Laparotomy is a surgical act that involves opening the abdomen through an incision. “It is not an intervention, but a way to get into the belly”, summarizes Dr. Franck Denimal, visceral and digestive surgeon at the La Louvière clinic in Lille. This opening then leaves the direct passage to various surgical acts. It is therefore indeed a surgical approach: it allows the abdominal cavity to be opened in order to access the organs to be operated on, such as the internal abdominal or pelvic organs. Laparotomy has been performed since Antiquity, it was notably performed in India as early as 1500 BC The first more recent surgeon to have performed this type of act in order to remove an ovarian cyst from a patient is Dr. McDowell, in 1809, but laparotomy was in fact already performed long before, for Caesarean sections in particular. Laparotomy is often replaced today, whenever possible, by laparoscopy.

Laparotomy is a surgical act. The term surgery is used, generally, to describe the various procedures that involve manually making incisions, or sutures of tissue, in order to treat diseases, injuries or deformities. Laparotomy, more precisely, consists of an act of incision of the abdomen. The term laparotomy was created in 1790 and derives from ancient Greek: thus, it is formed from the word “lapara” which means “flank” associated with the suffix “-tomie” which means “to cut, to cut”. If etymologically the term therefore means “opening of the flanks”, in fact, the surgeon generally goes through the middle rather than the side. “Fewer laparotomies are currently being performed, says Dr. Franck Denimal, because they are increasingly replaced, when possible, by laparoscopies”. Laparoscopy allows you to open only small parts of the abdomen.

It is since Antiquity, at the time of the beginnings of medicine, that this type of incision has been practiced today called laparotomy. Emergency medicine has its roots in the distant past: in ancient Egypt, in particular, where one already practiced, among other things, the treatment of war wounds or the resuscitation of drownings and where analgesics were used. such as poppy or mandrake. And it was in India, around 1500 BC, that the first laparotomies were carried out, as Professor François Bertrand, emergency doctor at the University Hospital of Nice, indicated during a conference.

In more recent times in medicine, the first surgeon to open a patient’s abdomen in order to remove a cyst was Dr. Ephraim McDowell in December 1809. The opening of the patient the abdomen was until then mainly reserved for the cesarean section. The professors of Ephraim McDowell as well as the surgeons of his time believed, in fact, that abdominal exploration resulted in peritonitis and death; but Ephraim McDowell had enough confidence in his knowledge of anatomy and his skills as a surgeon that he tried the experiment ”, as he called it. He successfully completed the first oophorectomy and his patient survived. Jane Crawford’s operation lasted only twenty-five minutes, but it had been carefully planned and prepared.

It is therefore on Christmas Day 1809 that this itinerant doctor, originally from Scotland and trained at the University of Edinburgh, will operate on Jane Crawford, a young American woman suffering from intense abdominal pain. She thinks she is pregnant: it is in fact a huge suffocating ovarian cyst. Doctor Mc Dowell, a doctor who travels from town to town on horseback, agrees to open the abdomen and perform the oophorectomy, while surgery on internal organs was then strictly prohibited. McDowell thus performs the first surgical procedure on internal organs, without anesthesia and without asepsis. He is very meticulous, and very concerned about cleanliness: his patient will have no infection or peritonitis. 

In summary, laparotomy is therefore an approach to the abdomen which allows direct passage to various surgical procedures performed on the internal abdominal and pelvic organs. This surgical act, which therefore consists of opening the abdomen through an incision, also allows certain patients in some cases to benefit from an exploratory laparotomy.

Following a clinical evaluation, some patients who have suffered abdominal trauma must therefore undergo an exploratory-type laparotomy, that is to say for diagnostic purposes, rather than examinations, mainly those suffering from the following pathologies:

• Peritonitis;
• Hemodynamic instability after penetrating abdominal trauma;
• Gunshot wounds (most);
• Evisceration.

In addition, many operations require the opening of the abdomen: all abdominal surgeries, and which concern digestive surgery, but also urology, gynecology, and even cosmetic surgery (large abdominal apron, abdominoplasties, stretch marks at the base of the abdomen).

“In the past, all operations involving the abdomen were done by laparotomy. Today, more and more are done under laparoscopy, which consists of very small incisions. But in any laparoscopy, the specialist may need to open more if there is a problem, and the patient is warned in advance, ”says Dr Denimal. Therefore, any intervention performed in the belly can potentially justify a laparotomy. 

The main cases where laparotomy is necessary are as follows:

• An appendectomy: this is a very small laparotomy, when the surgeon opens to the right of the abdomen in order to operate on the appendicitis;
• It is also advisable, for certain operations, to carry them out preferably by laparotomy: this is the case in particular with colon cancers, for example, or even cancers of the rectum which are very invasive, and for which laparotomy will be preferred to laparoscopy (conversely, small, not very invasive cancers can be treated by laparoscopy);
• Peritoneal carcinosis, that is, cancer that has spread to the peritoneum, is necessarily made by laparotomy;
• When cancer has invaded an organ other than the original organ, again the incision by laparotomy will be obligatory.

“There are times when laparotomy is formally indicated, and other situations which are at the discretion of the surgeon. But today, in the majority of situations, the surgeon can proceed by laparoscopy ”, summarizes Dr. Denimal. He insisted: “Even if laparoscopy has many advantages, it is not necessary to favor aesthetics over the expected benefit”.

There are large laparotomies or very small laparotomies. All types of incisions are possible. The duration of the procedure can be extremely variable: sometimes the incision is made only to see what is going on in the belly, so it can be very fast, and in other cases, such as a liver transplant or a intervention on pancreatic cancer for example, the interventions can on the contrary be very long.

• The most common incision is the one called “a median”: the surgeon makes an incision in the middle. The advantage is that it goes between the muscles, so there is no muscle section, which is therefore less dilapidated;
• For larger operations, it is possible to have to open from the sternum to the pubis;
• Then, depending on the organ to which the operation is to be performed, there are subcostals: obliquely incisions under the ribs, and it is also possible to perform transversals;
• For caesarean sections, it may sometimes be necessary to make mid-umbilical incisions, but if the situation presents itself well, the operating doctor may very well also make a simple transverse incision just above the pubis, which is turns out to be more aesthetic.

This act of laparotomy is simply to open. “We must first of all prevent it from bleeding, because otherwise the surgeon can no longer see to operate. So in general, when everything goes well, you don’t see a drop of blood, ”explains Franck Denimal. The surgery is done using a scalpel. 

The laparotomy is performed in the extreme majority of cases under general anesthesia. It is sometimes possible to fall asleep only the lower body, but at this time the level of the navel should not be exceeded: it is then necessary to operate only below the navel. For less important procedures, such as placing catheters (tubes inside the belly), it is also possible to use tap blocks: the anesthetist will then put only the wall of the abdomen to sleep. “But this gesture remains then more painful than for someone who is placed under general anesthesia”, assures the Lille surgeon.

After the operation, the methods of closing laparotomies are variable: they can be carried out using threads, staples, or sometimes simply glue when the incision is very small. It all depends on where the scar is, its length. The surgeon also adapts according to the area of ​​tension. There are also some rare cases where the specialist does not close: indeed, sometimes it is impossible to close so much the abdominal wall is distended. In these cases, the surgeon performs a laparostomy, i.e. the belly is left open and special dressings make it possible to manage this situation, in particular thanks to the use of VAC-therapy (kinds of dressings under empty) which almost halves the healing time.  

“On the overall appearance of the scar, the surgeon does not have much to do with it, it depends a lot on the patient’s skin,” says Dr. Denimal. On the other hand, the scar will be less beautiful when the operation is performed in an infected context, or if the person has already had multiple operations: in these situations, the surgeon generally removes the previous scar in order to find healthy tissue. . ”

Thanks to significant technological advances, it is now also possible to perform surgical procedures using smaller openings: this has the particular benefit of reducing tissue trauma, compared to traditional surgery. Concretely, surgeons insert small light sources, as well as cameras and surgical instruments through small incisions, and operate by means of images displayed on control screens: this allows them to guide and manipulate surgical instruments. This minimally invasive surgery is called laparoscopic surgery when it involves the abdomen.

Whereas previously, patients were advised not to move after an operation, it is exactly the opposite that is recommended today: “You have to walk again, move again, and recover. to eat as quickly as possible. The patient recovers much faster, and this allows what is called rapid rehabilitation. In addition, it has been proven that there are fewer complications by doing so ”, underlines Dr Denimal. The precautions and post-operative monitoring remain the same, but people who move much faster, in fact, recover much faster from the laparotomy and the operation.

For the resumption of sport, everything depends on the operation. If it is a small operation, it is generally advisable to wait a month before resuming normal intense physical activity. If it is a large incision, the patient will rather go two months without playing sports. The time before resuming a sporting activity also varies depending on risk factors, such as a multiple operation, a weakening linked to malnutrition or to chemotherapy. “In these cases, we can use other aids, such as compression belts,” says Dr. Denimal. 

These belts avoid in particular the risk of eventration, they are not worn for more than a month in general, because otherwise the belt will perform the work of the muscles, which has the consequence of atrophying them. Then the belt is removed and the patient will only use it if he performs more intense physical activity. It is also possible to use a compression belt in people who cough a lot.

To take care of your scar, the ideal is not to have an infection, and to respect the instructions given. The percentage of infection is ultimately very low. “This infection rate is all the lower when the intervention that has been carried out is clean,” emphasizes Franck Denimal. 

“The main advice after having a laparotomy is not to carry heavy things,” says Dr. Denimal. In addition to any risk inherent in surgery and anesthesia, the main undesirable effect to watch out for following a laparotomy procedure is distant eventration: in fact, given that the abdominal wall is weakened, the risk is that ‘there is a protrusion of the peritoneum sometimes accompanied by the digestive tract, that is to say that these organs are pushed abnormally outwards at the level of the scar.

Thus, like any intervention, laparotomy can have complications: 

• bleeding;
• disunity (loosening of sutures);
• disembowelment at a distance when the suture is loose. 

One of the important risk factors in laparotomy, for wall fragility, is the operation in obese people. There are also some cases of postoperative hematomas, and the risk of infection of the scar which, moreover, are also risk factors for an eventration. Another risk also concerns people who have already had multiple operations. But Franck Denimal is ultimately reassuring: “The actions are carried out by professionals, we are used to and we know the risks, and above all we know how to manage them”.