Letting the Demons Out! Some thoughts on exploratory laparotomy...

“We didn’t find anything particularly abnormal but we let the demons out!” Heard that before? Sure you have and we laugh out loud. But should we be? Are too many unnecessary negative exploratory laparotomy procedures performed? Are too many exploratory laparotomies performed prematurely?

An exploratory laparotomy is, as the name suggests (!), a laparotomy procedure that is done to explore the abdomen in a patient in whom there are clinical signs associated (at least) with the abdomen. The procedure may be done for example to:

• Establish an unknown diagnosis
• Confirm a suspected diagnosis and potentially establish its extent
• Collect samples that will later provide a diagnosis
• Perform a therapeutic intervention that can be palliative or curative including being life-saving in some cases

Potential aims/outcomes of an exploratory laparotomy procedure

Often more than one of these outcomes is achieved during the same laparotomy procedure.

At this point you may be thinking, tell us something we don’t know. What’s your point Shailen?

Well, I wanted to discuss when an exploratory laparotomy should be performed and the concept of a negative exploratory laparotomy. Ever done one? This is not a new topic of discussion, it has been going on for a long time and no doubt will continue for a long time. But I was prompted to write this post by two recent occurrences. One was it came to my attention that a colleague of a friend performs a statistically disproportionate number of exploratory laparotomy procedures many of which are negative; now I am the first to concede that second-hand information must be treated with caution but I am convinced of this individual’s less than ideal ‘scalpel happy’ tendencies. The second occurrence was becoming aware of a young adult dog that underwent a negative exploratory laparotomy procedure and sadly suffered what was presumed to be cerebral hypoxic injury from which the dog did not recover.

Let me state clearly that I do not believe that a negative exploratory laparotomy is of no value. However the majority of what we do in veterinary medicine is essentially about a risk-benefit analysis where ‘risk’ can also include financial costs – but financial costs can also feature on the benefit side. And then practical, logistical, and equipment-/facility-related factors undoubtedly can influence what is ultimately done – it would be naïve to think otherwise. And let’s not forget the part that the individual clinician’s approach, opinion, perspective, philosophy…plays in influencing clinical decision-making.

SO what are the ‘risks’ of an exploratory laparotomy procedure? Well:

It is true that modern anaesthetic drugs and modern general anaesthesia in veterinary medicine is very safe. It is safer in some environments, less safe in others, safer in some patients, less safe in others. But undoubtedly it is very safe. Moreover some people are able to perform exploratory laparotomy in a speedy and efficient manner minimising the time the patient spends under anaesthesia. However it is not risk-free as illustrated by the case above. Hypotension. Hypoxia. Always lurking as potential occurrences as well as random drug reactions, human errors with severe consequences etc.

Surgical risks: a negative exploratory laparotomy is not free of surgical risk either. Often an exploratory laparotomy is performed in a patient with gastrointestinal signs and there is a perspective that says that if nothing remarkable is found one should still use the opportunity to obtain (gastro)intestinal biopsy samples. Sure, I don’t disagree; but bear in mind that you will have opened the gastrointestinal tract which can have complications….you know like that slightly important septic peritonitis thing especially after 3-5 days. There are other ways too in which even a negative exploratory laparotomy can result in complications. If nothing else, you can get dehiscence or infection of the skin/subcutaneous layers.

PAIN and MORBIDITY: is it just me or do some people seem to think that performing an exploratory laparotomy is the same as a minor lump removal procedure as far as the patient is concerned? Yes, I know that nowadays we have some very effective analgesic agents but do people really think that that takes care of all the pain as well as any resulting morbidity? And that’s if modern multimodal pre-emptive dynamic liberal…analgesia is performed. Let’s not pretend it is by everyone. Now of course the amount of pain and morbidity can be moderated to an extent by good surgical skills and gentle tissue handling but the point remains very valid. Dogs especially are their own worst enemies in this regard because often their stoicism portrays that the procedure is benign enough to just do on a whim. Maybe they are not that bothered? Maybe I am over-blowing it? But we would rather not hurt patients unnecessarily right?

And then there are financial implications of a negative exploratory laparotomy procedure and the subsequent post-operative care. Now I obviously realise that these costs vary quite considerably depending on the practice in question but they are there. Note my point below on this too though.

Okay so what about the benefits?

Well there is the list above about the potential outcomes of an exploratory laparotomy procedure. It can help you to find out what is wrong with your patient and potentially to treat or cure him or her. We have to consider this in the context of emergency versus elective patients too; it can save the life of some patients, simple. And in all seriousness, there are a number – not sure of an exact number! – of anecdotal stories of dogs in particular who had a negative exploratory laparotomy procedure and their clinical signs seemed to improve or even resolve more or less straight afterwards. This is where “I let the demons out” comes from.

And then we have the financial considerations. It is undeniable that in some circumstances in some practices performing an exploratory laparotomy without any or with minimal pre-operative diagnostics is the most cost effective way forward. I don’t want to make light of this, it can be the motivation that has led to a number of exploratory laparotomies being performed.

One other thing we need to consider is peace of mind for the pet’s carer and more broadly the pet carer’s wishes. Sometimes the impetus for an exploratory laparotomy that may be premature or anticipated to be negative can be the pet’s carers and their wish for more definitive peace of mind.

With all of that said, based on my own personal experiences over the last 15 years and on anecdote, I think that too many exploratory laparotomy procedures are performed unnecessarily or at least prematurely. I think that there are many occasions in which some more rational clinical thinking about what is going on with the patient and additional diagnostics, or indeed the same diagnostics performed in a serial monitoring fashion (e.g. repeat abdominal radiographs) would lead one to conclude that surgery was not indicated.

Where I have worked for a significant part of my ECC career – a tertiary referral centre – negative exploratory laparotomies are very rare. “Well that’s because you have worked in a tertiary referral centre where many of the patients are insured, money is often not the major limiting factor and there are specialist diagnostic imagers” I hear you say. True. But I can also tell you that in my years spent doing first opinion Out-of-Hours work sitting here I cannot recall a time when I performed a negative exploratory laparotomy. That probably means that I have done at least one which I have chosen to forget but the point remains. And the same is true for the time I spent supervising and training and mentoring others doing first opinion Out-of-Hours work. When we talked through the case often the exploratory laparotomy they had concluded was necessary was not performed and the patient went on to recover fine. This blog is not about me of course, I am making a more general point but I wanted to share my experiences.

Okay I think that is all I really have to say on this. Basically please do what you can to avoid performing unnecessary exploratory laparotomy procedures and maybe try and share some of that philosophy with those around you…in a polite, collegiate and politically sensitive way of course!

As always I would love to hear your thoughts and opinions on this post.

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