Diagnostic peritoneal lavage (DPL) is a useful test to determine
which patients require a laparotomy based upon the presence of a
hemoperitoneum. The physical examination may be misleading in up
to 45 percent of patients with blunt abdominal trauma. It is helpful
to use the DPL to diagnose the need for a laparotomy sooner and
with greater accuracy.1,2
The technique of DPL was first described in 1964 by Dr. Root
in an attempt to improve the identification of the patient with
blunt abdominal trauma who required a laparotomy.3 His
description of the DPL represented an improvement upon the use of
paracentesis to identify a hemoperitoneum as described by Salomon
in 1906.4 Root’s initial description of DPL utilized
a trocar placed into the peritoneal cavity to instill fluid. The
fluid was visually inspected upon removal and the patient then underwent
a laparotomy if it appeared bloody.
DPL has undergone several modifications since its initial description.
The trocar technique was abandoned first in favor of the open technique
and later the Seldinger or closed technique.5,6 While the
DPL was first described for blunt trauma, it has found an indication
in the patient with penetrating trauma as well.2 Initial
attempts to quantify the effluent based on its appearance have been
replaced by the red blood cell count, the white blood cell count,
and the measurement of various enzymes.7–9 The
debate still rages in the literature as to which criterion best
determines the need for laparotomy.
The gross anatomy of the abdomen is well known to practitioners
and is important to review when preparing for a DPL. The abdominal
cavity is lined by the peritoneum and is protected from the environment
by the abdominal wall musculature, fat, and skin. The right and
left rectus muscles, which are nourished by the epigastric vessels,
meet in the midline at the avascular linea alba. The umbilicus is
located along the lower portion of the linea alba. The layers of
the anterior abdominal wall structures vary above and below the
level of the anterior superior iliac spine (Figure 55-1).
The layers of the anterior abdominal wall vary above
(A) and below (B)
the level of the anterior superior iliac spine.
DPL, unlike a paracentesis, is always
performed in the anterior midline of the abdomen (Figure 55-2).
The linea alba is an avascular location through which the peritoneal
cavity may be entered using either an open technique or a closed
Seldinger type technique. This midline location minimizes the number
of false positive lavages that occur due to bleeding from the abdominal wall
muscles or blood vessels. This also allows the Surgeon to perform
a midline laparotomy, if necessary, through the lavage site and
avoid the formation of an ...