METHODS AND TECHNIQUES
Diagnostic Peritoneal Lavage Vincent ,1. Markovchick, MD Stephen C. Elerding, MD Ernest Eugene Moore, MD Peter Rosen, MD Denver, Colorado
A technique for peritoneal lavage which has increased accuracy and eliminated complications is described. A curved incision is made to one side of the umbilicus at the level of the infraumbilical ring extending over the linea alba for 4 cm. The advantages of the site are its avascularity, paucity of peritoneal fat, and adherence of the peritoneum. By placing the incision at the infraumbilical ring, the rectus muscle is avoided. By adhering to the technique described, false lavage results and iatrogenic injuries to abdominal structures have been significantly decreased. Markovchick VJ, Elerding SC, Moore EE, Rosen P: Diagnostic peritoneal lavage. JACEP 8:326-328, August, 1979.
peritonea/ /avage, technique
INTRODUCTION Diagnostic peritoneal lavage is a reliable means of evaluating the patient with blunt abdominal trauma when physical examination is either equivocal or unobtainable. 1"4 Recently, t h i s procedure has been extended to assess stab wound victims. ~,6 Although there is a variety of techniques for performing peritoneal lavage, at Denver General Hospital we have used a technique that has increased the accuracy and significantly decreased complications, even in those patients with relative contraindications 7 to lavage, such as marked obesity, previous abdominal surgery, or distended bowel. TECHNIQUE If possible, an upright chest x-ray film is obtained prior to the procedure to exclude free intraperitoneal air. A Foley catheter is inserted to decompress the bladder in all patients. In the pediatric age group, it is particularly important to also decompress the stomach with a nasogastric tube. The periumbilical area is shaved, prepped with povidone-iodine solution, and draped. Local anesthesia is obtained with 1% xylocaine with epinephrine. A gently curved incision is begun to one side of the umbilicus, at the level of the infraumbilical ring, over the linea alba for 4 cm (Figure 1). The course of the incision allows incorporation into a vertical midline incision should celiotomy be required. This site is commonly used in peritoneoscopy and has recently been suggested for use in peritoneal lavage, s The advantages of the site are its relative avascularity, paucity of peritoneal fat, and adherence of the peritoneum resulting from obliteration of the umbilical arteries and urachus. The. incision is extended through the subcutaneous fat and meticulous hemostasis achieved. The linea alba is then grasped on both sides with towel clips (Figure 2). This maneuver elevates the fascia from underlying structures. From the Departments of Emergency Medicine and Surgery, Denver General Hospital, Denver, Colorado. A,Cldressfor reprints:Vince Markovchick, MD, DenverGeneral Hospital, Emergency Medical Services, 750 Cherokee Street, Denver, Colorado 80204.
56/326
JACEP
8:8 (August) ~1979
/
I
~
~
J _
I fl I I Fig. 1. Incision at site of infraumbilical ring.
Fig. 3. Catheter inserted at 45 ° toward pelvis through inferior umbilical ring.
Fig. 2. Elevation of fascia with towel clips.
a 1 cm v e r t i c a l i n c i s i o n is m a d e through t h e l i n e a a l b a at the level of the i n f r a u m b i l i c a l r i n g exposing the p r e p e r i t o n e a l fat. A p e d i a t r i c peritoneal dialysis c a t h e t e r is introduced through the peritoneum with the trocar in place. After p u n c t u r i n g the peritoneum, the trocar is w i t h d r a w n and t h e c a t h e t e r d i r e c t e d t o w a r d the pelvis ( F i g u r e 3). On i n i t i a l a s p i r a t i o n with a 20 cc syringe, if g r e a t e r t h a n 10 cc of free flowing blood is obtained, the procedure is t e r m i n a t e d and the t a p i n t e r preted as positive. If gross blood is not a s p i r a t e d , an i n t r a v e n o u s infusion set i s connected to the c a t h e t e r and I liter of Ringer's lactate solution is infused (15 ml/kg body w e i g h t ia c h i l d r e n ) . T h e p a t i e n t is r o l l e d
8:8 (August) 1979
from side to side, the bottle lowered to the floor a n d t h e lavage fluid ret u r n e d by siphonage. Care m u s t be t a k e n not to d i s r u p t the continuity of the line t h r o u g h o u t the procedure since the siphon effect m a y be lost and fluid r e t u r n diminished. Gross i n s p e c t i o n of the l a v a g e e f f l u e n t is u n r e l i a b l e . 1 T h e f l u i d should be s u b m i t t e d for l a b o r a t o r y a n a l y s i s of t h e r e d a n d w h i t e cell c o u n t s , a m y l a s e level, p r e s e n c e of bile, and Gram stain. A red cell count g r e a t e r t h a n 100,000 cu m m is i n d i c a t i v e of s i g n i f i c a n t i n t r a p e r i t o n e a l injury. A white cell count exceeding 500 cu m m and an e l e v a t e d a m y l a s e are only r e l a t i v e indications for e x p l o r a t i o n a n d m u s t be i n t e r preted along with other Clinical findings.6, 7 Following r e m o v a l of the catheter, the defect in the p e r i t o n e u m is left open, t h e l i n e a a l b a a p p r o x i m a t e d w i t h one or two s u t u r e s of 0-polypropylene suture, and the s k i n a l i g n e d w i t h 3-0 p o l y p r o p y l e n e suture. If a p r e v i o u s u p p e r a b d o m i n a l incision is present, the incision for lavage is m a d e one t h i r d the distance f r o m t h e u m b i l i c u s to t h e p u b i s . Prior lower abdominal incisions necessitate lavage via an incision above t h e u m b i l i c u s , a l t h o u g h t h i s approach is h i n d e r e d by the falciform l i g a m e n t and greater=distance to the pelvis. If t h e r e is a n y q u e s t i o n a b o u t a d h e r e n t bowel or omentum, a 1 cm
JACEP
i n c i s i o n is m a d e d i r e c t l y in t h e p e r i t o n e u m and a finger inserted to confirm free i n t r a p e r i t o n e a l access. T h e c a t h e t e r is t h e n i n t r o d u c e d g e n t l y w i t h o u t t h e trocar.
DISCUSSION The efficacy of peritoneal lavage in e v a l u a t i n g a b d o m i n a l t r a u m a is well established. 1-6 However, complications continue to occur2 O u r previous site for a b d o m i n a l lavage was one t h i r d t h e distance between umb i l i c u s a n d p u b i s in t h e m i d l i n e . F a l s e positive r e s u l t s due to b l e e d i n g from the a b d o m i n a l wall, rectus abdominus a n d p r e p e r i t o n e a l fat were encountered and false n e g a t i v e lavages occurred from infusion of the lavage solution into the p r e p e r i t o n e a l space. By p l a c i n g the incision at the i n f r a u m b i l i c a l ring, the rectus muscle is a v o i d e d a n d t h e a m o u n t of p r e p e r i t o n e a l fat t r a n s v e r s e d m i n i m a l . T h i s m o d i f i e d a p p r o a c h is p a r t i c u l a r l y a d v a n t a g e o u s in t h e obese patient. By strictly a d h e r i n g to the above techniques, false lavage results and i a t r o g e n i c i n j u r i e s to i n t r a - a b d o m i nal structures have been signific a n t l y decreased (unpublished data), s
REFERENCES 1. Engrav LH, Benjamin CI, Strate RG, et al: Diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 15"854-859, 1975.
327/57
2. Olsen SR, Redman HC, Hildreth DH: Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 104:536543, 1972. 3. Parvin S, Smith D, Asher WM, et al: E f f e c t i v e n e s s of p e r i t o n e a l l a v a g e in b l u n t a b d o m i n a l t r a u m a . Ann Surg 181:255-261, 1975. 4. Root HD, Hauser CW, McKinley CR, et al: Diagnostic p e r i t o n e a l lavage.
58/328
Surgery 57:633-637, 1965. 5. McAlvanah MJ, Shaftan GW: Selective conservatism in penetrating abdominal wounds: A continuing reappraisal. J Trauma 18:206-212, 1978. 6. Thal ER: Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma 17:642-648, 1977. 7. Ahmad N, Polk HC: Blunt abdominal
JACEP
trauma. A prospective study with selected peritoneal lavage. Arch Surg 3:489-492, 1976. 8. Slavin SA: A new technique for diag. nostic peritoneal lavage. Surg Gynecol Obstet 140:446-448, 1978. 9. B r e e n PC, R u d o l f LE: Potential sources of error in the use of peritoneal l a v a g e as a d i a g n o s t i c tool. JACEP 3:401-404, 1974.
8:8 (August) 1979
Diagnostic Peritoneal Lavage Vincent ,1. Markovchick, MD Stephen C. Elerding, MD Ernest Eugene Moore, MD Peter Rosen, MD Denver, Colorado
A technique for peritoneal lavage which has increased accuracy and eliminated complications is described. A curved incision is made to one side of the umbilicus at the level of the infraumbilical ring extending over the linea alba for 4 cm. The advantages of the site are its avascularity, paucity of peritoneal fat, and adherence of the peritoneum. By placing the incision at the infraumbilical ring, the rectus muscle is avoided. By adhering to the technique described, false lavage results and iatrogenic injuries to abdominal structures have been significantly decreased. Markovchick VJ, Elerding SC, Moore EE, Rosen P: Diagnostic peritoneal lavage. JACEP 8:326-328, August, 1979.
peritonea/ /avage, technique
INTRODUCTION Diagnostic peritoneal lavage is a reliable means of evaluating the patient with blunt abdominal trauma when physical examination is either equivocal or unobtainable. 1"4 Recently, t h i s procedure has been extended to assess stab wound victims. ~,6 Although there is a variety of techniques for performing peritoneal lavage, at Denver General Hospital we have used a technique that has increased the accuracy and significantly decreased complications, even in those patients with relative contraindications 7 to lavage, such as marked obesity, previous abdominal surgery, or distended bowel. TECHNIQUE If possible, an upright chest x-ray film is obtained prior to the procedure to exclude free intraperitoneal air. A Foley catheter is inserted to decompress the bladder in all patients. In the pediatric age group, it is particularly important to also decompress the stomach with a nasogastric tube. The periumbilical area is shaved, prepped with povidone-iodine solution, and draped. Local anesthesia is obtained with 1% xylocaine with epinephrine. A gently curved incision is begun to one side of the umbilicus, at the level of the infraumbilical ring, over the linea alba for 4 cm (Figure 1). The course of the incision allows incorporation into a vertical midline incision should celiotomy be required. This site is commonly used in peritoneoscopy and has recently been suggested for use in peritoneal lavage, s The advantages of the site are its relative avascularity, paucity of peritoneal fat, and adherence of the peritoneum resulting from obliteration of the umbilical arteries and urachus. The. incision is extended through the subcutaneous fat and meticulous hemostasis achieved. The linea alba is then grasped on both sides with towel clips (Figure 2). This maneuver elevates the fascia from underlying structures. From the Departments of Emergency Medicine and Surgery, Denver General Hospital, Denver, Colorado. A,Cldressfor reprints:Vince Markovchick, MD, DenverGeneral Hospital, Emergency Medical Services, 750 Cherokee Street, Denver, Colorado 80204.
56/326
JACEP
8:8 (August) ~1979
/
I
~
~
J _
I fl I I Fig. 1. Incision at site of infraumbilical ring.
Fig. 3. Catheter inserted at 45 ° toward pelvis through inferior umbilical ring.
Fig. 2. Elevation of fascia with towel clips.
a 1 cm v e r t i c a l i n c i s i o n is m a d e through t h e l i n e a a l b a at the level of the i n f r a u m b i l i c a l r i n g exposing the p r e p e r i t o n e a l fat. A p e d i a t r i c peritoneal dialysis c a t h e t e r is introduced through the peritoneum with the trocar in place. After p u n c t u r i n g the peritoneum, the trocar is w i t h d r a w n and t h e c a t h e t e r d i r e c t e d t o w a r d the pelvis ( F i g u r e 3). On i n i t i a l a s p i r a t i o n with a 20 cc syringe, if g r e a t e r t h a n 10 cc of free flowing blood is obtained, the procedure is t e r m i n a t e d and the t a p i n t e r preted as positive. If gross blood is not a s p i r a t e d , an i n t r a v e n o u s infusion set i s connected to the c a t h e t e r and I liter of Ringer's lactate solution is infused (15 ml/kg body w e i g h t ia c h i l d r e n ) . T h e p a t i e n t is r o l l e d
8:8 (August) 1979
from side to side, the bottle lowered to the floor a n d t h e lavage fluid ret u r n e d by siphonage. Care m u s t be t a k e n not to d i s r u p t the continuity of the line t h r o u g h o u t the procedure since the siphon effect m a y be lost and fluid r e t u r n diminished. Gross i n s p e c t i o n of the l a v a g e e f f l u e n t is u n r e l i a b l e . 1 T h e f l u i d should be s u b m i t t e d for l a b o r a t o r y a n a l y s i s of t h e r e d a n d w h i t e cell c o u n t s , a m y l a s e level, p r e s e n c e of bile, and Gram stain. A red cell count g r e a t e r t h a n 100,000 cu m m is i n d i c a t i v e of s i g n i f i c a n t i n t r a p e r i t o n e a l injury. A white cell count exceeding 500 cu m m and an e l e v a t e d a m y l a s e are only r e l a t i v e indications for e x p l o r a t i o n a n d m u s t be i n t e r preted along with other Clinical findings.6, 7 Following r e m o v a l of the catheter, the defect in the p e r i t o n e u m is left open, t h e l i n e a a l b a a p p r o x i m a t e d w i t h one or two s u t u r e s of 0-polypropylene suture, and the s k i n a l i g n e d w i t h 3-0 p o l y p r o p y l e n e suture. If a p r e v i o u s u p p e r a b d o m i n a l incision is present, the incision for lavage is m a d e one t h i r d the distance f r o m t h e u m b i l i c u s to t h e p u b i s . Prior lower abdominal incisions necessitate lavage via an incision above t h e u m b i l i c u s , a l t h o u g h t h i s approach is h i n d e r e d by the falciform l i g a m e n t and greater=distance to the pelvis. If t h e r e is a n y q u e s t i o n a b o u t a d h e r e n t bowel or omentum, a 1 cm
JACEP
i n c i s i o n is m a d e d i r e c t l y in t h e p e r i t o n e u m and a finger inserted to confirm free i n t r a p e r i t o n e a l access. T h e c a t h e t e r is t h e n i n t r o d u c e d g e n t l y w i t h o u t t h e trocar.
DISCUSSION The efficacy of peritoneal lavage in e v a l u a t i n g a b d o m i n a l t r a u m a is well established. 1-6 However, complications continue to occur2 O u r previous site for a b d o m i n a l lavage was one t h i r d t h e distance between umb i l i c u s a n d p u b i s in t h e m i d l i n e . F a l s e positive r e s u l t s due to b l e e d i n g from the a b d o m i n a l wall, rectus abdominus a n d p r e p e r i t o n e a l fat were encountered and false n e g a t i v e lavages occurred from infusion of the lavage solution into the p r e p e r i t o n e a l space. By p l a c i n g the incision at the i n f r a u m b i l i c a l ring, the rectus muscle is a v o i d e d a n d t h e a m o u n t of p r e p e r i t o n e a l fat t r a n s v e r s e d m i n i m a l . T h i s m o d i f i e d a p p r o a c h is p a r t i c u l a r l y a d v a n t a g e o u s in t h e obese patient. By strictly a d h e r i n g to the above techniques, false lavage results and i a t r o g e n i c i n j u r i e s to i n t r a - a b d o m i nal structures have been signific a n t l y decreased (unpublished data), s
REFERENCES 1. Engrav LH, Benjamin CI, Strate RG, et al: Diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 15"854-859, 1975.
327/57
2. Olsen SR, Redman HC, Hildreth DH: Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 104:536543, 1972. 3. Parvin S, Smith D, Asher WM, et al: E f f e c t i v e n e s s of p e r i t o n e a l l a v a g e in b l u n t a b d o m i n a l t r a u m a . Ann Surg 181:255-261, 1975. 4. Root HD, Hauser CW, McKinley CR, et al: Diagnostic p e r i t o n e a l lavage.
58/328
Surgery 57:633-637, 1965. 5. McAlvanah MJ, Shaftan GW: Selective conservatism in penetrating abdominal wounds: A continuing reappraisal. J Trauma 18:206-212, 1978. 6. Thal ER: Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma 17:642-648, 1977. 7. Ahmad N, Polk HC: Blunt abdominal
JACEP
trauma. A prospective study with selected peritoneal lavage. Arch Surg 3:489-492, 1976. 8. Slavin SA: A new technique for diag. nostic peritoneal lavage. Surg Gynecol Obstet 140:446-448, 1978. 9. B r e e n PC, R u d o l f LE: Potential sources of error in the use of peritoneal l a v a g e as a d i a g n o s t i c tool. JACEP 3:401-404, 1974.
8:8 (August) 1979
