ABDOMINAL SURGERY
Abdominal access
techniques (including
laparoscopic access)
Nabeel Merali
Sukhpal Singh
Abstract
This article discusses the safe exposure of intra-abdominal organs
using laparoscopy and laparotomy. Newer methods of minimal access
surgery including single incision laparoscopic surgery (SILS), and
natural orifice transluminal endoscopic surgery (NOTES) are also dis-
cussed. Common abdominal incisions are illustrated.
Keywords Laparoscopy; laparotomy; natural orifice transluminal
endoscopic surgery; single incision laparoscopic surgery
Introduction
The field of general surgery is evolving and new technologies
promise to lead us to an era of less-invasive procedures with the
ultimate goal of scar-less surgery with reduced postoperative
pain. Within this article, we will discuss the robust preparation
and latest techniques on safe exposure and entry into the
abdominal cavity and surgical site infection.
Brief history on abdominal access
The word laparotomy has Greek roots, ‘lapara’ referring to ‘the soft
parts of the body between the costal margin and hips’ and ‘tome’
meaning ‘cutting’. In 1809 Ephraim McDowell performed the first
laparotomy on a kitchen table without anaesthetic. An ovarian
cyst was removed from a 46-year-old lady who then survived to 78.
The first laparoscopy in a human was credited to Hans Christian
Jacobaeus of Sweden in 1910. Zollikofer of Switzerland
substituted oxygen for carbon dioxide as an insufflator to reduce
the risk of explosion and improve rapid absorption in 1924. The
Hungarian Janos Veress created the spring-loaded needle in 1938.
In 1950, Hopkins designed a rod lens system, which made the
laparoscope more rigid and robust, giving a brighter image.
In 1981, a German gynaecologist Kurt Semm published on the
first laparoscopic appendicectomy. Eriche Mu € he of Bo€blingen,
Germany performed the first laparoscopic cholecystectomy in
1985. This achievement was recognized by SAGES (The Society
of American Gastrointestinal Surgeons) in 1999. Laparoscopic
cholecystectomy rapidly became the gold standard after Phillipe
Mouret performed the first one in France in 1987. Thus thera-
peutic abdominal laparoscopy had begun and minimally invasive
Nabeel Merali MRCS MSc is a Surgical Research Fellow at Frimley
Park Hospital, Frimley, UK. Conflicts of interest: none declared.
Sukhpal Singh FRCS (Gen Surg) MS is a General and Upper
Gastrointestinal Consultant Surgeon at Frimley Park Hospital,
Frimley, UK. Conflicts of interest: none declared.
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laparoscopic methods are now routinely used in many branches
of surgery.
Preparation in the operating theatre
The abdomen of the anaesthetized patient should be examined as
further information regarding intra-abdominal pathology may be
elicited when the musculature of the abdominal wall is relaxed,
influencing the surgical approach. Common abdominal incisions
are shown in Figure 1.
Positioning
The main reason for placing a patient in a specific surgical position is
to optimize access to the area of interest. The patient must be placed
on a non-slip surface. Safe positioning is a critical perioperative
component that the surgeon must lead and ensure that the patient is
stabilized and protected from injury. Several factors can increase the
risk for injury related to positioning, such as type of surgery and
anaesthetic, time of surgery, age, weight and nutritional status,
comorbidities and the improper use of theatre equipment.
Most often a supine position is used; however, for surgery
involving the pelvis or perineum, the LloydeDavis or lithotomy
(‘legs up’) positions provide better access. In the latter, so named
from the Greek to ‘cut for the stone’, the patient is supine with
the buttocks placed at the lower break in the table and the legs
flexed at the hips and knees, with sufficient abduction to allow
access to the perineum. The lower legs are placed in attachable
pneumatic supports or hanging stirrups. In the Lloyd-Davies
position, often used in colorectal surgery, the legs are abducted
with slight flexion of the knees and hips. Supports are now
usually a cushioned boot design to reduce pressure, especially on
the popliteal fossa and common peroneal nerve. Prolonged
placement in this position increases the risk of deep venous
thrombosis or compartment syndrome and intermittent pneu-
matic compression can be applied to reduce the former.
The position may be further adjusted to facilitate different
steps of the operation; however, this may cause physiological
effects, especially with pneumoperitoneum for example:
 Trendelenburg (head-down, to facilitate access to the
pelvis) e This position may reduce venous pooling in legs
and enhance venous return. However, gravity will impact
on pulmonary capillary blood volume and decrease lung
compliance creating a greater need for ventilator pressure
support. Increased cardiac output would lead to an
increased intro-ocular and intracerebral pressure.
 Reverse Trendelenburg (head-up, for better access to the
upper abdomen) e This position may be unavoidable in
operations like gastric-bypass or fundoplication and im-
proves visualization of upper abdominal structures. How-
ever, gravity combined with pneumoperitoneum will
increase pooling of blood in legs, decreasing venous return
and cardiac output. To minimize the impact of the pneu-
moperitoneum upon venous return and stasis in the legs,
one must only use this manoeuvre when necessary, with
calf compression stockings, low intra-abdominal pressures
and avoidance of extreme flexion of the hips and knees.
 Left, right tilt or prone position e Decreases the compli-
ance of the lungs and the ability of the thoracic ribcage to
expand.
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 ABDOMINAL SURGERY

Areas of high microbiological counts (groin, axilla, pubis,

Common abdominal incisions open wounds) should be prepared last and stoma sites isolated
from the prepared area. The antiseptic agent must remain on the
skin for sufficient time to achieve maximum effectiveness. This is
D the time taken to air-dry for alcoholic agents; at least 30 seconds
B A is needed for non-alcoholic agents. Alcohol-based solutions are
quick, sustained and durable, with broader spectrum antimi-
C
crobial activity. However, they should not be used on mucous
E F membranes or open wounds. Care must be taken to prevent
alcoholic antiseptic agents from pooling beneath the patient or
around diathermy pads to reduce the risk of diathermy burns or
G fire.

H Drapes
I J The prepared area of the skin and drape fenestration should be
sufficiently large to accommodate extension of the incision, the
K need for additional incisions, and all potential drain or stoma
sites. The passage of bacteria through surgical drapes is a po-
tential cause of wound infection so the drape type should be
appropriate for that procedure. Drapes may be linen or imper-
meable (disposable or non-disposable) materials. Impermeable
drapes result in significantly fewer bacteria in the operative field
Name of incision Commonly used for and wound compared with permeable linen drapes (through
A Palmer’s point Insertion of Veress needle which bacteria can easily penetrate). Adhesive plastic drapes,
B Kocher’s Open cholecystectomy with or without iodine impregnation, through which the surgeon
C Rooftop Liver surgery makes the incision, are sometimes used.
D ‘Mercedes Benz’ Liver transplantation
Diathermy versus scalpel skin incisions
E Midline Can be upper, lower –
many abdominal operations Skin incisions have traditionally been made using a scalpel.
F Paramedian Now less commonly used for laparotomy Recent literature has shown that skin incisions made by cutting
G Transverse Closure of stomas diathermy are quicker, result in less blood loss and have no
differences in the rate of wound complications or postoperative
H Gridiron Open appendicectomy
(now old fashioned) pain.
I Lanz Open appendicectomy
Wound irrigation
J Rutherford Morrison Renal transplant
Organisms that are formed from the incision of skin or contam-
(either on left or right side of abdomen)
K Pfannenstiel Gynaecological, laparoscopic colectomy inate the wound can theoretically be washed away with wound
irrigation. One study compared 283 patients undergoing surgery
for acute appendicitis and compared the risk of SSI after saline
Figure 1 wound irrigation to no irrigation. A statistically significant dif-
ference in wound infection rate favouring saline wound irrigation
in appendicectomy was demonstrated.1 Within the literature,
Surgical site infection Povidone-iodine may reduce SSI in wound irrigation; however
this is only licensed for use on intact skin.
Many aspects of perioperative management are aimed at
reducing surgical site infections (SSIs). SSI is a large subject area Surgical approach
that cannot be covered in its entirety in this article; however, we Colorectal surgery has been associated with a high rate of SSIs. A
will cover a number of relevant aspects. For further reading meta-analysis compared the risk of SSI between open and lapa-
please refer to the ‘Infection’ issue of Surgery. roscopic surgery for general surgical operations in obese patients.
Eight randomized controlled trials and 36 observational studies
Preoperative removal of hair were included and concluded that laparoscopic surgery in obese
If it is necessary to remove hair then both clipping and depilatory patients reduces SSI rate by 70%e80%.2
creams in the 24 hours prior to surgery results in fewer SSIs than
shaving using a razor. Laparoscopy
Skin cleaning preparation Diagnostic laparoscopy is a minimally invasive surgical procedure
Skin is cleaned with an antiseptic agent, usually povidone-iodine that allows direct inspection of the abdominal cavity as well as
or chlorhexidine in either aqueous or alcoholic solution, pro- surgical intervention in a less traumatic setting. It has the benefits
gressing from the incision site to the periphery. of smaller incisions, better cosmetic results, less postoperative

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 ABDOMINAL SURGERY

pain, an attenuated stress response and a quicker recovery time.

Important adjuncts to optimizing access at laparoscopy are cath-
eterizing the bladder to allow better views of the pelvis, and
decompressing the stomach with a naso/orogastric tube.

Pneumoperitoneum
The abdomen is distended with carbon dioxide to create a
working space and allow visualization of organs for surgery.
Carbon dioxide is a highly soluble non-combustible gas that is
readily absorbed into the circulation. Pressures are maintained
<15 mmHg to minimize physiological changes.

Gaining laparoscopic access to the abdomen

The pneumoperitoneum may be achieved via open (Hasson) or
closed (Veress needle, see below) methods.
A meticulous and careful approach to access is essential for:
 patient safety
 optimal display of the tissues
 safe and effective handling of tissues
 the surgeon’s comfort.

Closed method
The closed method uses a spring-loaded Veress needle to insuf-
flate the peritoneal cavity with carbon dioxide followed by blind
introduction of the first port. The anterior abdominal wall may be
elevated to provide counter traction with sharp towel clips,
following dissection down to the umbilical cicatrix-linea alba
junction (Figure 2).
The needle angulation should vary from 90 in overweight or
obese patients to 45 in thin patients. As the needle traverses
the abdominal wall, two clicks/points of resistance should be
noted, the first passing through the linea alba and the second
entering the peritoneal cavity. Confirmation of the correct po-
sition can be by several methods as well as the ‘double click’,
these include:
 Manometer test: The insufflator is connected with low
flow (3 l/min). If the needle is in the correct place, the gas
flows freely; initial intra-abdominal pressure is low and
increases gradually with the volume of gas insufflated.
 Hanging drop test: a drop of saline is placed on the open
end of the Veress needle and is ‘sucked’ into the peritoneal
Figure 2 Veress needle insertion. (a) Following incision just below the
cavity by negative intra-abdominal pressure when the
umbilicus, the umbilicus is elevated with a towel clip and the stalk is
anterior abdominal wall is manually elevated. dissected and the junction with the linea alba defined. (b) Insertion of
 Aspiration test: a syringe with saline is attached to the the Veress needle. The needle is held halfway down the shaft with the
Veress and instilled and aspirated: aspiration should not tap open. The ring and little finger stabilize the needle as it is advanced
possible if the needle is intraperitoneal but saline may be through the abdominal wall at the base of the umbilicus with abdom-
aspirated if it is extraperitoneal. inal wall elevation as counter-traction.
The Society of Obstetricians and Gynaecologists of Canada
(SOGC) clinical guidelines have suggested that these additional
safety tests are unnecessary, not required and provide very little Open methods
clinical information. Instead a Veress intraperitoneal pressure of Hasson introduced the open method of port insertion for lapa-
<10 mmHg is a reliable indicator of correct intraperitoneal roscopic procedures in 1971. The technique is essentially a mini-
placement of the Veress needle.3 Many surgeons find the tests laparotomy, whereby the linea alba is identified and incised, and
useful. the peritoneum identified, elevated with two clips and incised
The first port is then introduced blindly (Figure 3). Note the (Figure 4). The main problem with this method is that there is
position of the index finger reduces the risk of inserting the port often a gas leak, which may be minimized by using a threaded
too far. Twisting on insertion may also increase control. Hasson cannula or balloon-tip port.
Most complications of laparoscopy (Box 1) are related to blind A semi-open method involves making a 1-cm incision in the
insertion of the Veress needle or of the first port. umbilical ligament after dissecting the cicatrix to the linea alba.

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 ABDOMINAL SURGERY

Figure 4 Semi-open technique I. The fat of the umbilical ligament

Figure 3 Insertion of the first trocar following induction of pneumo- bulges through the vertical incision.
peritoneum with Veress needle (Figure 2). The index finger prevents
the trocar from being fully inserted.

Complications of laparoscopy

Specific
Immediate: extraperitoneal insufflation, injury to viscera or blood
vessels, intra-abdominal, of the abdominal wall or retroperitoneum
Early: pain in shoulder tip
Late: incisional (port site) hernia, metastases at port site

General
Immediate: bradycardia, inadequate oxygenation secondary to dia-
phragmatic splinting by excessive peritoneal insufflation or extreme
head-down position in an obese patient, reduced venous return,
pneumothorax, pneumomediastinum, gas embolism
Early: deep vein thrombosis/pulmonary embolism, hypothermia,
nausea and vomiting
Box 1
The abdominal cavity is then entered blindly using a clip
(Figure 5). A gas leak is less likely with this method.
Palmer’s point
In cases where a patient has had multiple previous operations,
risk of per umbilical adhesions a pneumoperitoneum may be
created by placing the Veress needle in the right or left upper
quadrant (Palmer’s point, 3 cm below the left costal margin in
the mid-clavicular line, see Figure 1).
Overall, there is insufficient evidence to recommend one
laparoscopic entry technique over another.4
Secondary trocars
The position of secondary trocars depend on the surgery being
performed and should be inserted under direct vision.
Ports and trocars
Wide ranges of port and trocar designs have been developed.
Each has their own specialist indications, advantages, disad-
vantages and surgeon preference. Trocars are usually disposable,
but reusable versions are available.
Figure 5 Semi-open technique II. The peritoneal cavity is entered with
an artery clip.
Classification of trocars
Cutting: Trocars with cutting blades eeither a flat blade or
pyramidal-tipped to cut the tissue in either a single plane or three
planes, and generally are fitted with retractable shields.
Noncutting: Basic designs include pointed conical trocars that
penetrate by separating tissue fibres along the paths of least
resistance and blunt conical trocars that dilate an expandable
sheath inserted over a Veress needle. Bladeless trocars dilate
rather than cut the tissues of the abdominal wall although a skin
incision is still needed.
Optical trocars, either with or without a blade, are composed of a

transparent distal shaft into which the 0 laparoscope is inserted
to visualize the tissue planes as the trocar goes through the
abdominal wall. They are especially useful in obese patients with
a deep abdominal wall.
Literature has shown no advantage of the use of a specific
trocar design to minimize major trocar-related complications.
Rules common to all techniques of access
 Never point towards the great vessels.
 Always look before you insufflate.

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 ABDOMINAL SURGERY

 Avoid rapid insufflation in elderly or ill patients.
 Do not attempt to gain access near a scar.
Smoke evacuators
High-flow suction and filtering devices are used to remove, or
capture, the smoke and toxic chemicals generated at the surgical
site during the use of lasers and electrosurgery. Smoker filters are
attached directly to a trocar, electrosurgical unit pencil or suction
wand. Other systems include cell foam smoke capture technol-
ogy and electromechanical evacuation systems.
Closure of port sites
To avoid trocar-site hernia (incidence 0.75%), it is recommended
that all trocar sites above 10 mm in adults and all 5 mm port sites
in child be closed, integrating the peritoneum into the fascial
closure.5 In obese patients, where closure of ports may be diffi-
cult, the use of laparoscopic closure devices such as Endo CloseÔ
Trocar Site Closure Device can be used to safely place suture
under direct vision intraperitoneally.
Handeassisted laparoscopic surgery
Hand-assisted laparoscopic surgery (HALS) is so-called because
the surgeon inserts a hand into the abdomen through a hand-
port device to assist with surgery while the pneumo-
peritoneum is maintained. This has been applied to many sur-
gical procedures, from colorectal resections to nephrectomy and
aneurysm surgery. Hand-assistance has the advantage of
allowing tactile feedback and safe retraction, facilitates dissec-
tion, tumour assessment and anastomosis. It is still used by
many surgeons.
Single incision laparoscopic surgery (SILS)
The introduction of multi-instrument access ports has enabled
laparoscopic surgery through a single incision, i.e. SILS.
(Figure 6). Many procedures have now been performed by SILS
and include appendicectomy, cholecystectomy, inguinal hernia
repair, gastric banding and sleeve gastrectomy, colectomy and
hysterectomy. Potential benefits include reduced postoperative
pain, improved cosmesis and postoperative recovery.
Difficulties associated with this technique include loss of
triangulation and clashing of instrumentation and considerable
experience with standard laparoscopic surgery is required.
Curvilinear and angulated laparoscopic instruments are now
available that allow more intracorporeal triangulation and
improve surgical ergonomics.
A systematic review including eight studies involving 547
patients compared SILS for colorectal cancer with multiport
laparoscopic colectomy. Concluding SILS had less postoperative
pain with no significant reduction in length of hospital stay and
acceptable margin resection in both techniques.7

Minimal access to the retroperitoneum or extraperitoneal

space
Retroperitoneoscopy, with dissection of the retroperitoneal space
via a balloon catheter, balloon trocar or finger dissection with a
hand-port, allows excellent access to the kidneys (e.g. in donor
nephrectomy for renal transplantation), adrenal glands, blood
vessels, lymph nodes and the lumbar spine.
Access to the extraperitoneal space for mesh repair of bilateral
or recurrent inguinal hernia is achieved via a sub-umbilical
transverse incision, starting in the midline and extended 2 cm
laterally. The anterior rectus sheath is identified, incised in the
line of the incision, and the rectus muscle retracted laterally to
reveal the posterior rectus sheath. The extraperitoneal space is
then developed manually with the laparoscope or with a balloon
dissector.

Needlescopic surgery
Needlescopic surgery is defined as a procedure using less than
3 mm laparoscopic instruments. A systematic review included 16
trials and a total of 1549 patients comparing laparoscopic and
needlescopic cholecystectomies, concluding that using 2-mm
ports led to longer operative time and a higher rate of conver-
Figure 6 (a) Single incision laparoscopic surgery (SILS) port (Copyright
sion. There was no difference in the number of intraoperative _2014 Covidien. All rights reserved. Used with the permission of
and postoperative complications. However, cosmetic appearance Covidien). (b) TriPort in use (Copyright _ all rights reserved to Olympus
and less postoperative pain were noted in the needlescopic Keymed Group Ltd. Use of this photo needs a prior written permission
group.6 from Olympus KeyMed Group Ltd.).

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 ABDOMINAL SURGERY

Natural orifice transluminal endoscopic surgery (NOTES)

NOTES is a term coined in 2005 to describe ‘scarless surgery’.
Access to the peritoneal cavity is gained by a viscerotomy
through either stomach, oesophagus, vagina, rectum or bladder.
An operating endoscope is inserted for peritoneoscopy and flex-
ible instruments used to perform the surgical procedure. Diffi-
culties relate to achieving adequate triangulation, retraction and
the quality of suitable endosurgical instrumentation. There are
concerns about the consequences of causing a perforation in an
otherwise normal organ for access and subsequently achieving a
secure closure.
A total of 533 patients who underwent NOTES procedures
were included in the EURO-NOTES Clinical Registry. A majority
performed in hybrid fashion with laparoscopic assistance. The
techniques were deemed practicable and safe alternatives to
conventional laparoscopic procedures.8 Bulian et al. analysed
217 hybrid NOTES appendectomies, concluding it is a safe
Figure 7 Transanal endoscopic surgery (TES) operating room setup (A)
technique. The data compared the transvaginal (TVAE) and Camera, (B) light source, (C) lens clearing fluid, (D) insufflation tubing,
transgastric (TGAE) procedures directly. The median procedural (E) laparoscopy tower, (F) operating instruments, (G) suction, (H) ports,
time (TVAE: 35 minutes vs TGAE: 96 minutes; p < 0.001) and (I) operating anoscope, (J) TES scope holding arm.
conversion to laparotomy rate (TVAE: 0% vs TGAE: 5.6%;
p < 0.023) were significantly less after TVAE.9 microscopic margins in comparison with transanal excision (OR,
Hybrid NOTES combines access through a natural orifice with 5.281; 95% CI, 3.201e8.712; p < 0.001).11
small-sized abdominal trocars. Steinemann et al. conducted a
meta-analysis of 2186 patients, comparing pain and morbidity in Robotic laparoscopic surgery
hybrid NOTES and standard laparoscopy. The score for cosmetic
Technical limitations can be an issue when surgeons perform
satisfaction was higher after NOTES with reduced postoperative
complex minimally invasive operations. Robotic surgery has
pain scores, shorter hospital stay and a lower complication rate
been designed specifically to overcome problems associated with
compared with standard laparoscopy.10
the positioning of the surgeon, range of movement of in-
Other procedures described include PEG rescue, cystgas-
struments, visualization and dexterity.12 Robotic systems allow
trostomy and trans oesophageal myotomies in achalasia. At
for technical advantage over traditional laparoscopic techniques
present NOTES remains an interesting and developing new
as they have 3D imaging, tremor filter, and articulated
technology that is emerging as a complimentary new clinical
instruments.
practice.

Litigation and abdominal access

Endoscopic management of early cancers
Valid consent is essential in minimizing litigation. All common
Promotion of education and effective screening tools has led to
and relevant risks need to be discussed. The risk of complications
early detection of cancers that can be managed endoscopically by
related to laparoscopic entry is between 0.05% and 0.3%; how-
surgeons. Endoscopic full-thickness resection (EFTR) is a pro-
ever, if an injury does occur than mortality rate could be high as
cedure that makes it achievable to access intramucosal and larger
13%.13 Cases such as retroperitoneal vascular injury, bowel
carcinomas using endoscopic mucosal resection (EMR) and
perforation, wound herniation and air embolus has been
submucosal tunnelling endoscopic resection (STER). EFTR uses a
described within literature. Laparoscopic trocars are the most
flexible endoscope with electric scalpels for ultra minimally
common device named in malpractice injury claims associated
invasive full-thickness local excision for gastrointestinal cancer.
with laparoscopic procedures, representing one-third of all
Many studies support this approach.
claims.
Transanal endoscopic surgery (TES) is a new minimally
Safety shields, retracting or optical trocars do not prevent
invasive technique that allows resection of premalignant lesions
injury, however the potential complications associated with
in the mid-to proximal rectum through transanal access
blind insertion of the Veress needle and primary port make the
(Figure 7). TES does not address loco-regional lymph nodes;
open technique the first-choice method for some surgeons.
therefore it is used for low-risk tumours. However, allowing for
oncologic cure while maintaining postoperative bowel function.
Laparotomy
TES allows better visibility and access to the rectum, requiring
no abdominal incisions and shorter hospital stay. TES has shown There must be sufficient exposure to allow the procedure to be
to have a lower recurrence rate and lower cost compared to local done efficiently and safely. The required exposure depends on:
transanal excision of rectal neoplasms. A meta-analysis  the diagnosis (if known) and the planned surgery
compared six series and 927 local excisions were identified.  whether surgery is elective or emergency
Transanal endoscopic microsurgery had a higher rate of negative  the speed at which exposure must be achieved

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 ABDOMINAL SURGERY
 whether exposure can be increased if required by extend-
ing the incision
 previous surgical history, scars and body habitus.
 potential placement of stomas.
Classification of laparotomy incisions
Midline vertical incisions allow rapid access, with minimal blood
loss, and are easily extended. Non-midline incisions can be
muscle splitting or cutting. Paramedian incisions provide access
to more lateral structures and, in theory, are more secure as the
rectus can support the re-approximated anterior and posterior
sheath incisions. However, they take longer, are associated with
more blood loss, and risk denervating or devascularizing the
muscle medial to the incision. Incisions placed more transversely
in Langer’s lines offer comparable access to focused intra-
abdominal structures as vertical incisions and can have fewer
complications (pain, respiratory complications, dehiscence) as
well as an excellent cosmetic result, but are more difficult to
extend.
The incision: pointers and pitfalls
Whether to incise around or through the umbilicus when car-
rying out a midline laparotomy is surgical preference. The easiest
place to enter the peritoneum with a midline laparotomy wound
(having incised skin, subcutaneous fat, and the linea alba) is just
below the umbilicus. The peritoneum is grasped between two
clips, elevated and incised, and the peritoneal contents fall away
as air enters the abdominal cavity. The inner aspect of the inci-
sion line is palpated to ensure that there are no adherent struc-
tures, and the incision completed.
The falciform ligament will be encountered in midline in-
cisions that extend above the umbilicus. Rather than incising
the falciform (which increases the risk of bleeding) it is more
elegant to dissect to one side or other in the extraperitoneal
plane and enter the peritoneal cavity lateral to the falciform
ligament. Injury to the bladder must be avoided for midline
incisions that extend towards the symphysis pubis. The po-
tential requirement and site for a stoma should also be
considered. One must avoid inadvertent enterotomy when
entering the distended abdomen, or where there have been
multiple previous laparotomies. For this latter group, it is
preferable to extend the incision onto the unscarred abdominal
wall and enter the peritoneal cavity there because there is less
risk of damaging adherent bowel. The incidence of inadvertent
enterotomy during reopening of the abdomen can be as high as
20%. Patients with inadvertent enterotomy during adhesiolysis
are more at risk of postoperative complications, relaparoto-
mies, ICU admissions, use of parenteral nutrition and hospital
stay.
Optimizing access at laparotomy
Access is optimized and maintained by skilled assistance and
retraction. Retractors can be reusable or disposable and vary
from the assistant’s hand to:
 hand-held retractors (Deaver’s, Morris’, St Mark’s)
 self-retaining retractors (Goligher’s, Balfour)
 ring retractors (TurnereWarwick)
 fixed retractors (Thompson, Omnitract)
 lone star self-retaining retractors.
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Wound-edge protection devices (WEPDs) are a simple and
effective intervention that hold promise to reduce SSIs. Chen
et al. conducted a meta-analysis on WEPDs in gastrointestinal
surgery. Sixteen studies with 3663 patients were included. The
study illustrated that Double-ring WEPDs significantly decreased
the risk of SSI after gastrointestinal and biliary tract surgery.14 It
also provides an element of wound retraction.
Strategies to control unwanted viscera from entering the
operative field include systematic packing with swabs, or using a
bowel bag, which also limits loss of heat and fluid from exter-
nalized bowel.
Postoperative pain and wound healing
The complications of laparotomy are shown in Box 2.
Obtaining adequate exposure must be balanced with mini-
mizing postoperative pain. The size and location of the incision is
paramount, but the strategy for relief of postoperative pain must
be considered preoperatively and should be multimodal.
Pharmacological methods include:
 local anaesthetic blockade at time of surgery or by infusion
catheter postoperatively, i.e. rectus sheath catheters
 spinal injection or epidural catheter
 patient-controlled analgesia devices to deliver intravenous
boluses of opioid
 regular or prn use of analgesics (WHO analgesic ladder)
including paracetamol, NSAIDs, opioids
Non-pharmacological methods are also important including
explanation, reassurance, education, emphasized in the context
of enhanced recovery or fast track surgical pathways.
Closure of laparotomy
Tensile strength never rises to higher than 93% of the strength of
unwounded fascia. Careful closure of wounds avoids the com-
plications of wound dehiscence, infection or incisional hernia.
Traditionally, mass closure involves 1-cm bites of tissue, 1 cm
apart, at least 1 cm from the wound edge (through all layers of
the incision apart from the skin). Systematic review and meta-
analysis have concluded that a continuous closure technique
with none or slowly absorbable (e.g. nylon, PDS) sutures is su-
perior to interrupted. Studies have shown that the most impor-
tant factor is using a suture length to wound length ratio or four
to one (Jenkins’ rule). However, a recent randomized-controlled
trial assigned 560 patients to small bites (5 mm by 5 mm) and
large bites (1 cm by 1 cm) continuous laparotomy closure. At 1-
Complications of laparotomy
Specific
Immediate: injury to adherent intra-abdominal structures
Early: wound infection, wound dehiscence
Late: incisional hernia, pour cosmetic result, adhesions
General
Early: cardiovascular (myocardial infarction/arrhythmias) respiratory
(basal atelectasis, pneumonia, deep vein thrombosis/pulmonary
embolism), renal failure
Box 2
7 Ó 2018 Published by Elsevier Ltd.
 ABDOMINAL SURGERY
year follow-up, 57 (21%) of 277 patients in the large bites group
and 35 (13%) of 268 patients in the small bites group had inci-
sional hernia.15
The skin is closed with clips, interrupted non-absorbable su-
tures, or a subcuticular absorbable suture (the first two options
are more appropriate if infection is present). Skin glue can be
applied and has shown to reduce risk of wound infections. Care
must be taken to achieve a good cosmetic appearance.
Occasionally, abdominal wound closure is not possible, e.g.
after dehiscence or loss of abdominal wall volume by necrotizing
infection, as part of damage-control surgery or management of
abdominal compartment syndrome. Strategies for management
including temporary abdominal closure methods are discussed
elsewhere.
Conclusion
Good access is fundamental to successful surgery, but optimizing
access requires careful planning. This is relatively straightfor-
ward for elective surgery but, for emergencies, careful preoper-
ative examination, patient positioning and an appropriately sited
incision allows the operation to proceed smoothly and success-
fully. Adherence to safe principles is more important than the
choice of access. A and meta-analysis. Dis Colon Rectum 2015 Feb; 58: 254e61.
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