Diagnostic Peritoneal Lavage - Closed technique

Most patients who require a DPL can be managed using the "closed" or Seldinger technique.

Here is the procedure:

Step 1.             Obtain informed consent if time permits.

Step 2.             Decompress the stomach and urinary bladder by inserting a gastric tube and a urinary catheter.

Step 3.             After donning mask, sterile gown and gloves, surgically prepare the abdomen (costal margin to the pubic area and flank to flank, anteriorly).

Step 4.             Inject local anesthetic midline just below the umbilicus. Use lidocaine with epinephrine to avoid blood contamination from skin and subcutaneous tissue.

Step 5.            Insert an 18-gauge beveled needle attached to a syringe through the skin and subcutaneous tissue. Resistance is encountered when traversing the skin, the fascia and again when penetrating the peritoneum (ie. 3  "pops").  Aspirate.  If gross blood is not obtained, continue to step 6.  If gross blood is aspirated, the patient should be taken to laparotomy.

Step 6.           Pass the flexible end of the guidewire through the 18-gauge needle until resistance is met or 3 cm is still showing outside the needle. Then remove the needle from the abdominal cavity so that only the guidewire remains.

Step 7.          Make a small skin incision at the entrance site of the guidewire, and insert the peritoneal lavage catheter over the guidewire into the peritoneal cavity. Then remove the guidewire from the abdominal cavity so that only the lavage catheter remains.

Step 8.          Instill 1 liter of warmed isotonic crystalloid solution (10 mL/kg in a child) into the peritoneum through the intravenous tubing attached to the lavage catheter.

Step 9.          Gently agitate the abdomen to distribute the fluid throughout the peritoneal cavity and increase mixing with the blood.

Step 10.         If the patient’s condition is stable, allow the fluid to remain a few minutes before allowing it to drain by placing the IV bag on the floor and allowing the peritoneal fluid to drain from the abdomen.   Adequate fluid return is >20% of the infused volume.

Step 11.       After the fluid has returned, send a sample to the laboratory for Gram stain and erythrocyte and leukocyte counts (unspun). A positive test and the need for surgical intervention are indicated by 100,000 RBCs/mm³ or more (for blunt or ant. abd. SW) OR 10,000 RBCs/mm or more (for GSW or thoracoab. SW, or back/flank SW) OR greater than 500 WBCs/mm³, or a positive Gram stain for food fibers or bacteria.