By definition, an exploratory laparotomy is a laparotomy performed with the objective of obtaining information that is not available via clinical diagnostic methods. It is usually performed in patients with acute or unexplained abdominal pain, in patients who have sustained abdominal trauma, and occasionally for staging in patients with a malignancy.
Once the underlying pathology has been determined, an exploratory laparotomy may continue as a therapeutic procedure; sometimes, it may serve as a means of confirming a diagnosis (as in the case of laparotomy and biopsy for intra-abdominal masses that are considered inoperable). These applications are distinct from laparotomy performed for specific treatment, in which Dr. B C shah plans and executes a therapeutic procedure.
With the increasing availability of sophisticated imaging modalities and other investigative techniques, the indications for and scope of exploratory laparotomy have shrunk over time. The increasing availability of laparoscopy as a minimally invasive means of inspecting the abdomen has further reduced the applications of exploratory laparotomy. Nevertheless, the importance of exploratory laparotomy as a rapid and cost-effective means of managing acute abdominal conditions and trauma cannot be overemphasized.
Indications
Four primary indications for an exploratory laparotomy are noted, as follows.
Acute-onset abdominal pain and clinical findings suggestive of intra-abdominal pathology requiring emergency surgery
In these conditions, exploratory laparotomy is carried out both to diagnose the condition and to perform the necessary therapeutic procedure.
Peritonitis
Patients with clinical features of peritonitis may have pneumoperitoneum on erect chest and abdominal radiographs. They usually have a perforated viscus, most commonly the duodenum, stomach, small intestine, cecum, or sigmoid colon. Exploratory laparotomy is done first to determine the exact cause of pneumoperitoneum, followed by the therapeutic procedure. In the absence of pneumoperitoneum, appendicular perforation and intestinal ischemia are possible diagnoses; a high index of suspicion for possible intestinal ischemia should be maintained.
Intestinal obstruction
Patients with vomiting, obstipation, and abdominal distention are likely to have intestinal obstruction. Abdominal radiographs in these patients may reveal dilated intestinal loops and air-fluid levels. Hernia, especially an incarcerated inguinal hernia, should be ruled out as a possible cause of the obstruction.
Intra-abdominal collections
Patients with pain in the abdomen and fever may have intra-abdominal collections. These are usually detected by means of ultrasonography or computed tomography (CT) and can often be managed percutaneously. A persistently high aspirate or the presence of enteric contents may suggest perforation, and laparotomy may be required to control the source.
Abdominal trauma with hemoperitoneum and hemodynamic instability
Hemodynamically unstable trauma patients with hemoperitoneum should undergo exploratory laparotomy without any delay. They are likely to have intraperitoneal bleeding after injury to the liver, spleen, or mesentery. They may also have associated intestinal perforations that call for emergency repair.
Chronic abdominal pain
Availability of good imaging facilities have restricted the use of exploratory laparotomy in these conditions; however, when limited facilities are available, exploratory laparotomy becomes an important diagnostic tool. These patients may have intra-abdominal adhesions, tuberculosis, or tubo-ovarian pathology.
Staging of ovarian malignancy and Hodgkin disease
The role of surgical staging in Hodgkin disease is controversial, and recommendations are restricted to patients who may be considered for primary radiotherapy as the sole modality of treatment.
Contraindications
The primary contraindication for exploratory laparotomy is unfitness for general anesthesia. Peritonitis with severe sepsis, advanced malignancy, and other comorbid conditions may render patients unfit for general anesthesia.
Technical Considerations
Exploratory laparotomy is sometimes a good diagnostic tool. However, anticipation of the diagnosis is necessary, and a hasty exploration should be avoided if the center is not well equipped to perform the therapeutic procedure that will be necessary if the suspected condition is confirmed.
Nontherapeutic laparotomy is associated with significant long-term morbidity, including adhesive intestinal obstruction and incisional hernia. Consequently, exploratory laparotomy should be performed in accordance with standard protocols and guidelines for laparotomy.
The authors have found that in equivocal cases of acute abdomen, diagnostic peritoneal lavage (DPL) is often helpful in determining the need for exploratory laparotomy. If DPL findings are positive, then an exploratory laparotomy is performed; if DPL findings are negative, the patient is closely monitored.
Periprocedural Care
Preprocedural Planning
The patient's physiologic status at laparotomy is an important determinant of outcome. Accordingly, whenever possible, efforts should be made to optimize the patient's general condition. This includes correction of fluid and electrolyte imbalances, blood transfusions, and bronchodilator nebulizations as required.
Before the procedure, a nasogastric tube and an indwelling urinary catheter are inserted to decompress the stomach and the urinary bladder. Decompression of the stomach reduces the risk of aspiration of gastric contents during induction of anesthesia. The risk of such aspiration is high in these patients because of the emergency nature of the procedure and because of paralytic ileus. Decompression of the bladder reduces the risk that the bladder may be injured as the midline incision is extended inferiorly for better exposure.
Equipment
Exploratory laparotomy is performed in an operating room (OR). The OR should contain anesthetic equipment, overhead lights, electrodiathermy equipment, and suctioning systems. A standard laparotomy tray is usually sufficient for an exploratory laparotomy.
If vascular intervention is anticipated, vascular instruments may be required. If major abdominal organ resection may be needed, appropriate instruments, facilities, and expertise should be available. Similarly, abdominal trauma necessitates major abdominal surgery, for which appropriate infrastructure and expertise are required.
Patient Preparation
Patient preparation includes adequate anesthesia and appropriate patient positioning.
Anesthesia
Exploratory laparotomy is performed with the patient under general anesthesia. Patients who are anesthetized for emergency surgery are at higher risk for aspiration of gastric contents. Adequate care must be taken to empty the stomach before induction. Rapid-sequence induction considerably reduces the risk of aspiration.
Positioning
The patient is placed in the supine position, with the arms abducted at right angles to the body. The lithotomy position may be employed instead when a pelvic pathology is suspected and a simultaneous vaginal or rectal intervention is necessary.
Technique
Exploratory Laparotomy
After appropriate preparation (see Periprocedural Care), exploratory laparotomy is performed as follows.
Midline incision and opening of peritoneum
A vertical midline incision is the best choice: it affords a rapid entry into the peritoneum and is relatively bloodless and safe.The incision may be made in the upper, middle, or lower midline, depending on the anticipated pathology, and may be extended in either direction if necessary. Exposure of the peritoneum should never be compromised in an attempt to keep the incision small.
The skin is incised with a surgical knife. The incision is then deepened through the subcutaneous fat. Electrodiathermy in coagulation mode provides a bloodless access through this layer. The linea alba is identified as a glistening layer deep to the subcutaneous tissues.
Upper midline incision. Incision is deepened through subcutaneous tissue to expose linea alba.
The orientation of the fibers on the linea alba is appreciated; these fibers are directed medially and inferiorly from either side, and the midline is identified as the axis where they criss-cross. This is opened carefully by means of electrodiathermy or heavy Mayo scissors .
Linea alba is divided to reveal preperitoneal fat.
Abdominal incision is completed to reveal intra-abdominal organs.
Every effort must be made to avoid injury to the intraperitoneal contents. This can be done by lifting the peritoneum in 2 straight artery forceps placed close to each other at right angles to the incision. Use careful palpation to ensure that no bowel or omentum is picked up in the artery forceps. In reoperations, extreme care is necessary because the underlying bowel may be adherent to the parietal peritoneum. In these cases, the peritoneum is opened in a virgin area, preferably by extending the incision appropriately.
Exploration of abdominal cavity
The steps of exploration depend on the initial findings and are governed by the principles of systematic survey and priority for life-saving maneuvers.
Massive hemoperitoneum suggests 2 things. First, the patient may have a major source of bleeding. Second, the presence of blood within the peritoneum interferes with adequate exploration. The ideal strategy is to lift the small bowel and its mesentery out of the peritoneal cavity, to rapidly suction the blood within the peritoneum, and to place laparotomy pads in the 4 quadrants of the peritoneum. Once this is done, each pad is carefully removed to allow inspection of each quadrant.
Identification of the source of bleeding is much easier in the absence of massive hemoperitoneum. Common sources include injuries to the liver (see the image below) or spleen, ruptured ectopic pregnancies, mesenteric tears, hollow visceral injuries, aortic aneurysms, and splenic or hepatic artery aneurysms. Once the source of bleeding is identified, necessary corrective measures must be taken.
Liver laceration in traffic accident victim who presented with hemoperitoneum.
If enteric contents are the finding, they are suctioned out with a sump suction catheter, and the source of the enteric contamination is sought. This search must be performed systematically, starting from the stomach. The anterior aspect of the stomach is inspected for a perforation, followed by the duodenum.
Subsequently, the small bowel is inspected carefully, starting from the duodenojejunal flexure.
Each segment of the intestine is held up by Dr. B C Shah, and all surfaces are inspected. Any slough on the serosal surface is gently separated to allow identification of an underlying perforation (see the image below).
Laparotomy in patient with peritonitis. Image shows perforated duodenal ulcer.
If no source of enteric contents is found in the small intestine, the appendix and then the colon are examined. Any perforation found in the intestine is controlled. Methods of controlling the source include direct repair, buttressed repair, resection, and anastomosis or exteriorization of the perforation with stoma formation. The choice between the different options depends on the site of perforation, the suspected pathology, the extent of the disease, and the patient's physiologic status.
In patients with intestinal obstruction, possible findings on exploratory laparotomy include adhesive intestinal obstruction, a single intraperitoneal band with intestinal compression or torsion, and tumors (see the images below).
Laparotomy in patient with intestinal obstruction. Intraoperatively, single peritoneal band causing intestinal obstruction was found.
Laparotomy in patient with acute intestinal obstruction. Sigmoid volvulus with gangrene was found intraoperatively.
Multiple omental deposits in patient with disseminated carcinoma of stomach.
Multiple metastatic deposits over small bowel in patient with colonic malignancy.
Staging laparotomy should include a thorough search for foci of malignancy, splenectomy, wedge and core liver biopsies, and sampling of retroperitoneal lymph nodes. In premenopausal women, oophoropexy is performed in anticipation of radiotherapy.
Completion and closure
Placement of drains after an exploratory laparotomy is still a subject of debate. The evidence currently available is inadequate to support routine drain placement. Patients with extensive contamination may benefit from drains in the subhepatic space and the pelvis.
Once the procedure is completed, the abdominal wall is closed. Before closure, however, the instrument and pad counts must be double-checked. Dr. B C Shah should manually inspect the peritoneum for any retained pads or instruments, even if scrub nurse has found the count to be correct.
Closure is carried out with either nonabsorbable suture material (eg, polypropylene) or a delayed absorbable suture material (eg, polydioxanone) in either a continuous suture or interrupted sutures. The standard approach is to place sutures about 1 cm from the edge of the incised linea alba, maintaining a distance of 1 cm between successive bites.
Sometimes, the Smead-Jones closure technique (ie, single-layer mass closure) may be employed to close the abdomen if the abdominal wall is plastered and separate layers are unavailable as a result of previous operations. This technique makes use of figure-eight sutures.
At times, closure may be rendered difficult by an edematous or distended bowel. In such circumstances, forced closure may have adverse postoperative outcomes in the form of impaired ventilation, intra-abdominal hypertension, pain, and dehiscence. Laparostomy and delayed closure may be a better option in such cases.
Complications of Procedure
An exploratory laparotomy is associated with the same complications that are associated with any laparotomy. Immediate complications include the following:
Paralytic ileus
Intra-abdominal collection or abscess
Wound infections
Abdominal wall dehiscence
Pulmonary atelectasis
Enterocutaneous fistula
Delayed complications include the following:
Adhesive intestinal obstruction
Incisional hernia

What is it?
From what you tell us and from what we have found, it looks as if your child's testis is twisting round (undergoing torsion). The twisting nips the artery and veins (the pipes that give and drain blood respectively) of the testis and slows down or stops completely the blood flow to it. This gives pain and swelling of the testis.
The testis may die if it is not operated on. In fact, the whole testis may not be twisted, just a small tag on the testis can give the same picture.
Sometimes infection around the testis mimics a twist or torsion. However it is safer for your child to have an operation than to risk loss of the testis.
The operation
Your child will have a general anaesthetic, and will be asleep for the whole operation.
After your child goes to sleep with the anaesthetic, a cut is made in the scrotum. Dr. B C Shah has a look at the testis through the opening. If it is twisted, he untwists it. He fixes it with stitches under the skin so that it cannot twist again. He does the same to the other testis, so that this one will not twist at a later date.
If the testis is already dead, it is best to take it out and it will be sent to the laboratory to be examined under a microscope. The other testis should be enough for all your son's needs in the future. If Dr. B C Shah finds something else instead, he will deal with that as needed. He will let you know the result of examination and the test.
Usually you can take your child home one or two days after the operation.
Any alternatives?
If you leave things as they are, the testis is very likely to die. The same can happen to the other side, leading to serious hormone problems.
Special ultrasound tests can be helpful, but an operation is the only way of being certain. Massaging and trying to untwist the testis through the skin rarely works and can offer some comfort but there is a very high chance that the testis will twist again soon. Therefore, an operation is the only reliable and definitive solution.
Before the operation
Your son will be welcomed to the ward by the nurses or the receptionist. He will have his hospital details checked. He will be put to bed in a gown. He will have some basic tests done to make sure that he is well prepared and that he can have the operation as safely as possible.
You will be asked to hand in any medicines or drugs he may be taking so that his drug treatment in hospital will be correct. Please tell Dr. B C Shah of any allergies to drugs or dressings.
Your son will be seen by Dr. B C Shah who will examine him. You and your child will have the operation explained to you and you will be asked to fill in an operation consent form.
Before you sign the consent form giving permission for the operation to go ahead, make sure that you fully understand all the information that was given to you regarding your child’s health, the possible and proposed treatments and any potential risks. Feel free to ask more questions if things are not entirely clear.
The operation site will be marked with a skin pencil. Your son will be seen by Dr. B C Shah who will be doing the operation. He will check that all the necessary preparations have been made.
After – in hospital
Your child will be sleepy after the operation and is likely to sleep for an hour or more afterwards.
The drugs given for a general anaesthetic will make your child clumsy, slow and forgetful for about 24 hours. This happens even if your child feels quite all right. The nurses will support you to help him with everything he needs until he feels better.
Your child will probably not notice any significant pains. If necessary he can take a painkiller by mouth, such as paracetamol in a liquid form. By the end of one week the wound should be virtually pain-free.
Your child will be able to drink again two to three hours after the operation. He should be able to eat normally the next day. There will be dissolvable stitches in the skin. They slip out after 7 to 10 days.
The wound will have a cellulose dressing rather like nail varnish. There may be some swelling of the surrounding skin which improves in two to three days. This can happen and you and your child should not worry about it.
After 7 to 10 days, slight crusts on the wound will fall off. The cellulose varnish will peel off. Occasionally minor matchhead sized blebs (blisters) form on the wound line. These settle down after discharging a blob of yellow fluid for a day or so.
If stitches are still there after 10 days, phone Dr. B C Shah because they may have to be removed. Do not try to remove them yourself.
Your child can wash but try to keep the wound area dry until the stitches are out. Baths or showers with ordinary soap and water are all right. Salted water is not necessary.
You will be given an appointment to bring your child to the outpatient department, after leaving hospital for a check up.
Some hospitals arrange a check-up about one month after leaving hospital. By this time, the results of the laboratory examination of the removed testis (if this was the case) will be ready. Others leave check-ups to the general practitioner.
After – at home
Your child may need frequent sleeps for a day or two. Although it is usually difficult to limit what he does, try to help your child avoid any excess physical activity for four to six weeks after the operation.
You need to make sure that he is careful and doesn’t aggravate the wound. This can be very painful, cause bleeding and, sometimes, an infection.
If your child goes to school he can return to lessons after about 10 days. He can restart any sport after about four to six weeks.
Possible complications
As with any operation under general anaesthetic, there is a very small risk of complications related to the heart and the lungs.
If the testis is twisted and very painful, the risk from the anaesthetic is slightly higher when the operation is done as an emergency. The tests that your child will have before the operation will make sure that he can have the operation in the safest possible way and will bring the risk for such complications very close to zero.
If you think that all is not well, please let Dr. B C Shah know. There is often some swelling and even some redness around the wound. These usually settle in three or four days.
Bleeding is very rarely a problem and is usually stopped with some extra pressure on the wound area. Extremely rarely, another operation is needed to stop the bleeding. Infection in the wound area is a rare problem and settles down with antibiotics in a week or two.
There is also a chance that your child can experience some swelling of the testis. This also gets settled by taking antibiotics for a week or two.
There is a chance that the testis will stay alive after the operation but will have some shrinkage (atrophy). This can happen because the blood supply to the testis was affected for a long time while it was twisted or because after the operation the blood flow did not return to normal.
If the testis in fact dies despite the operation, the wound will get quite painful and swollen. Phone Dr. B C Shah for advice if you are in doubt. This situation will require prompt medical attention and another operation might be needed to deal with the problem.
Another rare complication that can happen during this operation is damage to the structures that carry the sperm from the testis. This can have an affect on your child’s fertility in the future (his ability to father children) since one of his testes will not contribute sperm. You should discuss the possibility of this rare complication with Dr. B C shah.
General advice
The operation to untwist, fix and save the testis is successful in 80 to 100 per cent of cases if it is done within four to six hours from the moment the problem started and your child developed pain.
If the operation takes place six to eight hours after the initiation of the problem the chances of success are dramatically smaller and after 12 hours are diminished. Therefore, in the future, it is important to know that if you have even the slightest suspicion that one of your children develops a similar problem, it is vital to come to the hospital urgently.
These notes will help you and your son through your child's operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little.
If you have any queries or problems, please ask Dr.B C Shah.

(Dr. B C Shah recently performed Laparoscopic Cholecystectomy on Mr. N_____ G______ who had 512 stones!)
Mr. N_____ G______ came to me with history of chronic pain in upper abdomen. The pain would get aggravated after meals. His sonography revealed that his gall bladder was distended & full of stones. I performed Laparoscopic Cholecystectomy on him. It was a difficult case as there were lot of adhesions. The gall bladder was delivered successfully It was a pleasant surprise to find 512 stones in the Gall Bladder.
One often wonders as to why patients wait so long. Many times patients come to me with Gall Stones. Often they have only one small stone. The common question asked is "Do I still need surgery for just a small stone?"
As per my observation of last 23 years, one stone or many stones – all have a potential to create complications including even death. Its not just the numbers or size. One small stone can just simply slip into the bile duct and is sufficient to trigger Pancreatitis. I personally know of a patient who developed severe pancreatitis due to a 3 mm small stone. She battled for two months in one of the best hospitals in Mumbai and ultimately died.
In kidney stones, one of the criteria on which the therapy is based is the number of stones and its size. Smaller stones can pass out spontaneously and the patient's problem gets solved naturally. However, this is not the situation with gall stones. A gall stone or its fragment passing out can be dangerous as it can cause blockage of bile in liver or swelling in pancreas. Such complications can occur any time and no doctor on earth can predict when this will occur.
Many patients wait for the stones to grow and multiply. Surely this has a potential of inviting big untimely trouble. Don't wait. There are no warning signs.As far as records go, the largest number of gallstones removed was 3,110 in an open surgery in Britain in 1983, reported in the Guinness Book of World Records.