Laparotomy involves open a patient’s abdomen to access his organs. Concretely, it therefore makes it possible to carry out “open belly” operations. Given its invasive nature, it is frequently replaced by micro-invasive surgical techniques, such as the laparoscopy and robotic surgery. In which cases is it still indicated? How is the intervention carried out? What can be the complications? What to expect during recovery? Answers from Pr Michel Ducreux, head of the digestive oncology department at the Gustave Roussy Institute.
Definition: what is a laparotomy?
“Laparotomy is a surgical technique which consists of opening the abdomen by making a more or less wide incision to be able to access the internal organs and practice various surgical procedures (biopsy, treatment of an abdominal condition, repair of a hernia, removal of an organ, management of an injury, etc.“, says Professor Ducreux. And to clarify, “the term laparotomy derives from the Greek ‘lapara’, which means ‘belly’ and ‘tomy’, which means ‘incision'”. Practiced since antiquity, this intervention therefore makes it possible to take care of various diseases, but also deformities or injuries. But at present, it faces strong competition from other less invasive techniques, such as laparoscopy.
What is an exploratory laparotomy?
As its name suggests, exploratory laparotomy involves opening the abdomen pour explorer un diagnostic : the doctors are not certain of what they will find.
It is particularly indicated in the event of clinical signs compatible with an intra-abdominal pathology, provided that no other less invasive examination is possible.
Median, horizontal, vertical laparotomy, Pfannenstiel laparotomy…
The incision can be made in different ways. We therefore distinguish:
- the midline laparotomywhich consists in opening the abdomen between the pubis and the sternum;
- the laparotomy horizontalmost often performed in the context of caesarean sections;
- the laparotomie verticalewhich consists in opening the abdomen from the pubis to the navel;
- and the Pannenstiel laparotomywhich consists of opening the abdomen at the level of the lower abdomen horizontally.
Laparotomy or laparoscopy (laparoscopy): what are the differences between these two operations?
Laparoscopy, also called laparoscopy, is a surgical procedure that involves making small incisions to introduce micro cameras and micro instruments into the patient’s abdomen, following inflating it with carbon dioxide. Said incisions are most often made above the pubis. As stated above, laparoscopy has many advantages over laparotomy:
- elle reduces postoperative pain ;
- elle limit blood loss during the operation;
- and it allows shorten the length of hospitalization.
In addition, laparotomy has a strong impact on intestinal transit. Not to mention the maintenance and vigilance necessary to prevent complications and promote healing.
Indications: when and why to perform a laparotomy?
Laparotomy may be indicated in several cases:
- when laparoscopic surgery is not possible (in case of evisceration or extensive cancer, for example);
- in case of cancer, if the tumors are too big so that they can be removed by laparoscopy;
- if the intervention requires removal of a foreign body or removal of an organ (kidney, stomach, etc.) accompanied by a transplant;
- and visibility is impaired during a laparoscopic intervention;
- Etc.
In other words, we practice a laparotomy when we have no other choice, sometimes in first intention, and sometimes in second.
What precautions should be taken before an abdominal laparotomy?
Laparotomy is usually scheduled, but it can also be performed on an emergency basis. Ideally, to promote the smooth running and success of the intervention, patients should:
- having taken a shower with an antiseptic product.
- fasting (stop eating at least 6 hours before the procedure and stop drinking at least 3 hours before the procedure);
- have quit smoking in the two months preceding the intervention (or at least severely limit your consumption) to promote healing;
- regarding alcohol, it is better to avoid drinking in the seven days preceding the operation. And obviously ban any alcoholic drink on D-Day.
How is a laparotomy performed?
Laparotomy is most often performed under general anesthesia. But some procedures may require “simple” local anesthesia. As for the timingthe laparotomy can last one or more hoursdepending on the type of intervention performed (liver transplant, tumor removal, bullet extraction, etc.).
Once the patients anesthetized and intubated, the surgeon incises the abdomen using a scalpel at the level of the skin, the muscles and the peritoneum. Then, once the intervention is finished, it carefully close the wound by suturing the muscles (if they have been cut), then the fat and the skin using threads, staples, or even glue, if the incisions are small. The medical team then install a suction drain to ensure the flow of liquids.
Note: in some cases, the surgeon fails to close the wound, so much the abdominal wall is distended. He then makes a laparostomie : the patient’s stomach remains open, but special dressings, called suction, are applied.
Scar: how long does it take to disappear?
The scar is one of the most dreaded points of laparotomy. The teams strive to do their best to make it as “aesthetic” as possible, but unfortunately they have not no impact on the healing process.
Moreover, the healing will be longer and less “aesthetic” if the patient has already been operated on many times in the same place, or if the scar becomes infected.
What are the operational consequences?
Length of hospitalization and postoperative medical follow-up differ depending on the nature of the operation. In all cases, patients may experience significant fatigue and the functioning of their intestines may be altered for a few days.
In case of pain, painkillers (paracetamol, Acupan, morphine, etc.) are prescribed.
To avoid any risk of abscess or eventration, the scar is regularly monitored by the medical team who removes dressings and drains on the surgeon’s instructions.
Then once the patient is outside, a postoperative consultation is scheduled within 3 to 4 weeks.
What are the potential complications ?
Laparotomy is considered an invasive procedure due to the risks associated with general anesthesiabut also because:
- risks of’infection,
- risks of bleeding,
- risks of blood clots
- of the potential respiratory complications
- and some postoperative pain.
Also, the larger the incision, the more a risk of abscess.
And beyond the risks inherent in anesthesia and the surgery itself, laparotomy above all presents a significant risk of remote eventration (the organs come out of the abdomen because a suture has come loose or because the healing is not fast enough), warns Professor Ducreux.
The risk factors are advanced age, obesity, smoking, malnutrition or tissue strength problems.
Convalescence: how to recover from a laparotomy?
As indicated above, the duration of hospitalization is variable: it depends on the type of intervention, the recovery of each patient and possible complications. To facilitate the return home, it is better to ask for help from those around you for certain everyday tasks, such as shopping or driving children. Indeed, it is not uncommon to feeling extremely tired for two to three weeks. Without counting disabling pain, potential nausea, even vomiting which can occur during early recovery.
What diet following a laparotomy?
After the operation, it is essential to stay hydrated daily and to follow the hygieno-dietetic advice of the medical team. To avoid constipation, doctors generally advise betting on high fiber foods such as fruits, vegetables, seeds and cereals. We also limit too fatty meals that complicate digestion. In general, patients start eating “normally” once more following a few weeks.
How to take care of your scar?
Laparotomy scars do not require no special care if they do not present an infectious risk. The dressing is usually removed following 48 to 72 hours and the wound is left exposed. To promote healing, you can use moisturizing or healing creams and especially massage his scar twice a day to soften the tissues and counter adhesions. On the other hand, if the scar is infected (redness associated with fever and purulent secretions), it requires regular nursing care.
Note: to promote healing, avoid baths, swimming pools and other hammams or saunas for a few weeks. Showers are of course possible, provided you use a mild pH soap and dry the scar well by patting it gently.
What sport to practice? When can we make love once more?
On a daily basis, wearing a restraint belt can be recommended. As for sports practice, all doctors insist on this point: strenuous physical activity is avoided within two months of the operation. The resumption of daily activities must be gradual: initially, avoid sudden movements and the carrying of heavy loads. As far as sexual intercourse is concerned, it is better not to hold on to frolics without penetration until the healing is sufficiently advanced.