Diagnostic Peritoneal

Lavage

By
Dr. Mohamed Kamara
Plan
 Assessment And Diagnostic Findings
 Introduction  Seat-Belt Sign
 FAST, CT-SCAN, DPL  Cullen Sign
 Indication For Dpl  Kehr’s Sign
 Blunt Trauma  Balance’s Sign
 Penetrating Trauma  Grey-Turner’s Sign
 Contraindication  Labia And Scrotum
 DPL Techniques  Handlebar Sign
 Open Technique  Materials
 Close Technique  Advantages And Disadvantages
 Preferred Site Of DPL  Surgical Management Decision
 Standard Criteria For A Positive DPL  
 Criteria Of Positive DPL For A Bloody Lavage
Effluent
 DPL Procedure: Open And Close Technique.
 What is DPL?

After fluid is instilled, the bag is placed onto the floor to allow the intraabdominal fluid to return. 30% of the
original amount of instilled fluid is required for an adequate sample.
Introduction
Diagnostic peritoneal lavage (DPL):
 Is an invasive, rapid, and highly accurate test for evaluating
intraperitoneal hemorrhage or a ruptured hollow viscus.
 Plays a role in both blunt and penetrating abdominal trauma.
 First described in 1965.
 Replaced the four-quadrant abdominal tap, boasting a higher
sensitivity and specificity in identifying intraabdominal injury.
 Today DPL is performed less frequently, as it has been replaced by
focused abdominal sonography for trauma (FAST) and helical
computed tomography (CT). Yet, each of these diagnostic modalities
has unique advantages and disadvantages.
 Is the only invasive test of the three, but while lacking organ
specificity it remains the most sensitive test for mesenteric and hollow
viscus injuries
  FAST exams are rapid, non-invasive, and can be repeated
multiple times throughout the resuscitation period. They are
more user-dependent than DPL or CT scanning.
 Both fast and DPL ineffectively evaluate retroperitoneal and
diaphragmatic injuries and poorly identify solid organ
FAST, DPL injuries.
 Abdominopelvic CT scanning still requires a
AND CT hemodynamically normal patient, is costly, and carries a

SCAN small but significant lifetime risk of malignancy.

 However, CT scanning reliably diagnoses solid organ
injuries and evaluates the retroperitoneum, but its sensitivity
and specificity for blunt bowel and mesenteric injuries is not
superior to DPL.
 As a result of these differences, all three tests continue to
play important roles when evaluating a trauma patient for
abdominal injuries.
 Since DPL is performed less commonly today, a review of its
indications, technique, and interpretation is pertinent.
 Blunt abdominal trauma (i.e., motor vehicle
crashes, falls, blows, or explosions)

Penetrating abdominal trauma (i.e., gunshot

wounds, stab wounds)

Abdominal catastrophe
INDICATION In blunt abdominal injuries, DPL has a number of indications:
S OF DPL  Hemodynamic instability despite resuscitation.

 Hypotension with evidence of abdominal injuries .

 Multiple injuries and unexplained shock.

 Potential abdominal injuries in patients who are unconscious, intoxicated, or

paraplegic.

 Equivocal physical findings in patients who have sustained high-energy forces

on the torso.
  Patients with asymptomatic anterior abdominal
stab wounds.
 Patients with an anterior stab wound to the
INDICATION
abdomen who are hemodynamically normal and
OF DPL IN
have no signs of peritonitis are evaluated with a
PENETRATI
NG local wound exploration and if positive, a DPL

TRAUMA is performed.
 Patients with flank wounds that track anteriorly
are also candidates for DPL if the local wound
exploration is positive
 CONTRAINDICATIONS
 Clear indication for exploratory laparotomy.
Relative CIs:
 Previous exploratory laparotomy
 Pregnancy
 Obesity
 Infections
 Coagulopathy
 DPL TECHNIQUES
Two
 Closed Technique
 Opened Technique
 
 PREFERRED SITE OF DPL
– Standard adult: Infraumbilical midline
– Standard paediatric: Infraumbilical midline
(In cases of Pelvic fractures, pregnancies, Previous lower mid-line incisions, the Supra-umbilical
incision is used.)

– 2ed &3ed trimester pregnancy: Suprauterine/supra-umbilical midline

– Midline scarring: Left lower quadrant
 STANDARD CRITERIA FOR A POSITIVE DPL

– If > 10 mL of blood is aspirated, the procedure stops because intraperitoneal

injury is likely:

• Has a positive predictive value of > 90% for intraperitoneal injury

– If the DPL detects no or < 10ml of blood

• Perform a lavage of the peritoneal cavity with normal saline and the effluent is

sent for laboratory evaluation.

 CRITERIA OF POSITIVE DPL FOR A BLOODY
LAVAGE EFFLUENT

• RBC count greater than 100,000/mm3

• WBC >500/mm3

• Amylase value greater than 175 IU/dl

• Detection of bile, bacteria, or food fibres

 PROCEDURE DPL
Diagnostic Peritoneal Lavage Is actually a 2 Step Process.
Step 1. DPA (closed).
• Patient supine
• Landmark is 2 finger widths below umbilicus
• Local freezing, puncture skin 30-degrees to the head
• Seldinger technique to introduce a DPL catheter
• Aspirate using 30cc syringe
• If 10cc frank blood or more is aspirated,
you are done, patient needs to go to the
OR. • If the DPL is negative, you proceed
to Step 2…
Step 2. DPL.
• Hook up 1L of Ringer’s to the peritoneal catheter, and squeeze
into the abdomen.
• Once infused, put the empty Ringer’s bag on the floor, and let it
back-fill via gravity
• Send off 10cc for analysis, if 100,000 RBC/cc it is positive
 •UNSTABLE

BLUNT • Is There Peritonitis? YES Or NO.

TRAUMA • Is There A Positive Fast? YES Or NO

UNSTABL
E • Is There A Positive DPL? YES Or NO

PATIENTS • CT Scan Is Your Friend.

 Inspection – Obvious Signs Of Injury, Including
Penetrating Injuries, Bruises, Abrasions

Assessment and Auscultation – Bowel Sounds

Diagnostic
Findings
Further Abdominal Assessment:

- Signs Of Peritoneal Irritation: Progressive Abdominal

Distention, Involuntary Guarding, Tenderness, Pain,
Muscular Rigidity, Rebound Tenderness
 SEAT-BELT SIGN

Tear/ avulsion of mesentery

Rupture of small bowel or colon
Rib fracture
 CULLEN SIGN
Bluish discoloration around
umbilicus Diffusion of blood
along periumbilical tissues or
falciform ligament
Hemoperitoneum
Severe pancreatitis
 KEHR’S SIGN
•Referred Pain, Left Shoulder
Irritation Of The Diaphragm
(Splenic Injury, Free Air, Intra-
abdominal Bleeding)
 BALANCE’S SIGN

Dullness on percussion of the left

upper quadrant ruptured spleen
GREY-TURNER’S
SIGN

Bluish discoloration of the flanks

Retroperitoneal Hematoma
haemorrhagic pancreatitis.
 LABIA AND SCROTUM

Pooling Of Blood From Abdominal And Pelvic Cavities.

Handlebar Sign
MATERIALS
 CLOSED
TECHNIQUE
Material For opened
Technique
 SEMI-OPEN
TECHNIQUE
 • Advantages
– Performed bedside
•– Widely available
– Highly sensitive for
Advantages •hemoperitoneum – Rapidly performed
• Disadvantages
and •–  Invasive
Disadvantages •–  Risk for iatrogenic injury (<1%)
•–  Low specificity (many false
positives)
•– Does not evaluate the
retroperitoneum
 –  Catheter in preperitoneal space
Causes for –  Catheter insertion through an
abdominal wall hematoma or inadequate
false negative hemostasis
DPL •–  Fluid in compartment 2 adhesions
•–  Diaphragmatic tear, so fluid goes into
thoracic cavity
•–  Obstruction of fluid outflow (e.g., by
omentum)
SURGICAL ANAGEMENT
Making Decision
Is the patient stable or unstable?
 STABLE
PATIENTS

Stable
UNSTABLE
PATIENTS
Thank you for your
attenion!!!