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The diagnostic peritoneal lavage (DPL) was first described in 1965 by Dr. Root who developed a method for sampling the peritoneal cavity to more rapidly determine the presence of hemoperitoneum after trauma.1 The initial physical examination can be misleading in up to 45% of blunt trauma patients, and DPL can be useful in diagnosing intraabdominal injury in a timely fashion.2-4 DPL is performed less frequently due to the use of focused abdominal sonography for trauma (FAST) bedside ultrasound (US) scanning and helical computed tomography (CT).5,6 DPL is the only invasive test of the three and remains a highly sensitive test for mesenteric and hollow viscus injuries.4,7,8 The main disadvantages of DPL are that it gives no information about the specific organ injured and a positive DPL requires an invasive procedure in the Operating Room versus conservative management and observation. The overall use of DPL is declining with the progression of advanced CT scanning, repeat/serial FAST exams, and the increased availability of these modalities.3,5,9
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Dr. Root’s description of the DPL represented an improvement upon the use of paracentesis to identify a hemoperitoneum as described by Salomon in 1906.10 His initial description of a DPL used 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.
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DPL has undergone several modifications since its initial description. The trocar technique was initially abandoned in favor of the open technique, which later fell to the Seldinger or closed technique.11,12 A novel method that combines the use of diagnostic laparoscopy and DPL has been termed laparoscopic diagnostic peritoneal lavage (L-DPL).13 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the patient with penetrating abdominal trauma.2 Initial attempts to quantify the effluent based on its appearance have been replaced by the red blood cell (RBC) count, the white blood cell (WBC) count, and the measurement of various enzymes.14-16 The debate is still present in the literature as to which criterion best determines the need for a laparotomy.
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ANATOMY AND PATHOPHYSIOLOGY
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The gross anatomy of the abdomen is well known to the Emergency Physician 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 ...