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Alternative Names

exploratory laparotomy; laparotomy

Definition

Surgery to open the abdomen (laparotomy), to explore (exploratory laparotomy), examine, and treat problems.

Description

The abdomen contains many vital organs: the stomach, the small intestine (ileum), the large intestine (colon), the liver, the spleen, the gallbladder, the pancreas, the uterus, the Fallopian tubes, the ovaries, the kidneys, the ureters, the bladder, and many blood vessels (arteries and veins). Some problems inside the abdomen can be easily diagnosed, but many require surgery to "explore" the abdomen (exploratory laparotomy).
While the patient is deep asleep and pain-free (general anesthesia), the surgeon makes an incision into the abdomen and examines the abdominal organs. Tissue samples (biopsies) can be taken and diseased areas can be treated. When the treatment is complete, the incision is closed.

Indications

An exploratory laparotomy may be recommended when there is abdominal disease from an unknown cause (to diagnose).
Diseases that may be discovered by exploratory laparotomy include:

• inflammation of the appendix (acute appendicitis)
• inflammation of the pancreas (acute or chronic pancreatitis)
• pockets of infection (retroperitoneal abscess, abdominal abscess, pelvic abscess))
• presence of uterine tissue (endometrium) in the abdomen (endometriosis)
• inflammation of the Fallopian tubes (salpingitis)
• scar tissue in the abdomen (adhesions)
• cancer (of the ovary, colon, pancreas, liver)
• inflammation of an intestinal pocket (diverticulitis)
• hole in the intestine (intestinal perforation)
• pregnancy in the abdomen instead of uterus (ectopic pregnancy)
• to determine the extent of certain cancers (Hodgkin's lymphoma)

Risks

Risks for any anesthesia are:

• reactions to medications
• problems breathing

Risks for any surgery are:

• bleeding
• infection

Additional risks include incisional hernia.
 

Expectations After Surgery

The outcome from the surgery itself is usually excellent.

Convalescence

Eating and drinking can usually resume 2 to 3 days after the surgery. Hospital stays vary with the severity of the underlying problem. Complete recovery usually takes about 4 weeks.
 

[Alternative Names]  [Definition]  [Causes, Incidence and Risk Factors]  [Symptoms]  [Signs And Tests]  [Treatment]  [Expectations (Prognosis)]  [Complications]  [Calling Your Health Care Provider]  [Prevention] 

Alternative Names

appendicitis

Definition

A sudden inflammation of the appendix. The appendix is a narrow, small, finger-shaped tube that branches off the large intestine.

Causes, Incidence and Risk Factors

Appendicitis is one of the most common causes of emergency abdominal surgery in children. Approximately 4 appendectomies per 1000 children under age 18 are done anually in the United States (Note: appendicitis is not diagnosed in 100% of appendectomies). It is more common in males than females and incidence peaks in the late teens and early twenties. Appendicitis is uncommon under age two but can occur. Appendicitis generally follows obstruction of the appendix by feces (fecalith), a foreign body, or tumor.
Symptoms of appendicitis in young children are seldom classic so diagnosis is commonly delayed and perforation more likely. Older children and adolesents have a more typical presentation.
Classic presentation of appendicitis begins with crampy or "colicky" pain around the navel (periumbilical). There is usually a marked loss or total absence of appetite (anorexia). As the inflammation in the appendix increases the pain tends to move downward and to the right (right lower quadrant, RLQ) and localizes directly above the position of the appendix at a point called "McBurney's Point". (If a line is drawn from the navel to the prominence on the right pelvic bone (right superior iliac crest) and divided into thirds, McBurney/s Point is 2/3 away from the navel).
The child may be quite tender when the abdomen is pressed at McBurney's Point. When the abdomen is depressed on the left side, held momentarily, and then rapidly released the child may experience a momentary increase in pain (rebound). This finding suggests inflammation has spread to the peritoneum.
If the appendix ruptures the pain may disappear for a short period and the child feels suddenly better. However, within a short period peritonitis sets in, the pain returns, and the child becomes progressively more ill. At this time the abdomen may become rigid and extremely tender.
 

Symptoms
The appendix is a small, finger-shaped pouch of intestinal tissue located between the small intestine (cecum) and large intestine (colon).

The appendix is near the junction of the small bowel and the colon. On occasion, it may become infected. Although most people are familiar with appendicitis, it is a relatively rare disease. It is treated by surgical removal of the appendix (appendectomy). Recovery time for uncomplicated appendicitis is usually just three days.
Symptoms

• abdominal pain
  • pain may begin in the upper-middle abdomen (epigastric), then develop to sharp localized pain
  • pain may shift from the epigastric area to become most intense in the lower right side of the abdomen ("typical" presentation), tenderness of this area is common
  • pain initially may be vague, but getting increasingly more severe
• point tenderness

  McBurney's point

  Definition

  A symptom in which pain is noted when pressure is applied over a specific point on the abdomen.

  Common Causes

  • appendicitis
  • ovarian torsion (twisted Fallopian tube)
  • pelvic inflammatory disease
  • abdominal abscess
  • hepatitis

  Note: There may be other causes of point tenderness. This list is not all inclusive, and the causes are not presented in order of likelihood. The causes of this symptom can include unlikely diseases and medications. Furthermore, the causes may vary based on age and gender of the affected person, as well as on the specific characteristics of the symptom such as exact location, quality, time course, aggravating factors, relieving factors, and associated complaints. Use the Symptom Analysis option to explore the possible explanations for point tenderness, occurring alone or in combination with other problems.
   

  Considerations

  The abdomen is an area of the body easily examined by touch (palpation). Without bony shielding, such as the rib cage around the chest, masses and organs within the abdomen can be felt and pain can often be localized.
  Two types of tenderness are recognized, rebound tenderness and point tenderness. Rebound tenderness is a non-localizing sign and occurs when the membrane that lines the abdominal cavity (the peritoneum) is irritated, inflamed, or infected (peritonitis).
  The most common recognized point tenderness is that of McBurney. The McBurney point is located by drawing a line from the navel to the highest part of the pelvic bone on the right side (the right iliac crest). Divide the line into three equal lengths. McBurney's point is 2/3 of the way from the navel to the iliac crest. Pressure over this point will elicit pain in people with appendicitis who have been symptomatic for a period of time.

  Call Your Health Care Provider If

  • point tenderness occurs.

  Note: Any person with point tenderness should be examined promptly by the health care provider!

  What To Expect At Your health Care Provider's Office

  The medical history will be obtained and a physical examination performed.
  Medical history questions documenting point tenderness in detail may include:

  • time pattern
    • When did the abdominal pain associated with this point tenderness develop?
    • Is this the first time that this kind of discomfort has occurred?
    • If it has occurred before, have you noticed any pattern to the occurrences?
  • other
    • What other symptoms are also present?
    • Is there vomiting?
    • Is there rebound tenderness (the tenderness is worse when the area is gently pressed and then the pressure is suddenly released).
    • Is there diarrhea or constipation?
    • Is there a fever?

  The physical examination will include a detailed abdominal examination.
  Diagnostic testing may include:

  • abdominal film
  • abdominal CT scan (occasionally)
  • laboratory tests such as a CBC

  Interventions:
  Sometimes, the history and physical examination will indicate a need for immediate surgery (an exploratory laparotomy or an emergency appendectomy).
  Pain medication can disguise signs and symptoms of appendicitis and other disorders. For this reason, pain medications are often NOT given to people with abdominal pain until all examination and testing is completed.
  After seeing your health care provider:
  You may want to add a diagnosis related to point tenderness to your personal medical record.
   

• abdominal pain may be worse when walking or coughing
• nausea and vomiting
• fever usually occurs within several hours
• the patient may prefer to lie with knees pulled up to abdomen to relieve muscletension on the abdomen

Later symptoms:

• fever
• loss of appetite
• nausea
• vomiting
• constipation
• rectal tenderness
• chills and shaking

Additional symptoms that may be associated with this disease:

• urine, bloody (microscopic hematuria)
• anal lump
• menstruation, painful

Signs And Tests

When the abdomen is gently pressed in the painful area, and then the pressure is suddenly released, the pain increases (rebound tenderness). Touching the abdomen may cause spasm of the abdominal muscles if peritonitis is developing. Rectal examination causes pain that is localized on the right side. Psoas sign is positive--the person is placed on his (her) back in a supine position and the legs are extended straight. Tapping the heels or jarring the leg upwards causes increased pain on the right side of the abdomen.
Appendicitis may be strongly suspected based on the following tests:

• An abdominal sonography may show appendicitis.
• A CBC shows increased white blood cell count.
• An abdominal X-ray may or may not show signs of appendicitis.

The diagnosis may be confirmed by the surgeon during an exploratory laparotomy.
This disease may also alter the results of the following tests:

• barium enema
• abdominal tap (paracentesis)
• abdominal CT scan

Treatment

Close observation within the first 8 to 12 hours after the onset of symptoms is indicated.
For uncomplicated appendicitis, surgery (appendectomy) is performed as soon as possible. Little preparation is required. If an abscess is suspected, the surgery may be delayed until antibiotic therapy has reduced the infection.

Expectations (Prognosis)

Early surgery has a death rate of less than 1%.

Complications

• perforation of the intestines
• gangrene (tissue death) of the intestines
• peritonitis
• abscess

Calling Your Health Care Provider

Call your health care provider if right-lower quadrant abdominal pain or other symptoms suggestive of appendicitis develop.
 

Prevention

Not preventable.