- Open Access
Diagnostic peritoneal lavage: a review of indications, technique, and interpretation
© Whitehouse and Weigelt; licensee BioMed Central Ltd. 2009
- Received: 21 January 2009
- Accepted: 08 March 2009
- Published: 08 March 2009
Diagnostic peritoneal lavage (DPL) is a highly accurate test for evaluating intraperitoneal hemorrhage or a ruptured hollow viscus, but is performed less frequently today due to the increased use of focused abdominal sonography for trauma (FAST) and helical computed tomography (CT). All three of these exams have advantages and disadvantages and thus each still play unique roles in the evaluation of abdominal trauma. Since DPL is performed less frequently today, a review of its indications, technique, and interpretation is pertinent.
- Compute Tomography Scanning
- Abdominal Trauma
- Helical Compute Tomography
- Stab Wound
- Hollow Viscus
Diagnostic peritoneal lavage (DPL) is an invasive, rapid, and highly accurate test for evaluating intraperitoneal hemorrhage or a ruptured hollow viscus. DPL plays a role in both blunt and penetrating abdominal trauma. First described in 1965, DPL replaced the four-quadrant abdominal tap, boasting a higher sensitivity and specificity in identifying intraabdominal injury . Today DPL is performed less frequently, as it has been replaced by focused abdominal sonography for trauma (FAST) and helical computed tomography (CT). Yet, each of these diagnostic modalities has unique advantages and disadvantages.
DPL is the only invasive test of the three, but while lacking organ specificity it remains the most sensitive test for mesenteric and hollow viscus injuries [2, 3]. FAST exams are rapid, noninvasive, and can be repeated multiple times throughout the resuscitation period. They are more user-dependent than DPL or CT scanning. Both FAST and DPL ineffectively evaluate retroperitoneal and diaphragmatic injuries and poorly identify solid organ injuries. Abdominopelvic CT scanning still requires a hemodynamically normal patient, is costly, and carries a small but significant lifetime risk of malignancy [4, 5]. However, CT scanning reliably diagnoses solid organ injuries and evaluates the retroperitoneum, but its sensitivity and specificity for blunt bowel and mesenteric injuries is not superior to DPL . As a result of these differences, all three tests continue to play important roles when evaluating a trauma patient for abdominal injuries.
Since DPL is performed less commonly today, a review of its indications, technique, and interpretation is pertinent.
DPL is indicated in both blunt and a selective group of penetrating abdominal injuries. In blunt injuries, DPL has a number of indications but is dependent upon the patient's condition and availability of CT scanning and FAST. DPL is useful for patients who are in shock and when FAST capability is not available. Hypotensive patients should not be evaluated with CT scanning. In the absence of CT scanning, DPL is also useful in patients with an unreliable abdominal exam due to altered mental status or spinal cord injury. Other indications, when CT scanning is not available, include equivocal physical exam findings, the presence of a lap-belt sign, injuries to adjacent structures such as the lower ribs, lumbar spine, or pelvis, anticipated prolonged loss of contact with the patient (i.e. extraaabdominal procedures), or a high clinical suspicion of an intraabdominal injury.
The role of DPL in penetrating trauma is focused on patients with asymptomatic anterior abdominal stab wounds [7, 8]. Patients with an anterior stab wound to the abdomen who are hemodynamically normal and have no signs of peritonitis are evaluated with a local wound exploration and if positive, a DPL is performed. Patients with flank wounds that track anteriorly are also candidates for DPL if the local wound exploration is positive .
The only absolute contraindication to DPL is previous abdominal surgery and this contraindication often is tempered by clinical judgment. The concern in these patients is that the DPL will actually injury an intra-abdominal organ when the catheter is introduced or that the fluid entrance and exit will be impeded by adhesions. Clinical judgment will allow some patients with previous abdominal surgery to be assessed with a DPL while in others the amount of surgery will clearly be a contraindication to DPL. Relative contraindications include preexisting coagulopathy, advanced cirrhosis, and morbid obesity. Relative contraindications to the standard infraumbilical approach include patients with a pelvic fracture or females beyond the 1st trimester of pregnancy.
DPL is performed one of three different ways [10, 11]. The open technique utilizes a vertical infraumbilical incision and direct visualization of peritoneal entry with a scalpel. The closed technique relies on percutaneous needle access to the peritoneal cavity, followed by the insertion of a catheter using Seldinger technique. The semi-open technique follows the same principles of the open technique except that the midline fascia is penetrated with a needle and the catheter is advanced using the Seldinger technique. There is no difference in overall outcomes or rates of injury to visceral contents between the techniques [12–14]. The closed method is faster, but often has more technical complications such as wire placement and inadequate fluid return [12–14].
Regardless of the technique chosen, patient preparation is the same. First, the patient is positioned flat in the supine position. A Foley catheter and a nasogastric tube are inserted to decompress the bladder and stomach. The periumbilical area is surgically prepped and draped widely. A combination of local anesthesia and intravenous conscious sedation is used in hemodynamically normal patients. Local anesthesia alone will suffice in a hemodynamically abnormal patient. 1% lidocaine with epinephrine is used for local anesthesia to reduce the amount of cutaneous bleeding, which may lead to a false positive test.
A syringe is used to aspirate the peritoneal contents. If blood flows easily into the syringe, most accept this as a positive aspirate and proceed with laparotomy. Others suggest 10 ml of blood constitutes a positive result . In the absence of 10 ml blood, the DPL catheter is connected to a warmed liter bag of Lactated Ringers or normal saline using standard intravenous tubing. Care must be taken that the tubing has no one-way valves which would not allow fluid to flow freely back into the IV fluid bag. While the fluid infuses, gently rock the patient to allow mixing of the fluid with peritoneal contents. Once the bag is almost empty, place it on the floor and allow the intraabdominal fluid to return (Figure 4). Adequate fluid analysis requires at least 30% of the original amount infused. This usually amounts to 300–350 ml in an adult. In the pediatric patient, 10–15 ml/kg of fluid is infused and an adequate return is 20–30% of the total infusion . This fluid is sent for gram stain and analysis of the red blood cell count and white blood cell count. It also should be grossly examined for enteric, bilious, or vegetable matter content. The wound is irrigated and only the skin requires surgical closure with either sutures or staples. If the open technique is used, the incised fascia should be closed. This stitch can be placed while the fluid is infusing and secured once the catheter is removed. If a closed technique is used then no stitch is required.
A positive DPL in an adult classically requires one of the following results: 10 ml gross blood on initial aspiration, > 500/mm3 white blood cells (WBC), > 100,000/mm3 red blood cells (RBC), or the presence of enteric/vegetable matter . These thresholds were originally developed in the setting of blunt trauma and have since been applied to penetrating trauma [1, 17, 18]. In the presence of gross blood or enteric matter, immediate laparotomy is performed. Without those findings, accurate cell counts should be obtained, which in our institution takes approximately 30 minutes to receive from the laboratory. During this time period, if the patient's clinical status deteriorates or signs of peritonitis develop, laparotomy is not delayed.
Some authors advocate lowering the threshold of RBCs in penetrating trauma to as low a 1,000 cells/mm, but others have shown significantly increased nontherapeutic procedure rates at lower thresholds [7, 9, 17–21]. Thacker reported an increase in the nontherapeutic celiotomy rate from 2.5% to 44% without a decrease in the number of missed injuries when 10,000 RBCs/mm3 was used as the cutoff. Thal reported a comparable nontherapeutic procedure rate of 4.1% when 100,000 RBCs/mm3 was used as the cutoff . In the face of a 22% morbidity rate from negative laparotomies, one must be cognizant of the risk of lowering the threshold to operate .
Patient safety is tantamount for all invasive procedures. Performing DPL safely is the goal. Most complications occur when principles are ignored. Not decompressing the urinary bladder or stomach increases the chances of injury to either organ with the DPL needle and catheter. In the obtunded patient, excessive pressure on the needle when entering the abdomen increases the likelihood of injury to the iliac vessels. When properly done, complication rates should be low. Two reports of over 2,500 DPLs each report an overall complication rate of 0.8%–1.7%, which included wound problems, inadequate fluid return, small bowel/mesenteric injuries, bladder punctures, and abdominal wall infusions [23, 24].
Following a negative DPL, the wound should be monitored for infection. There is no evidence supporting prophylactic antibiotics unless indicated for a separate clinical condition. Non-absorbable sutures or skin staples placed at the time of closure are removed after 3–7 days either in the hospital or in a clinic setting following discharge.
We would like to thank Rebekah A Dodson for creating the illustrations used in this review.
- Root HD, Hauser GW, McKinley CR: Diagnostic peritoneal lavage. Surgery. 1965, 57: 633-PubMedGoogle Scholar
- Ceraldi CM, Waxman K: Computerized tomography as an indicator of isolated mesenteric injury. A comparison with peritoneal lavage. Am Surg. 1990, 56: 806-810.PubMedGoogle Scholar
- Meyer DM, Thal ER, Weigelt JA: Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma. 1989, 29: 1168-1170.View ArticlePubMedGoogle Scholar
- Brenner DJ, Elliston CD, Hall EJ, Berdon WE: Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001, 176 (2): 289-296.View ArticlePubMedGoogle Scholar
- Hall EJ, Brenner DJ: Cancer risks from diagnostic radiology. Brit J Rad. 2008, 81: 362-378. 10.1259/bjr/01948454.View ArticleGoogle Scholar
- Ekeh AP, Saxe J, Walusimbi M, Tchorz KM, Woods RJ, Anderson HL, McCarthy MC: Diagnosis of blunt intestinal and mesenteric injury in the era of multidetector CT technology – are results better?. J Trauma. 2008, 65 (2): 354-359. 10.1097/TA.0b013e3181801cf0.View ArticlePubMedGoogle Scholar
- Thal ER: Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma. 1977, 17 (8): 642-648. 10.1097/00005373-197708000-00012.View ArticlePubMedGoogle Scholar
- Gallbraith TA, Oreskovich MR, Heimbach DM, Herman CM, Carrico CJ: The role of peritoneal lavage in the management of stab wounds to the abdomen. Am J Surg. 1980, 140: 60-64. 10.1016/0002-9610(80)90418-3.View ArticleGoogle Scholar
- Boyle EM, Maier RV, Salazar JD, Kovacich JC, O'Keefe G, Mann FA, Wilson AJ, Copass MK, Jurkovich GJ: Diagnosis of injuries after stab wounds to the back and flank. J Trauma. 1997, 42 (2): 260-265. 10.1097/00005373-199702000-00013.View ArticlePubMedGoogle Scholar
- American College of Surgeons: Abdominal trauma. Advanced Life Support Program for Doctors. 2008, Chicago, IL, 111-129. 8Google Scholar
- Schultz DJ, Weigelt JA: Diagnostic Peritoneal Lavage. Operative Techniques in General Surgery. Edited by: VanHeerden JA, Farley DR. 2003, Philadelphia, PA: WB Saunders, 5 (3): 139-144. 10.1016/S1524-153X(03)70005-0.Google Scholar
- Cue JI, Miller FB, Cryer HM, Malangoni MA, Richardson JD: A prospective, randomized comparison between open and closed peritoneal lavage techniques. J Trauma. 1990, 30 (7): 880-883.View ArticlePubMedGoogle Scholar
- Wilson WR, Schwarcz TH, Pilcher DB: A prospective randomized trial of the Lazarus-Nelson vs the standard peritoneal dialysis catheter for peritoneal lavage in blunt abdominal trauma. J Trauma. 1987, 27 (10): 1177-1180.View ArticlePubMedGoogle Scholar
- Lopez-Viego MA, Mickel TJ, Weigelt JA: Open versus closed diagnostic peritoneal lavage in the evaluation of abdominal trauma. Am J Surg. 1990, 160: 594-597. 10.1016/S0002-9610(05)80752-4.View ArticlePubMedGoogle Scholar
- Rozycki GS, McNeil J, Thal ER: Diagnostic procedures used to establish priorities. Operative Trauma Management: An Atlas. Edited by: Thal ER, Weigelt JA, Carrico CJ. 2002, Columbus, OH: McGraw-Hill, 20-33. 2Google Scholar
- Fernon DM, King BR: Diagnostic peritoneal lavage. Textbook of Pediatric Emergency Procedures. Edited by: King C, Henretig FM, King B, Loiselle JM, Ruddy RM. 2007, Philadelphia, PA: Lippincott Williams & Wilkins, 339-346.Google Scholar
- Thacker LK, Parks J, Thal ER: Diagnostic peritoneal lavage: is 100,000 RBCs a valid figure for penetrating abdominal trauma?. J Trauma. 2007, 62 (4): 853-857. 10.1097/TA.0b013e31803245d9.View ArticlePubMedGoogle Scholar
- Thal ER: Peritoneal lavage. Reliability of RBC count in patients with stab wounds to the chest. Arch Surg. 1984, 119: 579-584.View ArticlePubMedGoogle Scholar
- Merlotti GJ, Marce E, Sheaff CM: Use of peritoneal lavage to evaluate abdominal penetration. J Trauma. 1985, 25: 228-231. 10.1097/00005373-198503000-00011.View ArticlePubMedGoogle Scholar
- Sriussadaport S, Pak-Art R, Pattaratiwanon M, Phadungwidthayakorn A, Wongwiwatseree Y, Labchitkusol T: Clinical uses of diagnostic peritoneal lavage in stab wounds of the anterior abdomen: a prospective study. Eur J Surg. 2002, 168 (8–9): 490-493.View ArticleGoogle Scholar
- Gonzalez RP, Ickler J, Gachassin P: Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma. J Trauma. 2001, 51 (6): 1128-1136. 10.1097/00005373-200112000-00019.View ArticlePubMedGoogle Scholar
- Weigelt JA, Kingman RG: Complications of negative laparotomy for trauma. Am J Surg. 1988, 156: 544-547. 10.1016/S0002-9610(88)80549-X.View ArticlePubMedGoogle Scholar
- Nagy KK, Roberts RR, Joseph KT, Smith RF, An GC, Bokhari F, Barrett J: Experience with over 2500 diagnostic peritoneal lavages. Injury. 2000, 31: 479-482. 10.1016/S0020-1383(00)00010-3.View ArticlePubMedGoogle Scholar
- Fischer RP, Beverlin bC, Engrav LH, Benjamin CI, Perry JF: Diagnostic peritoneal lavage: fourteen years and 2,586 patients later. Am J Surg. 1978, 136: 701-704. 10.1016/0002-9610(78)90339-2.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.