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How To Do Diagnostic Peritoneal Lavage (DPL)

By

Dorothy Habrat

, DO, Department of Emergency Medicine, University of New Mexico School of Medicine

Last full review/revision Mar 2021| Content last modified Mar 2021
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Diagnostic peritoneal lavage (DPL) is an invasive emergency procedure used to detect hemoperitoneum and help determine the need for laparotomy following abdominal trauma. A catheter is inserted into the peritoneal cavity, followed by aspiration of intraperitoneal contents, often after their dilution with crystalloid.

DPL is rarely done for the detection of intraabdominal bleeding in the developed world because it has been replaced with Extended Focused Assessment with Sonography in Trauma (E-FAST). DPL has low specificity, identifying many lesions that cause bleeding but do not require operative repair, and results in a high negative laparotomy rate. DPL is invasive and risks iatrogenic damage to abdominal organs during the procedure. DPL also misses retroperitoneal injuries. However, DPL is more sensitive than E-FAST for mesenteric, diaphragmatic, and hollow viscus injury because these injuries (and the lesser volume of hemorrhage they produce) are more difficult to visualize on imaging.

The most common DPL techniques are

  • Closed: Percutaneous needle insertion into the peritoneal cavity followed by catheter-over-wire (Seldinger technique)

  • Semi-open: Dissection down to (and sometimes through) the rectus fascia followed by needle and catheter-over-wire technique into the peritoneal cavity

An open technique (mini-laparotomy) in which the operator dissects into the abdominal cavity to directly visualize the peritoneum and incise it to insert the catheter in a more directed fashion is less often done and is not discussed here.

Indications

DPL is indicated if imaging is not available and intraabdominal injury possibly requiring surgery is suspected, typically based on

  • Blunt abdominal trauma with hemodynamic instability

  • Stab wound to the abdomen penetrating the fascia (ie, seen on local wound exploration), or with other concerns for intraabdominal entry (eg, from instrument used, clinical findings)

  • Multiple trauma with shock of unclear etiology, especially in patients with an unreliable physical examination of the abdomen (eg, due to altered mental status from head injury, intoxication, spinal cord injury, or other distracting painful injuries)

Rarely, DPL is indicated when imaging is available, such as in hypotension plus an unclear E-FAST examination result or imaging that shows free pelvic fluid but no apparent solid organ injury (eg, ascites).

Contraindications

Absolute contraindications

  • Obvious clinical indications for laparotomy (eg, gunshot wound to the abdomen or flank, other penetrating abdominal injury with shock, evisceration, impalement)

Relative contraindications

  • Availability of appropriate imaging (eg, E-FAST, CT)

  • Pelvic fracture*

  • Inability to place a urethral catheter*

  • Pregnancy (2nd or 3rd trimester)*

  • Previous abdominal surgery†

  • Morbid obesity‡

* Supraumbilical open DPL is needed, to avoid an anteriorly spreading retroperitoneal bleed, distended bladder, or gravid uterine fundus, respectively.

† Adhesions from previous surgery make uniform distribution of fluid in the abdomen difficult and increase the risk of perforated viscus. Open DPL is done, making the incision distant from the surgical incision site (elsewhere on the midline if possible or in the left lower quadrant).

‡ Infraumbilical semi-open or open DPL is done to more safely and accurately access the peritoneal space through thick subcutaneous fat.

Complications

Complications of DPL include

  • Herniation of bowel through the incision

  • Injury to organs and/or vessels by needle or catheter

  • Infection

  • Cutaneous bleeding and/or hematoma

Non-complication problems include inadequate fluid return.

Equipment

Sterile procedure, barrier protection

  • Antiseptic solution (eg, chlorhexidine, povidone iodine)

  • Sterile drapes (large), towels

  • Sterile head caps, masks, gowns, gloves

  • Face shields

General equipment

  • Nasogastric tube

  • Urethral catheter

  • Sterile gauze pads

  • 1 L IV bag of normal saline or lactated Ringer's, warmed ideally to body temperature, for peritoneal infusion

  • IV tubing set, without one-way valve

  • Blood collection tube for blood cell counts

  • Nonabsorbable suture (eg, size 3-0 or 4-0 nylon), or staples, for skin closure

Closed (Seldinger, catheter-over-guidewire) technique

Prepackaged kits or surgical trays may be available, but typical equipment includes

  • Local anesthetic (eg, 1% lidocaine with epinephrine)

  • 25-gauge needle and 5 to 10 mL syringe for anesthetic

  • 18-gauge introducer needle (about 7.5 cm long) and 5 to 10 mL syringe

  • Flexible J-tipped guidewire (about 45 cm long)

  • Scalpel (with No. 11 or No. 15 blade)

  • Flexible peritoneal dialysis catheter

Semi-open technique

Equipment as above, plus

  • Razor

  • Right-angle retractors

  • Scissors, hemostat, and pickups

  • Cautery device or absorbable suture for hemostasis

Additional Considerations

  • Coagulopathy, either therapeutic (ie, due to use of anticoagulants) or clinical (eg, due to severe liver disease), increases the risk of procedural bleeding but is not a contraindication; diagnosis of serious intraabdominal injury is a more pressing concern.

  • Prior to DPL, place a urethral catheter and gastric tube to decompress the bladder and stomach and thereby avoid injury by the needle, guidewire, or catheter insertions. Before attempting urethral catheterization, suspected urethral trauma (eg, as suggested by meatal blood or perineal bruising or hematoma) should be excluded by retrograde urethrography.

  • Prophylactic antibiotics are not needed for DPL.

Positioning

  • The patient is supine.

Relevant Anatomy

  • The catheter is inserted on the longitudinal midline 2 cm inferior to the umbilicus. This site is distant from both the stomach and omentum, and the underlying fascia (linea alba) is not very vascular.

Step-by-Step Description of Procedure

Usually the closed technique is appropriate. The semi-open technique is an alternative (eg, for patients with thick abdominal fat).

Prepare the patient

  • Insert a nasogastric tube (see How To Insert a Nasogastric Tube)

  • If semi-open DPL is anticipated, shave a broad area about the anticipated incision site.

  • Swab a broad area of skin about the site* with antiseptic solution and allow to dry.

  • Place sterile towels about the site.

  • For semi-open technique, place large sterile drapes to establish a bigger sterile field.

  • Inject anesthetic at and around the needle entry point, covering the length of any anticipated incision (for semi-open technique) and down to the fascia.

* Standard entry site is midline, 2 cm inferior to the umbilicus.

Access the peritoneal cavity

Closed technique

  • Insert the introducer needle in the midline of the abdomen 2 cm inferior to the umbilicus angled at 45 degrees to the skin and directed inferoposteriorly toward the pelvis.

  • Advance the needle until you feel it pop through the fascia and the peritoneal membrane and then continue another 2 to 3 mm.

  • Hold the needle motionless and gently aspirate: If > 10 mL of blood is aspirated, hemoperitoneum is diagnosed and the procedure is ended. This test result is also positive if there is free aspiration of gastrointestinal contents or bile.

  • If no blood is aspirated, insert the J-curve end of the guidewire into the needle, with the curve pointing in the same direction as the needle bevel, to steer the guidewire into the right or left pelvic gutter.

  • Advance the guidewire until it stops or until the length of wire protruding from the needle hub remains slightly longer than the peritoneal catheter. If you feel resistance or if the patient experiences pain as you advance the guidewire, stop the procedure and withdraw the needle and guidewire together as a unit (to prevent the needle tip from shearing through the guidewire within the patient). Reinsert the needle at a slightly different site, but still on the midline.

  • Hold the end of the guidewire and withdraw the needle until the point just exits the skin.

  • Grasp the guidewire at the skin surface and slide the needle off the wire.

  • Use the scalpel to make a small incision where the guidewire enters the epidermis, to permit passage of the catheter.

  • Thread the catheter over the guidewire and slide the catheter down to your fingers, grasping the guidewire at the skin. The end of the guidewire should now be protruding from the end of the catheter hub; if it is not, slowly retract the guidewire out of the abdomen until the end protrudes.

  • Grasp and control the guidewire where it protrudes from the catheter hub and advance the catheter over the wire, using a corkscrew motion as necessary, until the catheter is fully inserted.

  • Remove the guidewire and begin the lavage.

Semi-open technique (alternative)

An assistant is useful, particularly if the patient is obese.

  • Make a 4 to 6 cm vertical, midline incision down to the fascia starting just below the umbilicus.

  • Stop any bleeding using electrocautery or sutures.

  • Grasp the fascia with hemostats to stabilize it and insert the introducer needle directly through the fascia.

  • Continue as per the closed technique.

Do the peritoneal lavage

  • Connect the bag of warmed lavage solution to the catheter with IV tubing and allow the fluid to flow into the peritoneal cavity.

  • Infuse 1 L in adults and 10 mL/kg in children.

  • Once fluid is instilled, lower the nearly empty solution bag well below the level of the abdomen and allow the fluid to return into the bag. Recover as much fluid as possible, but as little as 250 mL is adequate.

  • Send fluid for analysis. The lavage is positive if there are > 100,000 red blood cells/mL, > 500 white blood cells/mL, or a positive Gram stain test. A negative test does not exclude other solid organ injury, viscus perforation, diaphragmatic tears, or retroperitoneal injury.

  • Remove the catheter.

  • Close any skin incision with sutures or staples and dress the site.

Aftercare

  • Remove the urethral catheter and nasogastric tube if these are not otherwise needed.

  • After a negative DPL, most clinicians consider additional diagnostic testing and admit the patient to hospital for observation and serial abdominal examinations. Keep the patient NPO initially but introduce liquid and then food, depending on clinical status.

Warnings and Common Errors

  • Not achieving cutaneous hemostasis during a semi-open procedure risks allowing blood from skin vessels to enter the abdomen and falsely elevate the red blood cell count

  • During a semi-open procedure, inadvertently dissecting through the fascia and entering the abdomen

Tips and Tricks

  • If the flow of fluid is weak, the omentum may be blocking the catheter holes. Abdominal palpation, repositioning the patient to allow the lavage fluid to move, or slight repositioning of the catheter may improve the flow.

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