From Big Medical Encyclopedia

LAPAROTOMY (grech, lapara groin, stomach + tome section; synonym chrevosecheniye) — opening of an abdominal cavity.

Mentioning of L. met still B.C., in particular it was manufactured in Ancient India. The oldest operation L. it is considered Cesarean section (see). The Greek doctor Praksagor in 4 century BC produced L. at impassability of intestines. In China L. the surgeon Hua Tuo did (141 — 203). However wide spread occurance of L. got only in 19 century in connection with introduction antiseptic agents (see), and in the subsequent thanks to to an asepsis (see).

The laparotomy is an operative measure, the purpose to-rogo — performance of operation on abdominal organs or release it from blood, pus and others patol, accumulations.

Sometimes the Laparotomy is applied for the purpose of diagnosis, (diagnostic, trial, L.). In these cases it is possible to make small cuts (mikr about a laparotomy); such Laparotomy is used seldom in connection with a wide spread occurance of other methods of a research, in particular laparoscopies (see. Peritoneoskopiya ), laparocentesis (see). At L. the section of a parietal layer of a peritoneum is always made. However the term «extra peritoneal laparotomy» with a section of fabrics of a back abdominal wall for access to retroperitoneal space and its bodies — to a kidney, an ureter, an adrenal gland, a ventral aorta, the lower vena cava, a trunk of a sympathetic part of century of N of page is conditionally used. In these cases the peritoneum, as a rule, is not cut. Convention of the concept «laparotomy» can be tracked also at other operations. So, herniotomy is not called L., though at it the hernial bag which is a parietal layer of a peritoneum is opened; only at broad opening of an abdominal cavity by a section of a back wall of the inguinal channel, napr, at inguinal hernia, operation is called a herniolaparotomy.

Types of a laparotomy

Depending on an anatomic arrangement of an abdominal organ, on Krom an operative measure is made, and the nature of operation apply various laparotomichesky cuts.

Fig. 1. Schemes of cuts of skin at longitudinal laparotomies: 1 — upper median; 2 — paramedian; 3 — traksrektalny; 4 — pararectal; 5 — on the semi-lunar (spigeliyevy) line; 6 — lower median; 7 — side transmuskulyarny.
Fig. 2. Schemes of cuts of skin at cross and slanting laparotomies: 1 — parakostalny (subcostal); 2 — upper cross; 3 — lower cross; 4 — lower median variable (Pfannenshtil's section); 5 — lower side variable (Mac-Berney's section); 6 — upper side variable.

At L. through a front abdominal wall use longitudinal (fig. 1), cross and slanting sections, and also so-called variables and angular cuts (fig. 2). Quantity offered for L. cuts it is very big. So, only at liver operations and extrahepatic bilious ways, by data A. N. Volkova, is more than 70 accesses. In practical work the surgeon uses 10 — 20 most widespread laparotomiche-sky cuts for creation of optimum approach to this or that body, on Krom operation is made. It is necessary to choose, whenever possible, such cuts at which nerves are spared abdominal wall (see) which crossing creates conditions for an atrophy of muscles of an abdominal wall and development of its relaxation with the subsequent emergence of hernial protrusions.

The most often applied coal mine is access through white line of a stomach (see). Its advantage before others is defined by speed of opening of an abdominal cavity, a possibility of its broad survey, almost almost full beskrovnost and ease of sewing up of a wound after the end of operation. It is accepted to distinguish upper median, lower median, central median and total median L.

Fig. 3. The diagrammatic representation of an upper median laparotomy with a resection of a xiphoidal shoot: 1 — a midsternum; 2 — the resected xiphoidal shoot; 3 — a parietal layer of a peritoneum; 4 — divorced direct muscles; at the left in the bottom of border of a skin section (solid line); the dotted line designated costal arches.
Fig. 4. The diagrammatic representation of cross-section of an abdominal wall at an upper median laparotomy: and — the line of abdominal section (1 — skin and hypodermic cellulose, 2 — the white line, 3 — a parietal peritoneum); — a layer-by-layer celiorrhaphy (1 — a parietal peritoneum, 2 — the white line, 3 — skin with hypodermic cellulose)

Upper median L. allows to make to stomach operation, a cross colon, a jejunum, on the left hepatic lobe. Some surgeons prefer to use upper midsection at a cholecystectomia. Removal of a xiphoidal shoot allows to expand this section up (fig. 3). In case of need this section can be expanded and from top to bottom with a bypass of a navel at the left to keep an integrity of a round ligament of liver. The fabrics which are subject to a section at this L. are skin with hypodermic cellulose, the white line of a stomach, preperitoneal cellulose and a parietal peritoneum (fig. 4, a), edges a cut after its section are occupied clips and fastened to the sheet delimiting a surgery field. If during operation need of expansion of access comes to light, upper midsection is supplemented cross, cutting cross muscles and turning midsection into angular. Sewing up of an operational wound at upper median L. make in 3 layers: the continuous suture takes in a peritoneum, noose silk or synthetic sutures sew an aponeurosis and skin (fig. 4,6). At overdevelopment of hypodermic cellulose some surgeons sew it separate noose sutures.

By production lower median L. (fig. 1) needs to be meant that below the duglasovy line there is no back wall of a vagina of a direct muscle and, besides, the white line of a stomach here very narrow therefore quite often front leaf of a vagina of direct muscles of a stomach is cut on 1 — 2 mm to the right or to the left from the centerline. The abdominal cavity is opened after cultivation with hooks in sides of direct muscles of a stomach. This access can be applied at operations on a small bowel, a uterus, pipes, ovaries, a rectum. At sewing up of this section the cross fascia and a parietal peritoneum are taken one continuous suture, rare noose sutures pull together direct muscles of a stomach over which noose sutures sew the front leaf of an aponeurosis forming a vagina of a direct muscle of a stomach. Then stitches on skin are put.

At not clear diagnosis, especially in an urgent surgery, use midsection on the white line of a stomach 8 — 10 cm long above and below a navel, bypassing the last at the left (central median L.). After orientation in an abdominal cavity and establishment of the exact diagnosis this section can be prolonged up or from top to bottom, depending on need.

Sometimes the surgeon should use very broad opening of an abdominal cavity — from a xiphoidal shoot to a pubic symphysis (total median L.). This section considerably breaks in the subsequent function of an abdominal wall and therefore resort to it only at emergency, napr, at big tumors, at operations on a ventral aorta.

Fig. 5. Diagrammatic representation of a paramedian (left-side) laparotomy: and — the line of abdominal section in cross-section (1 — skin and hypodermic cellulose, 2 — a front leaf of a vagina of a direct muscle, 3 — the direct muscle is removed lateralno — it is designated by a dotted line, 4 — a back leaf of a vagina of a direct muscle, 5 — a parietal peritoneum); — a section of a front leaf of a vagina (2) straight lines of a muscle of a stomach (3); in — assignment of a direct muscle of a stomach (3) lateralno, the back leaf of a vagina of a direct muscle with a parietal peritoneum (5) is taken by tweezers; day — consecutive stages of option of closing of a paramedian section with removable seams; — the stitch (6) on a parietal peritoneum and a back leaf of a vagina of a direct muscle is put, the removable «holding» stitches (7) taking edges of skin and a front leaf of a vagina of a direct muscle are put; d — threads of the «holding» seams (7) are carried out, but not tied; stitches on a front wall of a vagina of a direct muscle are put (8); e — are tied removable seams (7), seams of a front wall of a vagina of a direct muscle (8) are tied, noose skin sutures are tied (9); — closing of a paramedian section in cross-section of an abdominal wall (in — a seam on a peritoneum and a back leaf of a vagina of a direct muscle, 7 — the removable «holding» seams on skin and a front leaf of a vagina of a direct muscle; 8 — a seam on a front leaf of a vagina of a direct muscle; 9 — noose skin sutures).
Fig. 6. The scheme of closing of upper cross section within a direct muscle of a stomach (and, and c) and knaruzh from it (and e). The sequence of suture on edges of a wound from the middle of a knaruzha; are sewed: 1 — the white line with a peritoneum, 2 — the semi-lunar line of an aponeurosis with a peritoneum, 3 — a back leaf of a vagina of a direct muscle with a peritoneum, 4 — a front leaf of a vagina of a direct muscle, 5 — an internal oblique muscle with a cross muscle and a peritoneum, 6 — an outside oblique muscle.

The so-called kulisny section of Lennander belongs to slits (paramedian L.), edges it is made on 2 cm to the right or to the left from the centerline of a stomach (fig. 5). It is recommended at some stomach, duodenum operations, on biliary tract. After a section of a front leaf of a vagina of a direct muscle of a stomach this muscle is taken away a hook lateralno then cut a peritoneum together with a back leaf of a vagina of a direct muscle of a stomach. During the closing of a wound the peritoneum is taken in together with a back leaf of a vagina usually continuous suture then stack a pas the place a direct muscle of a stomach and sew noose sutures a front leaf of a vagina of a direct muscle of a stomach, and then skin with hypodermic cellulose. Some surgeons on a front wall of a vagina of a direct muscle put the removable «holding» stitches or use imposing of 8-shaped seams across Spasokukotsky.

By production of a gastrostomy, transverzostomiya and at other operations in an upper half of a stomach L use transrectal. (fig. 1, 3). Her technician it is close to L. on Lennandera, only the direct muscle is not removed aside, and stupidly move apart its fibers on border between internal and median its thirds. At sewing up of a laparotomichesky wound after transrectal L. use a three-row seam, and the moved apart parts of a direct muscle are not sewed.

To longitudinal L. belongs and pararectal L. Razrez begins at costal edge and it is carried to the level of a navel at distance of 2 cm medialny the outer edge of a direct muscle of a stomach (fig. 1,4). Its advantage is that a direct muscle of a stomach upon termination of L. covers the line of the stitches put on a cross fascia and a peritoneum, and a shortcoming — in need of crossing of 3 — 4 motor nerves that leads to a muscular atrophy. The same shortcoming also the laparotomichesky section longs for the semi-lunar (spigeliyevy) line (fig. 1, 5) why most of surgeons avoids these cuts.

For a number of reasons some advantages before slits at L. have slanting and cross sections. In particular, at these cuts muscles of an abdominal wall are a little injured if cuts match a direction of fiber of oblique muscles of a stomach, it is not enough or almost intercostal nerves are not crossed. At suppuration of a wound these cuts disperse less, than vertical, and at them postoperative hernias are less often observed. Less broad access belongs to shortcomings of some slanting and cross sections, than at vertical cuts.

Upper cross L. (fig. 2, 2) can be carried out with crossing of both direct muscles of a stomach or only one right or left, depending on the nature of operation on the bilious ways or on a spleen. This section is made above a navel, coming for lateral edges of direct muscles of a stomach. In transverse direction cut front and back leaves of a vagina of direct muscles of a stomach, direct muscles, a cross fascia and a peritoneum, and after an alloying cross also a round ligament of a liver. At a good relaxation it is possible to be limited to a section only of front and back leaves of a vagina of direct muscles of a stomach, muscles move apart in the parties hooks. In need of very broad access cross section is expanded in both parties to the front axillary line, and in this direction cut an outside oblique muscle of a stomach, and internal slanting and cross muscles are moved apart stupidly. At operations on the bilious ways the section can be carried out from a costal arch at the level of the eighth or ninth mezhreberye to the white line of a stomach with a section slanting and cross muscles, both leaves of a vagina of a direct muscle of a stomach with assignment of the last aside. Closing of upper cross section is carried out, as shown in the figure 6. Cross L. it is very convenient at pancreas operations, a cross colon, a spleen.

Lower cross L. it is identical upper, only it is made below a navel on several centimeters. It is convenient for a hemicolectomy.

At this L. the surgeon shall tie up the lower epigastriß vessels.

Fig. 7. The scheme of a section of skin at a subcostal (slanting) laparotomy with an additional vertical section in an upper corner of a wound: 1 — the line of an additional section; 2 — the white line; 3 — direct muscles.

The L belongs to slanting cuts subcostal. (fig. 2, 7), opening on the right good access to bilious ways, at the left to a spleen and to an upper half of a stomach. There are many modifications of this of L. (Courvoisier, Kokher, Fedorov, Pribram, etc.). According to S. P. Fedorov's proposal the slanting section 10 — 12 cm long is carried out parallel to the right costal edge, otstupya from it on 4 — 5 cm. Cut outside two thirds of a direct muscle of a stomach, sometimes a part slanting and cross muscles of a stomach. At patients with a flabby abdominal wall are limited to a section only of a direct muscle, and in more difficult cases this section should be bent up on the white line (fig. 7).

Fig. 8. Diagrammatic representation of closing of a side transmuskulyarny laparotomichesky section with a four-row seam: 1 — a peritoneum; 2 — internal slanting and cross muscles; 3 — an aponeurosis of an outside oblique muscle; 4 — skin with hypodermic cellulose.

The L belongs to slanting cuts side transmuskulyarny. (fig. 1,7). This section is convenient for operations on a colon: on the right for a right-hand hemicolectomy, at the left for left-side. Usually the section is begun under bottom edge of the X edge and bring it to a comb of an ileal bone, and then out almost parallel to the outer edge of a direct muscle of a stomach. The outside oblique muscle of a stomach is cut along fibers, and internal slanting and cross muscles — across. After a section of a parietal peritoneum broad access is created. It is not necessary to approach area of the inguinal channel, to damage the semi-lunar line and an ilioinguinal nerve. Usually length of this section shall be apprx. 15 cm. During the imposing of an ileostoma or sigmostoma use cuts of smaller length. Sewing up of a section is made in 4 layers (fig. 8).

At L. often use so-called variable cuts. Their advantage is that muscles are moved apart along fibers and, thus, at sewing up of these wounds stronger hem turns out. A lack of these cuts is rather small surgery field for survey of bodies and manipulations on them therefore in need of expansion of a wound it is necessary to cross muscles across and, in case of suppuration of a wound, it widely gapes, creating conditions for formation of postoperative hernia. The most often applied variable section is offered by Mack-Berney (S. of McBurney) the section for appendectomies (see) in the right ileal area (fig. 2, 5). Obstetricians and gynecologists often use the lower variable suprapubic section of Pfannenshtil (see. Pfannenshtilya section ), carried out cross on a skin fold is 4 — 6 cm higher than a pubic symphysis (fig. 2, 4).

In children's surgery at the operation made concerning a pylorostenosis apply the section only 3 cm long parallel to a costal arch, knaruzh from a direct muscle of a stomach. Muscles move apart along their fibers. Layer-by-layer sewing together gives them in the subsequent a strong hardly noticeable hem.

Fig. 9. The diagrammatic representation of drainage of an abdominal cavity at insolvency of seams of a stump of a duodenum through additional abdominal section in right hypochondrium (the scheme of a section is given below at the left); leading of a drainage (1) and tampon (2) to a stump of a duodenum (3).

At insolvency of seams of a stump of a duodenum it is favorable to use the section 8 — 10 cm long going 2 — 3 cm below than the right costal arch and parallel to it (fig. 9) and at a section of a front leaf of a vagina of a direct muscle of a stomach it is removed medially, without cutting fibers.

Fig. 10. The scheme of a section of skin at a laparotomy on Petrovsky (solid line): 1 — the right costal arch; 2 — a xiphoidal shoot; 3 — the left costal arch.

During the performance of operations at a carcinoma of the stomach, especially at a high arrangement of a tumor, the abdominal cavity needs to be opened widely. In these cases the section offered by B. V. Petrovsky (fig. 10) is very convenient. It is begun at the right costal arch and conducted in transverse direction to the left costal arch, and then parallel to it brought to the front axillary line, crossing the white line of a stomach 5 — 6 cm lower than a xiphoidal shoot. To the left from the white line cut a straight line, slanting and cross muscles of a stomach, cut only the front and back leaves of an aponeurosis making a vagina of a direct muscle of a stomach on the right, removing the last a hook aside. The cross fascia together with a peritoneum is cut throughout a wound and tie up a round ligament of a liver.

Fig. 11. Diagrammatic representation of a laparotorakotomiya: the section of skin, hypodermic cellulose and a layer-by-layer section of muscles from the centerline of a stomach (1) through a costal arch (2) on the seventh mezhreberye (3) to the back axillary line (4) is made.
Fig. 12. The diagrammatic representation of access at a laparotomy across Topchibashev: step-by-step sewing together of edges of a diaphragm (1) and intercostal muscles (2) after each their section.

At the operations made at the same time on a stomach and a gullet and also on a liver, it is necessary quite often together with L. to make also opening of a pleural cavity. Such L. can be transthoracic and combined (abdominotorakalny and thoracoabdominal) depending on with what section the surgeon begins operation. At a thoracolaparotomy operation is begun with thoracotomies (see) in the seventh mezhreberye a section from a costal arch to the axillary line. On the course of a skin section cut the outside oblique muscle of a stomach covering here lower parts of a thorax, and a wide muscle of a back. Along the upper edge of the VIII edge cut intercostal muscles and a parietal pleura. The diaphragm is cut from its costal edge to an esophageal opening without crossing of a phrenic nerve. For a resection of lower chest department of a gullet use a section and in the sixth mezhreberye across Peterson. For broader access it is reasonable to cut a costal arch. In case of need this transthoracic transphrenic L. it can be turned into a thoracolaparotomy for what the intercostal section is continued on an abdominal wall. If at inspection of the patient the possibility of radical operation on a stomach is called in question, it is better to begin H.p. of an abdominal part of a section and, having only convinced of lack of dissimination of tumoral process, to open also a pleural cavity — a laparotorakotomiya (fig. 11). Use right-hand access at a resection of a liver. M. A. Topchibashev recommends the section beginning at the outer edge of the right direct muscle of a stomach is a little higher than a navel, carrying out this section to the seventh mezhreberye. After opening of an abdominal cavity cut a costal arch, enter the left hand into a wound, press a diaphragm to a chest wall, cut gradually intercostal muscles and a diaphragm, sewing its edges with intercostal muscles after each their section (fig. 12).

Fig. 13. The diagrammatic representation of the initial stages of sewing up of an operational wound after a thoracolaparotomy: 1 — noose silk sutures on edges of a section of a diaphragm; 2 — the polyspast catgut seams which are carried out through mezhreberye for tightening of a wound.

Sewing up of an operational wound after a thoracolaparotomy (fig. 13) is begun with a dome of a diaphragm with noose silk sutures. Pull together with the noose sutures which are carried out through mezhreberye a wound. A continuous suture sew a parietal peritoneum, taking also a dissect muscle, and then layer-by-layer sew muscles and skin. Through the drainage entered into a pleural cavity in the tenth mezhreberye at the end of operation delete air, and further constantly suck away by means of active aspiration (see. Aspiration drainage ).

Fig. 14. The scheme of a section of skin at a sternomediastinolaparotomiya with crossing of the left direct muscle of a stomach: 1 — the beginning of a section on the middle of a midsternum of a xiphoidal shoot 6 — 7 cm higher than the end; 2 — outside border of a section at edge of the left direct muscle of a stomach.

At a gastrectomy, a resection of the left hepatic lobe one more type of L is applied. — sternomediastinolaparotomiya. This operation begins with median upper L., then on the middle of a breast throughout 6 — 7 cm soft tissues are cut, under a xiphoidal shoot after a section of a peritoneum fibers of a diaphragm are stupidly divided. Two fingers otslaivat a mediastinal pleura and throughout 4 — 6 cm in lengthwise direction cut a breast with the maximum cultivation of a wound a powerful screw-type retractor. The diaphragm is cut at technically very difficult made resection of the left hepatic lobe. Sometimes in a bottom corner of a wound it is reasonable to cross a direct muscle of a stomach (fig. 14) in addition.

At gunshot wounds of a stomach the main section, the Crimea surgeons in the Great Patriotic War used, midsection was. Kosopoperechny cuts were applied at through wounds with the horizontal direction of the wound channel in the upper floor of a stomach. At through wounds with the short wound course and at gutter wounds of a stomach cuts like expansion of wounds were sometimes allowed. Pararectal cuts for L. in military conditions are not recommended.

Carrying out a laparotomy

In sovr, conditions the best type of anesthesia at L. the endotracheal anesthesia using relaxants is (see. Inhalation anesthesia ), allowing to relax muscles of an abdominal wall and to these to broaden the field of operation, without extending a section. However at contraindications to the general anesthesia use also local anesthesia (see. Anesthesia local ), occasionally at operations in the lower half of an abdominal cavity — peridural or spinal anesthesia.

Position of the patient on the operating table at L. depends on the nature of the planned operation.

Fig. 15. The diagrammatic representation of sagittal section of abdominal organs at position of the patient on the roller under the XII chest vertebra: the liver (1), a gall bladder (2), the general bilious channel (3), a pancreas (4) and a duodenum (5) are brought closer to a front abdominal wall.

The most part of operative measures is made in horizontal position of the patient on the operating table. At liver operations, bilious ways, a spleen, a pancreas under the XII chest vertebra the roller is enclosed that brings closer these bodies to a front abdominal wall (fig. 15). At L. in a lower part of a stomach, especially at ginekol, operations, on a rectum, etc., the provision of Trendelenburga is recommended (see. Trendelenburga situation ).

Training of the patient for L. happens various, depending on a condition of hemodynamic indicators, the nature of the forthcoming operation, its urgency and other conditions (see. Preoperative period ). At urgent operations preparation for L. it is carried out to the shortened terms, however the patient before operation needs to stabilize the ABP, at bleeding to make hemotransfusion, to bring the patient out of state of shock etc. The surgeon shall remember always that the preparation for surgery during 1 — 2 hour of the patient with peritonitis and its removal from heavy cardiovascular insufficiency allows to carry out more safely L. U of patients, the Crimea operation is appointed in a planned order, it is necessary to normalize a condition of cardiovascular system, a respiratory organs, intestines etc. Purpose of a diet depends on the nature of the forthcoming operation; in any case for 1 — 2 day of the patient to it it is transferred to more sparing table with an exception of the rough food rich with slags, purpose of vitamins and in the absence of a diabetes mellitus increase in amount of sugar. To the operating room of the patient it is delivered on an empty stomach. with the emptied bladder. In the field of alleged operation hair are the day before shaved off. In the presence of inflammatory diseases on skin (a folliculitis, a furuncle and so forth) planned operation shall be delayed. Preparation surgery field (see) it is made by usual rules of an asepsis. Some surgeons use by production of L. and to fasten with the special sterile films which are pasted on skin of a stomach after its processing that allows to make a skin section through a film the sheets limiting a surgery field directly to a parietal peritoneum. When in an abdominal cavity there is accumulation of pus, the abdominal cavity is fenced off by towels or big napkins which shall be fastened to the sheets delimiting a surgery field, in order to avoid accidental leaving of napkins in an abdominal cavity.

After opening of an abdominal cavity the surgeon carefully examines the struck bodies. At removal intestinal the heifer out of limits of a laparotomichesky wound follows after the research 2 — 3 loops to fill them in an abdominal cavity again before removing the following loops. In case of need for the period of operation to leave the removed bodies outside paws and the mouth of an ohmic wound them should be turned in the wet towel wipes impregnated hot fiziol. solution. In need of survey of all small bowel enter 0,25% into a root of a mesentery solution of novocaine. In the presence in an abdominal cavity of not infected blood it is deleted with a suction machine in sterile ware for possible reinfusion.

In the absence of bleeding, good peritonization of bodies the abdominal cavity is sewn up, as a rule, tightly. If capillary or parenchymatous bleeding is not stopped completely, then to a bleeding point enter tampons into an abdominal cavity (see. Tamponade ), which delete with care in several days after their sliming in order to avoid damage of adjacent bodies. At operations on the bilious ways, a pancreas, on a large intestine, etc. often in an abdominal cavity leave drainages (see. Drainage ); they are usually taken in 3 — 4 days. It is better to carry out introduction of drainages not through a laparotomichesky wound, and through a separate section 1 — 2 cm long in belly a stake, fixing a drainage to skin. For introduction to an abdominal cavity of antibiotics in the presence of peritonitis or other inflammatory center use the capillary microirrigators left in a stomach for 3 — 5 days. On the sewn-up laparotomichesky wound impose a kleolovy sticker or spray special glue. At very big cuts on a stomach impose belts. At the patients having overdevelopment of hypodermic cellulose during the mending of a skin wound it is recommended or to sew up with separate seams hypodermic cellulose, or to use the matratsny deep seams taking hypodermic cellulose to an aponeurosis between to-rymi usual noose sutures are put on skin. In order to avoid hematomas at very full patients some surgeons apply active aspiration of the blood accumulating in a wound, using the narrow drainage tubes which are carried out under cellulose which ends barrels with the air rarefied in them, or special devices are put on.

A removal of sutures at the patients who transferred L., it is made in different terms depending on length of a section, the general condition of the patient, his age, the nature of the made main operation on this or that body, existence or lack of complications etc. So, at median L. in the upper floor of a stomach seams can be removed in the absence of complications for the 8th day, at the weakened patients this term can be prolonged up to 10 — 14 days. At L., made by various other cuts, the term of removal of skin seams is defined individually.

The postoperative period

the Postoperative period at the patients who transferred L., depends not so much on access how many from character of a main type of an operative measure on this or that body (see. Postoperative period ). So, operations on hollow bodies (a stomach, intestines) tied with opening of the cavities containing microbic flora can create conditions, adverse for healing of an operational wound of an abdominal wall, promoting infection of an abdominal cavity with formation of abscesses (see. Peritonitis ) and other possible complications. In the postoperative period of L. quite often is followed by the paresis of a stomach and intestines creating a muscle strain of an abdominal wall that causes a tension of the put stitches. The weakened, exhausted patients can have a full discrepancy of edges of a wound to loss of interiors under skin or even on the surface of skin (see. Eventration ). For the course of a postoperative laparotomichesky wound without complications considerable value has the access elected by the surgeon. So, midsections on the white line of a stomach of big extent (from a xiphoidal shoot to a symphysis) create big danger to possible formation of postoperative hernias (see). Some slanting cuts when intercostal nerves are crossed, create conditions for the subsequent atrophy of muscles of a stomach with a possible relaxation them that comes to an end quite often also with formation of hernia. From cardiovascular and respiratory systems it is very important to apply respiratory gymnastics, an early rising to prevention of complications if drainages and tampons in an abdominal cavity were not left, hemodynamic indicators and the nature of the surgery made on this or that abdominal organ allow. It concerns both purpose of a diet, and various medicines, cleansing enemas and other appointments, in particular parenteral administration of drugs, hemotransfusion and so forth.

In case of clear signs of any complications (bleeding, peritonitis, etc.) which developed in an abdominal cavity it is necessary to open an abdominal cavity repeatedly, i.e. make relaparotomy for what remove all stitches put on a laparotomichesky wound. Relaparotomy is made in the operating room by the same rules which are obligatory for L. At suspicion on complications, however without the explicit clinically expressed symptoms or a lab. the indicators indicating accident in an abdominal cavity, surgeons sometimes use control removal of 2 — 3 seams, introduction to an abdominal cavity of a catheter; through it nasasyvat the liquid which accumulated in an abdominal cavity in the syringe and depending on its character resolve an issue of need relaparotomy in the presence in the syringe of a significant amount of blood, bile or intestinal contents remove all seams and make relaparotomy, edges establishes the reason of the arisen complication and a possibility of its elimination. At the patient with at the same time arisen suppuration of an operational wound in need of relaparotomy it is better to open an abdominal cavity by another, the most convenient for elimination of a complication a section to avoid infection of an abdominal cavity from the suppurated wound. During the mending of a relaparotomny wound because of inflammatory changes of an abdominal wall it is recommended to stitch all layers of a wound matratsny seams together with skin, and in intervals between these seams to put separate stitches on skin. At suppuration of its laparotomichesky wound it is necessary to open widely. At suppuration only of hypodermic cellulose treatment of a wound is carried out by usual rules (see. Wounds, wounds ). In case of penetration of pus under an aponeurosis seams from it are removed only in a zone of necrotic fabrics since removal from an aponeurosis of all seams threatens with eventration. At loss in a wound of an intestinal loop it is soldered often to a parietal peritoneum; in these cases the wound is covered with the bandage which is plentifully impregnated with any oily liquid (Vishnevsky's ointment, vaseline, etc.). After all necrotic fabrics are removed and the wound will become covered by granulations, regions pull together it with strips of an adhesive plaster or impose secondary seam (see).

At patients after L. and operative measures on abdominal organs quite often there are pulmonary complications: the pneumonia, an atelectasis of lungs, respiratory insufficiency more often observed at persons of advanced and senile age. Complications from cardiovascular system develop hl. obr. at patients with an idiopathic hypertensia II and III stages, hron, coronary insufficiency, especially at a postinfarction cardiosclerosis, etc. According to V. S. Mayat and N. S. Leontyeva, 3/4 all complications from cardiovascular and respiratory systems after L. arises at patients with a considerable and extraordinary risk degree. At equal technical specifications on the undergone operation at patients of advanced and senile age the postoperative period proceeds heavier, than at young people. So, according to V. D. Fedorov, discrepancy of wounds and eventration of bodies, intestinal fistulas and progressing of peritonitis are observed at this age by 2 — 3 times more often than at younger patients, and fibrinferments and embolisms are even 3 — 4 times more often. Therefore before planned L., made at patients of advanced and senile age, it is necessary to hold carefully events for normalization of functions of cardiovascular system, respiratory organs, and at change of a koagulogramma to appoint at once after L. anticoagulants (see), especially to the persons which had thrombophlebitis in the anamnesis.

For the purpose of prevention of tromboembolic episodes after operation it is important to include in a complex of respiratory gymnastics also the movements by the lower extremities. In the postoperative period at all patients who transferred L., it is also necessary to monitor bowel emptying and a bladder.

See also Stomach .

Bibliography: Wolves of A. N. Sternomediastinolaparotomiya, Cheboksary, 1971, bibliogr.; Littmann I. Belly surgery, the lane with it., Budapest, 1970; Mayatv. Page and Leontyeva N. S. Cardiovascular and pulmonary complications after abdominal operations at patients of advanced and senile age, Surgery, No. 6, page 134, 1974; Mait V. S. and d river. Resection of a stomach and gastrectomy, M., 1975; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 7, page 82, etc., M., 1960; Petrovsky B. V. Surgical cancer therapy of a gullet and cardia, M., 1950, bibliogr.; Sozon-Yaroshevich A. 10. Anatomic justifications of surgical accesses to internals, L., 1954, bibliogr.; Fedorov V. D. Treatment of peritonitis, M., 1974, bibliogr.; Fedorov S. P. Gallstones and surgery of bilious ways, M. — L., 1934; Bier A., Braun H. u. KiimmelH. Cliirur-gische Operationslehre, Bd 4, T. 1 — 2, Lpz., 1972 — 1975.

B. S. Mayat.