MORBIDLY OBESE PATIENT DIAGNOSTIC PERITONEAL LAVAGE

Diagnostic Peritoneal Lavage in morbidly obese patient
Diagnostic peritoneal lavage (DPL) is used for the early recognition of intraabdominal injury requiring exploratory laparotomy. In many centers, the use of DPL has been supplanted by imaging techniques because of increased accessibility to improved computed tomography (CT) and ultrasonography.

However, size and weight restrictions and transport difficulties may preclude the use of CT scanning in the obese trauma victim. Abdominal ultrasonography is also less reliable in the morbidly obese patient. Therefore DPL may be the best available diagnostic approach in these patients.

There are three general DPL techniques: the open, semiopen, and closed. In the open technique, a catheter is passed into the abdominal cavity through a large incision that exposes the peritoneum. Because of the larger incision required, the technical difficulties presented by the panniculus, and a potentially higher rate of wound infection and herniation, morbid obesity has been described as a relative contraindication to this procedure.

Closed DPL using a blind Seldinger technique with an 18-gauge needle has been shown to be as efficient as the open technique, and may represent the method of choice in the obese patient. In patients whose abdominal wall thickness exceeds the reach of the needle, a modified Seldinger technique has been described, in which a 2- to 4-cm incision is carried down to the midline fascia and an 18-gauge needle is then inserted at that point.

This procedure was used successfully in six morbidly obese patients whose weight exceeded the weight limit of the CT scanner, typically 350 pounds.