Emergency laparotomy

Surgical approach

• Indications: perforated viscus, bowel obstruction/strangulation, mesenteric ischaemia, intra-abdominal sepsis/abscess, GI bleeding, anastomotic leak, trauma (non-elective)
• Access: usually midline laparotomy (xiphisternum to pubis as needed); rapid entry and wide exposure
• Initial steps: suction/evacuate contamination, pack quadrants, identify source; control haemorrhage if present
• Definitive procedures (examples):
  • Perforation: repair (e.g. omental patch), lavage, drains
  • Obstruction: adhesiolysis, hernia reduction/repair, resection if non-viable bowel
  • Ischaemia: resection ± stoma, second-look laparotomy planned
  • Sepsis: source control, washout, drainage, resection if needed
• Damage control surgery (physiologically deranged patient): abbreviated laparotomy, haemorrhage/contamination control, temporary abdominal closure, ICU resuscitation, planned re-look
• Potential intra-op issues: major fluid shifts, blood loss, contamination, raised IAP/abdominal compartment syndrome risk, prolonged surgery, hypothermia

Anaesthetic management (overview)

• Type of anaesthesia: GA (almost always). Neuraxial may be adjunct (epidural) in selected stable patients; often contraindicated in sepsis/coagulopathy/urgent timing
• Airway: ETT with cuff (RSI usually). SGA inappropriate (full stomach, high aspiration risk, need for controlled ventilation)
• Duration: typically 2–4+ hours (high variability; damage control may be shorter; complex sepsis/adhesions longer)
• Pain: severe (upper abdominal incision, visceral manipulation). Plan multimodal + regional/neuraxial where appropriate
• Physiology: treat as high-risk major surgery with frequent sepsis, hypovolaemia, electrolyte derangement, AKI, aspiration risk

Pre-operative assessment and optimisation (time-critical)

• Aim: resuscitate while expediting source control; parallel processing with surgical/ED/ICU teams
• History: time course, vomiting/obstruction, peritonism, sepsis symptoms, bleeding, anticoagulants, last oral intake, comorbidities (IHD/HF/COPD/CKD), baseline function/frailty
• Examination: airway (RSI difficulty), haemodynamics, perfusion, respiratory status, abdominal distension, signs of shock, delirium
• Investigations: FBC, U&E, LFT, CRP, coagulation, group & save/crossmatch, VBG/ABG (lactate, base deficit), glucose/ketones, ECG, CXR if indicated
• Imaging: CT often already done; clarify pathology and anticipated surgical extent (resection/stoma/damage control)
• Resuscitation: oxygen, 2 wide-bore IVs, balanced crystalloid boluses guided by response; early blood if haemorrhage; correct severe electrolyte derangements (esp K+, Ca2+, severe acidosis)
• Sepsis bundle: cultures if feasible, broad-spectrum antibiotics within 1 hour, lactate, fluids, vasopressors if refractory; source control is definitive
• Gastric decompression: NG tube (often already) to reduce aspiration risk and improve ventilation if distended
• Consent: high-risk discussion (ICU, stoma, blood products, postoperative ventilation, death); document capacity and involve relatives when appropriate
• Risk stratification: NELA risk, P-POSSUM, frailty; triggers senior anaesthetist, ICU bed planning, invasive monitoring

Preparation and monitoring

• Team brief: pathology, aspiration risk, haemorrhage risk, expected contamination, antibiotics timing, blood availability, postoperative destination (PACU/HDU/ICU)
• Monitoring: standard + consider arterial line pre-induction if unstable/vasopressors/major blood loss expected; temperature, urine output; depth of anaesthesia if available
• Venous access: 2 large-bore cannulae; consider rapid infusion device; central line if vasopressors/poor access (do not delay surgery if urgent)
• Blood: group & crossmatch; activate major haemorrhage protocol if indicated; ensure calcium, fibrinogen, TXA availability as appropriate
• Aspiration prophylaxis: consider sodium citrate ± H2 blocker/metoclopramide if time and not contraindicated (do not delay)

Induction and airway (full stomach, physiological instability)

• Plan: RSI with cuffed ETT; head-up positioning if tolerated; suction ready; consider NG aspiration pre-induction if safe
• Pre-oxygenation: tight seal, 3–5 min; consider CPAP/PEEP if obese/hypoxic; apnoeic oxygenation
• Induction agent selection (haemodynamics):
  • Ketamine or etomidate (where available) for shocked patients; titrated propofol in stable patients
  • Opioid: cautious bolus (shock); consider short-acting (fentanyl/alfentanil) titrated
  • Muscle relaxant: rocuronium 1.2 mg/kg or suxamethonium if no contraindication; ensure plan for reversal if needed
• Cricoid pressure: apply correctly; release if impedes view/ventilation
• Anticipate hypotension: vasopressor boluses (metaraminol/phenylephrine) and early noradrenaline infusion if septic shock; treat underlying hypovolaemia concurrently
• Difficult airway: have plan A–D; consider awake intubation only if time and cooperation allow (often not feasible); ensure second anaesthetist if high risk

Maintenance: ventilation, haemodynamics, fluids, temperature

• Anaesthesia: volatile or TIVA; avoid awareness (high-risk with shock); consider processed EEG if available
• Ventilation: lung-protective (6–8 ml/kg IBW), PEEP; adjust for acidosis; recruitment if needed; beware high pressures with distension/Trendelenburg
• Haemodynamic targets: maintain perfusion (MAP often ≥65 mmHg, individualise); use dynamic assessment (echo, PPV/SVV where appropriate, lactate trend, urine output)
• Fluids: balanced crystalloids; avoid excessive chloride; consider albumin in selected cases; early blood products if bleeding; monitor Hb, coagulation, fibrinogen, ionised calcium
• Vasopressors/inotropes: noradrenaline first-line in septic shock; add vasopressin second-line in refractory shock (ICU practice); consider dobutamine if low cardiac output with adequate filling
• Temperature: forced-air warming, fluid warmer, warm theatre; hypothermia worsens coagulopathy and infection risk
• Antibiotics: ensure given and re-dosed for long cases/major blood loss; consider antifungal in selected high-risk intra-abdominal sepsis per local policy
• Glycaemic control: avoid severe hyperglycaemia and hypoglycaemia; check regularly in sepsis/diabetes

Analgesia strategy

• Multimodal: paracetamol (if safe), opioids titrated; NSAIDs often avoided in sepsis/AKI/hypovolaemia
• Regional options (choose based on urgency/coagulopathy/sepsis):
  • Thoracic epidural: excellent analgesia, may reduce ileus; risks: hypotension in sepsis, coagulopathy, time/technical difficulty
  • Spinal opioid (e.g. intrathecal diamorphine): rapid, useful if epidural unsuitable; watch respiratory depression
  • TAP block/rectus sheath block: helpful adjunct, less haemodynamic effect; limited for midline upper incision visceral pain
  • Wound infiltration/catheters: surgeon-assisted option
• Post-op: PCA opioids if no epidural; antiemetic plan; consider ketamine infusion or lidocaine infusion per local practice (contraindications apply)

Post-operative care and disposition

• Most patients require HDU/ICU (NELA guidance: higher-risk patients benefit from critical care); plan early
• Extubation decision: extubate only if warm, haemodynamically stable with minimal vasopressors, adequate gas exchange, acceptable acidosis/lactate trend, low aspiration risk, good analgesia
• Ongoing priorities: sepsis management, vasopressor wean, fluid balance, AKI prevention, early mobilisation, VTE prophylaxis (timing with neuraxial), nutrition (often early enteral if feasible)
• Complications to anticipate: ileus, anastomotic leak, wound infection, pneumonia, delirium, AKI, ongoing bleeding, abdominal compartment syndrome

Special situations

• Bowel obstruction: severe dehydration, metabolic alkalosis (vomiting), hypokalaemia; high aspiration risk; large gastric volumes; careful ventilation due to distension
• Perforation/peritonitis: septic shock, acidosis, capillary leak; vasopressors early; consider stress-dose steroids only if refractory septic shock per ICU plan
• Mesenteric ischaemia: profound metabolic acidosis, high lactate, arrhythmia risk (K+), high mortality; anticipate postoperative ventilation and ICU
• Anticoagulation/antiplatelets: assess neuraxial suitability; reverse warfarin (PCC + vitamin K) if urgent; DOAC reversal per agent/local policy; liaise haematology

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