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 a rapidly performed bedside procedure using simple equipment that may detect hemoperitoneum or intraperitoneal contents. However, DPL is rarely done for the detection of intraabdominal bleeding in facilities where CT scans and Extended Focused Assessment with Sonography in Trauma (E-FAST) are available. 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 for Diagnostic Peritoneal Lavage
DPL is indicated in the hemodynamically unstable, unresponsive trauma patient who may be in a facility with limited radiology resources. It may be considered in the following situations:
Blunt abdominal trauma
Stab wound to the abdomen penetrating the fascia (ie, identified 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 as a result of 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 caused by ascites rather than blood but no apparent solid organ injury (1, 2).
Contraindications to Diagnostic Peritoneal Lavage
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†
Serious obesity‡
* Supraumbilical open DPL is needed to avoid an anteriorly spreading retroperitoneal bleeding in a pelvic fracture, distended bladder if a urethral catheter cannot be placed, or a gravid uterine fundus in a pregnant patient.
† 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 of Diagnostic Peritoneal Lavage
Complications of DPL include
Herniation of bowel through the incision
Injury to organs and/or vessels by needle or catheter
Infection
Hemorrhage
Cutaneous bleeding and/or hematoma
Non-complication problems include inadequate fluid return.
Equipment for Diagnostic Peritoneal Lavage
Sterile procedure, barrier protection
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, ideally warmed 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
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 for Diagnostic Peritoneal Lavage
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 to decompress the bladder and a nasogastric tube to decompress the 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 for Diagnostic Peritoneal Lavage
The patient is supine.
Relevant Anatomy for Diagnostic Peritoneal Lavage
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 Diagnostic Peritoneal Lavage
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).
Insert a urinary catheter (see How To Do Urethral Catheterization in a Female or How To Do Urethral Catheterization in a Male).
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, bile, or gastric contents 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 has obesity.
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
Initial aspiration of > 10 mL of gross blood is considered positive
> 100 x 106 red blood cells/L (> 100,000 red blood cells per mm3) in blunt trauma
> 10 x 106 red blood cells/L (> 10,000 red blood cells per mm3) in penetrating trauma
> 0.5 x 106 red blood cells/L (>500 white blood cells per mm3)
Amylase level ≥ 2.92 µkat/L (≥175 U/L)
Alkaline phosphatase level ≥ 0.05 µkat/L (≥3 U/L)
Positive Gram stain
Presence of enteric matter or food particles
A negative lavage 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 for Diagnostic Peritoneal Lavage
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 for Diagnostic Peritoneal Lavage
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 for Diagnostic Peritoneal Lavage
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.
References
1. Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques. J Trauma 2009;67(2):330-336. doi:10.1097/TA.0b013e3181ae9b1d
2. Wang YC, Hsieh CH, Fu CY, Yeh CC, Wu SC, Chen RJ. Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage. Am J Emerg Med 2012;30(4):570-573. doi:10.1016/j.ajem.2011.02.014
