In gynecologic surgery, laparotomy is the preferred approach when full access to the pelvis and/or upper abdomen are desired, particularly when pelvic adhesions are suspected or exploration of the retroperitoneal space may be required. Pelvic or abdominal masses, suspected carcinoma, a history of prior abdominal surgery, and suspected retroperitoneal pathology are all indications for considering laparotomy over laparoscopy. The abdomen and pelvis may be accessed through either a longitudinal or transverse approach. The choice of incision is based on the area in which surgical exposure is desired while reducing patient discomfort and postoperative complications. Proper surgical technique and the judicious use of self-retaining retractors with awareness of abdominal and pelvic neuroanatomy can minimize postoperative complications. Incision closure technique has changed dramatically since the advent of longer-lasting absorbable suture material, resulting in fewer incisional complications, improved patient satisfaction, and reduced hospitalization.
Scope of the Problem
The widespread development of minimally invasive and robotic techniques for gynecologic and general surgery in urban and teaching hospitals has made the laparotomy a less commonly performed procedure. Availability of open and vaginal hysterectomies has diminished to the point that American residency programs are concerned about appropriate laparotomy experience for each resident. Gynecologic oncology services, long a source of laparotomies and hysterectomies for ovarian cancer cytoreduction and radical hysterectomies for cervical cancer, have reduced the use of laparotomy in favor of robotic procedures. The “open” abdominal hysterectomy is at risk of becoming a “lost art,” with some residency graduates unable to confidently perform the procedure in general practice. In a recent survey of gynecologic oncology fellowship directors, half of the respondents reported that their incoming fellows could not independently perform an abdominal hysterectomy, and 40 percent could not recognize anatomy and tissue planes. As the number of open teaching cases declines, it becomes more important that the surgeon maintain a conscious awareness of proper surgical technique and practices that optimize patient safety. Application of good surgical technique with reusable instruments can make the open hysterectomy a cost-effective alternative to laparoscopic and robotic procedures.
Prevention of Venous Thromboembolic Events
A number of factors must be considered when choosing the appropriate venous thromboembolic prophylaxis regimen for each patient. Patient age, expected length of time of surgery, history of prior thromboembolism, and diagnosis of inherited thrombophilia all influence the risk of postoperative thromboembolism.