Puncture of an Abdominal Cavity

· Puncture of an abdominal cavity or laparocentesis-puncture of an anterior abdominal wallby a

trocar.

· The puncture is carried out with the therapeutic purpose for evacuation of a liquid at an ascites
with the diagnostic purpose for detection of damage of organs of an abdominal cavity at a blunt
trauma of an abdomen, small penetrating wounds, and also as one of stages of laparoscopy

· The laparocentesis is for the patient with a abdominal distention, multiple postoperative scars
on a anterior abdominal wall, as the probability of damage of internal organs is very high.

· Position of the patient sitting, seriously ill patients-edgewise.

· Puncture made in points: on middle of distance between umbilicus and pubis on a median
line,little laterally from middle of distance between a umbilicus and anterior superior iliac splne

· Previously a urinary bladder emptied in order to prevent its wound

· For the prevention in the further ascetic fistula, infection of abdominal cavity the skin on a place
of a puncture should be displaced.

· By tip of a scalpel a small incision of a skin is made, through which by a trocar other layers of an
abdominal,wall are pierced and it is entered in an abdominal cavity. The stilets taken out. The
liquid should be let out slowly, observing for pulse and respiration of the patient. (therapeutic
purpose)

· At a diagnostic puncture, if the blood, exudate, bile, intestinal contents follows from an
abdominal cavity, means the organ is damaged. At this time the operation is stopped.

· Otherwise the technique of a "searching" catheter is applied. Into a tube of a trocar a

chlorvinyl catheter with apertures on the end introduced. A catheter entered in the direction
of a liver, lateral canals, to a pelvis. Thus the external end of a catheter is connected with a
syringe and the aspiration is made.

· It is possible to introduce into abdominal cavity 10 ml of a sterile solution (Novocainum,

normal saline solution etc.), and then it to aspirate. This method names as lavage of
abdominal cavity. If in a solution the impurity of a blood, intestinal contents, urine, muddy
exudate are found out, it proves damage of internal organs.

Complications: damages of an intestine (at presence of adhesive process), formation of an ascetic

fistula, infection of an abdominal cavity.

LAPROSCOPY

· Laparoskopy-optic-tool visual inspection of an abdominal cavity and its organs in the diagnostic
purpose.

· It is indicated for detailed survey of an abdominal cavity with the purpose of detection of
damages of organs, tumors and inflammatory processes, detection of a portal hypertension,
clottage of mesenteric vessels etc.

· It is counterindicatied for the extremely serious patient, at the phenomena of a meteorism and
adhesive process in an abdominal cavity.

· Troacar of a laparoscope are entered same as at a laparocentesis. For expansion of an abdominal

cavity into it a gas (air, Oxygenium, carbon dioxide) introduced through the special cock on a
trocar or through a special needle from a set of a laparoscope. For introduction of gas usually
use the special apparatus allowing it to sterilize. Then an optical tube entered for
survey.Illumination of an abdominal cavity make by the lighter paired to an optical tube by
means of a flexible light guide. That it is good to examine an abdominal cavity, it is necessary to
change a position of the patient on an operating table.

The Surgical Accesses

THE REQUIREMENTS TO SURGICAL INCISION

· The cut for an access to organs of an abdomen should satisfy to the following requirements: the
incision should be in a projection of an organ and provide the most brief way to it

· the size of a section should provide an easy approach to an operated organ:

· the incision should minimally traumatize soft tissues, vessels and nerves to provide formation of
strong postoperative scar,

· the incision should provide good cosmetic result.

For an access to organs of an abdominal cavity there is a plenty of incisions. Depending on a direction of
an incision to an median line of a body the abdominal sections subdivide on longitudinal, transversal,
oblique and angular

Longitudinal incisions
 · The median laparotomy (maline incision) is carried out on a linea alba of an abdomen Depending
on a position of incision in relation to a umbilicus are distinguished superior, medial and inferior
median laparotomy.

· At the superior midline laparotomy the incision is carried out between a xiphoid process and
umbilicus. A direction of a incision from a xiphoid process to the umbilicus (to not damage a
liver).

· The inferior midline laparotomy is carried out from a pubis up to a umbilicus (direction of a
incision from a pubis to not damage a urinary bladder)

· The middle midline laparotomy is carried out with round of a umbilicus at the left (so that the
manipulations in an abdominal cavity were not prevented by a round ligament of a liver). The
midline laparotomy has received the greatest application, as gives the following

advantages:

· quickness of performance

· a wide access to the majority of organs of an abdominal cavity

· does not damage a muscle, vessels and nerve

· an insignificant bleeding

· in case of necessity can be prolonged both up, and from top to bottom;

· the incision can be easily closed.

Disadvantages of a incision

· that the postoperative scar has a strong tension(as is a place of connection of three pairs wide
muscles) and the median initially is the badly strengthened and poorly blood supplied part of a
anterior abdominal wall - therefore postoperative hernias may occur

A paramedian incision

· carry out according to internal edge of a rectus abdominis muscle,the anterior leaf of its sheeth
is dissectied together with a parietal peritoneum.

The advantage of this incision consists in

· formation of strong postoperative scar, as the rectus muscle is displaced and also incisions of
 anterior and posterior layers of a sheeth of rectus muscle do not coincide.

disadvantage

· is the restriction of length

transrectal Incision

Anterior and posterior walls of a sheeth of a rectus muscle are dissectied, and muscle stratify on a course
of fibers.

The advantage

· same as the paramedian incision the muscular tissue rich vessels, quickly grows together and
strong scar formed(.However, at wide incisions the nervous branches going to medial
departments of a muscle are damaged. Development Fan antrophy of medial departments of a
muscle and occurrence of a postoperative hernia subsequently is possible).

A disadvantage

· is the restriction of length.

A pararectal incision.

· An example the Lenander incision- made parallel to lateral edge of a rectus muscle laterally and
below umbilicus. Anterior wall of a sheeth of a rectus muscle a dissectied, edge of the muscle
allocate medially and then posterior wall cut together with a parietal peritoneum. The Incision is
applied at appendectomy

The advantages and disadvantages are same as at transrectal incision.

The oblique incisions.

· This cuts usually made in the superior part of a anterior abdominal wall - parallel to edge of a
costal arch in the inferior part - parallel to inguinal ligament and little above it or under an angle
to it.

· they used mainly for accesses to a liver, gallbladder, bile ducts. vermiform appendix, sigmoid
colon, etc
The transverse incisions

· made with crossing of one or two rectus muscles above or below umbilicus.

· They provide a wide access to organs of an abdominal cavity, strong postoperative scar. However
they applied less often others in view of the greater difficulty of their performance and suture (in
comparison with a median laparotomy)

angular incision

· made if necessary prolongations or enlargement of the before made incision in the other
direction under angle (for example, at the superior median laparotomy as access to a liver the
incision may prolonged perpendicular to left costal arch).

The combined incisions

· are the incisions at which open two cavities - abdominal and thoracic (thoracoabdominal
accesses).

· They are applied, if necessary of wide access to organs of an abdominal cavity (at a gastrectomy,
splenectomy, resection of a liver and other operations), at a simultaneous operations on organs
of both cavities (for example, at thoracoabdominal wounds, when the organs of a abdomen and
thorax are injured), at operations on organ posed in both cavities (for example, at an
esophagoplasty).

The alternating (gridiron, muscle-splitiing) incision -

· Incision at which direction separations of tissues in different layers is changed on a course of

performance of cut.

· In each layer the direction of a section of tissues depended from a direction of muscular or
aponeurotic fibers, that is incision is made on a course of muscular or aponeurotic fibers.

The advantage of this incision -

· muscles do not cut and due to discrepancy of lines of separation of muscles, the abdominal wall
keeps after operation the durability

Example: McBurney-Volkovitch incision for appendectomy. Pfannenstiel incision for operation in

gynaecology

Disadvantage of alternating incision -

 · small access,

The basic rules, which are necessary for keeping at all laparotomies and operations on organs of an
abdominal cavity

At operations on organs of an abdominal cavity it is necessary to keep a sequence in performance of

stages of operation and certain rules of a laparotomy:

• The incision of a anterior abdominal wall should be made according to layers and according to layers to
sew up (sequence of dissected layers depends on a kind of a incision see above).

· For preservation from pollution of an abdominal wall by contents of an abdominal cavity a wound
covered by towels.

· Most responsible stage of a laparotomy - opening of a peritoneum. A peritoneum open always under
the control of an eye in order to prevent casual of organs of an abdominal cavity. The peritoneum is
grasped and rises by two anatomic forcepses. Having convinced that in the formed thus fold of a
peritoneum there are no organs,the peritoneum is dissected and fixed to towels by Mikulicz
forcepses.

· A wound of abdominal wall stretch by laminar hooks or retractors. It is necessary to keep up, that
under branches of hooks the loops of an intestine, omentum and other organs should do not
traumatize. In an abdominal cavity work only by anatomical forcepses

· The revision of an abdominal cavity should be carried out strictly methodically and in the certain
sequence depending on its purposes.

• The infringement of an integrity of a serousa of a organ should be well-timed is noticed and is

liquidated (sew).

• It is desirable to operate on the emptied organ of an abdominal cavity.

· To facilitate performance of operation and to prophylactic of infection of an abdominal cavity the

organ take from it and operated outside of an abdomina cavity. If it is impossible, it is carefully
covered by napkins in depth of a wound isolating thus from other organs.

· For preservation from a desiccation the taken organ covered by wet napkins.

· After applying internal infected series of an intestinal sutures closing a lumen of a organ, it is
necessary to change covering towels and instruments, the operating brigade processes (washes)
gloves by a disinfectant solution or changes them.
· Upon termination of operation reliability of a hemostasis is checked, whether the napkins, gauze
globules, instruments are left in it. The abdominal cavity is carefully drained from a blood, exudate.

· if it is necessary to put in an abdominal cavity a drainage or gauze tampons, they are recommended
to prevent a divergence of sutures make this not through an operational wound, and through a
contraperture - an additional incision away from basic