Exploratory laparotomy

The procedure and nursing considerations

Patients undergoing exploratory laparotomy surgery (ex-laps) can present in vary varied conditions. Some will be bright and alert, others may be in critical conditions. It is always worth considering bloods prior to the anaesthetic for all of these patients, regardless of their presentation as they may be compensating and may require interventions to help stabilise prior to anaesthetic. 

Ensure the patient is on a heat pad with blankets and is pre-oxygenated prior to intubation. If it is a cat, make sure that they are given a full 30-90 seconds between giving Intubeaze and intubating to avoid risk of trachaeal irritation.

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If the patient is critical, it could be worth discussing placing a central line at this stage as well if you have the equipment and capabilities. This is especially useful if the patient will be having frequent blood samples over the next few days.

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Have the patient on their back for clipping - sometimes they need sandbags to keep them steady. A full ex-lap can be incised the entire length of the abdomen, so you may need to clip fur up to the 10th/11th rib and down to the very base of the pubis. The edges will need to be clipped far back too, to reduce risk of any fur entering the abdomen. Clip away the fur using size 40 blade clippers and clean the surgical site with your scrub of choice. Sometimes it is useful to have a dedicated vacuum to remove fur from the surgical site prior to scrubbing. 

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At this stage it is recommended to place a urinary catheter and drain the bladder so that it isn't full whilst the surgeon is in the abdomen. For male dogs this procedure is straightforward enough, but this can prove more difficult in bitches. I will leave the urinary catheter in place throughout surgery and, for male dogs, secure it to the left thigh to keep it out of the way. (Often the incision will run along the right-hand side of the penis).

I recommend performing a local line block along the incision area at this stage using a 1-2mg/kg dose of bupivicaine (1mg/kg MAXIMUM for feline patients). Any bupivicaine left in the syringe can be kept for a splash block at the point of closing the surgical site.

Move the patient to the surgical table and postion on their back. If you have use of a vacuum mat, then these can be great to keep patients warm , supported, and stable throughout the surgery. Patients often lose a lot of heat during ex-laps due to the large clipped patch and the opened abdomen, so I would always recommend using active warming devices such as Bair Huggers to keep them warm. It is advised to wait until the patient is fully draped before turning on forced air warming devices. Then give another scrub and prep the area using a final cleaning stage e.g. ChloraPrep. I also like to place several incontinence sheets around the patient and the floor to help keep the theatre as clean and dry as possible - especially when it comes to lavaging the abdomen.

The surgeon can then perform the ex-lap procedure.

All abdominal surgeries have a risk of bleeding due to numerous vessels being present. Ensure that your patient is on IV fluids throughout the surgery (surgical maintenance rate is 5ml/kg/hr in canines and 3ml/kg/hr in felines) to help with blood pressure and have bolus rates prepared and written down in case of a bleed.

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Ideally the patient will have recieved sufficient analgesia with their premedication as well as an adjuvant analgesia prior to surgery. However, abdominal surgery can prove more painful for some patients than others. Watch out for changes in heart rate, respiration rate, or blood pressure at this point. Paracetamol can be given to canine patients only if it hasn't been given already (at a dose of 10-20mg/kg slow IV) or, if very severe pain response is seen, a one off dose of ketamine can be used (0.5mg/kg IM or slow IV) or fentanyl (5μg/kg slow IV). Be mindful for signs of apnoea if giving ketamine or fentanyl. Fentanyl can also slow heart rate too so be aware of this if giving.

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If the surgeon has entered the gastrointestinal tract, then fresh gloves and instruments are required once this area has been closed to maintain abdominal sterility.

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It is recommended to fully lavage the abdomen after any gastrointestinal surgery is performed as this can reduce bacterial load and help warm the patient. If any parts of the gastrointestinal tract have been opened, then it is recommended to flush through with up to 200ml/kg of sterile saline. Ensure any flush is warmed before using it (I like to have a bucket of warm water that the irrigating fluids can sit in to stay warm during surgery). 

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Before finishing surgery it is worth considering placing a feeding tube if the patient has not eaten in several days as nutrition plays a significant role in recovery - better to do it now and not need it, instead of in a days time!

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Remember to lubricate the eyes during surgery and on recovery to reduce risks of corneal ulcers forming and keep the patient wrapped up warm.