with the use of a pain scale. Appropriate pain relief can then be administered. Vital signs should be regularly monitored at half-hourly intervals for two hours postoperatively, hourly for two hours and, if stable, every four hours while the patient is recovering in hospital. If the patient has had a straightforward appendectomy the surgical team should review the patient on recovery and decide when they may eat and drink. A drain may have been inserted during surgery. If so, the output of the drain should be recorded every 24 hours. The drain can be removed when there is minimal drainage - usually 50ml or less. The wound should be managed aseptically. If the wound is covered with a dry dressing then it should be changed every 1-2 days. Clips/stitches should be removed 10 days postoperatively. The patient can go home with these in place and the district or practice nurse can remove them. If dissolvable stitches have been used this is unnecessary, although a visit to check the wound will reduce anxiety. Before discharge, the patient must be confident in how to manage their wound and have details of who they should contact in case of concern. The patient should be encouraged to get up and out of bed as soon as possible to prevent the formation of emboli. Anticoagulants are usually administered in the form of subcutaneous injections before surgery and postoperatively. Antiembolism stockings should be worn. If peritonitis has developed, the patient's postoperative management will be over a longer period but will follow the same principles. The patient will not be able to commence food and fluids for a few days, this is to enable the bowel to regain normal function. The convalescence period is almost invariably smooth and the patient recovers rapidly (Colmer, 1986). The hospital stay for patients who have undergone an uncomplicated appendectomy is usually 2-3 days. In most cases the patient will be discharged when their temperature is normal and their bowels have started to function again (Peterson, 2002). People can live a full life without their appendix. Changes in diet, exercise or other lifestyle factors are not necessary (NDDIC, 2004).