The diagnostic peritoneal lavage (DPL) was first described in 1965 by Root who described a method for sampling the peritoneal cavity to determine more rapidly the presence of a hemoperitoneum after trauma.1 The initial physical examination can be misleading in up to 45% of blunt trauma patients.2 A DPL can be useful in diagnosing abdominal injury in a timely fashion.2 It is performed less frequently today due to the use of focused abdominal sonography for trauma (FAST) bedside ultrasound scanning and helical computed tomography (CT). The DPL is the only invasive test of the three and remains the most sensitive test for mesenteric and hollow viscus injuries.3,4
Dr. Root's description of the DPL represented an improvement upon the use of paracentesis to identify a hemoperitoneum as described by Salomon in 1906.5 His initial description of a 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 trochar technique was abandoned first in favor of the open technique, and later the Seldinger or closed technique.7,8 A novel method which combines the use of diagnostic laparoscopy and DPL has been termed laparoscopic diagnostic peritoneal lavage (L-DPL).6 This procedure combines the visual advantages of laparoscopy with the sensitivity and specificity of a DPL for the diagnosis of significant penetrating intraabdominal injury. While the DPL was first described for blunt abdominal trauma, it has found an indication in the patient with penetrating abdominal trauma.2 Initial attempts to quantify the effluent based on its appearance have been replaced by the red blood cell (RBC) count, the white blood cell (WBC) count, and the measurement of various enzymes.9–11 The debate still rages in the literature as to which criterion best determines the need for a laparotomy.
The gross anatomy of the abdomen is well known to Emergency Physicians 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 66-1).
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 66-2)....