With sensitivities and specificities quoted as high as 87% and 82% in
select trauma patients and the highest sensitivity for hollow viscus
injury, DPL remains a vital diagnostic tool when used in conjunction
with advanced imaging.
Using tools commonly found in the ED and a DPL catheter, this
relatively quick and safe procedure allows providers to access and
evaluate the peritoneal cavity at the bedside and can be the deciding
factor between laparotomy, observation or discharge.
The decision to perform a DPL should generally involve consultation with the trauma surgery team.
In general, in hemodynamically stable patients, DPL can be considered in the following:
- Blunt abdominal trauma where CT or FAST is not available or where imaging is equivocal
- Anterior abdominal stab wounds with violation of peritoneum on local wound exploration
- High suspicion for hollow viscus injury with negative or equivocal imaging
- Unreliable abdominal exam (i.e. altered mental status, intubated, spinal cord injury) with negative or equivocal imaging
- Changes in abdominal exam or vitals in observed patients with negative initial imaging
- Hemodynamically tenuous patients with blunt or penetrating trauma
who cannot be safely transported out of the resuscitation bay (i.e. CT
scanner, interventions for other injuries)
DPL should not be considered in patients who clearly warrant emergent
laparotomy: hemodynamically unstable, gunshot wounds, stab wounds with
evisceration or peritonitis – or in patients with positive diagnostic
imaging (positive FAST or CT scan identifying an injury requiring
surgical intervention). Other relative contraindications include: morbid
obesity, pre-existing coagulopathy and cirrhosis/large volume ascites.
Relative contraindications to the infraumbilical approach include:
pregnancy greater than 12 weeks gestation, pelvic fractures and prior
lower abdominal surgeries or scars.
Equipment (for the open technique)
- Lidocaine 1% with Epi in 12cc syringe with injecting needle
- betadine or hibiclens
- fenestrated sterile drape
- scalpel (11 or 15 blade)
- retractors x 2
- towel clamps x 2
- DPL catheter
- 12 cc (or larger) syringe
- 1 liter bag of warm IV fluid (NS or LR) and IV tubing (without valve)
- 3-0 or 4-0 absorbable suture
- needle driver
There three different techniques for performing a DPL: open, semi-open
and closed. The open technique was used on this patient so is described
A nasogastric tube and foley catheter must be placed and the stomach
and bladder adequately decompressed. The patient must remain supine for
the procedure. The entire procedure should be performed under sterile
01 The infraumbilical area is prepped and draped in sterile
fashion. The area is then anesthetized using 1% lidocaine with
epinephrine using wide local infiltration. Conscious sedation can be
considered depending on urgency and the patient’s condition.
02 A 2-3 cm vertical midline skin incision is made approximately 2
cm below the umbilicus and the subcutaneous tissue is dissected down to
expose the linea alba. Retractors can be used to hold back the wound
edges and better expose the fascia.
03 The fascia on either side of the wound is then securely grasped
using the towel clips and raised up away from the abdominal contents and
a small vertical incision (~0.5 cm) is carefully made through the linea
alba and fascia, opening the peritoneum.
04 The DPL catheter is then carefully advanced into the peritoneum
through the fascial incision, directing it inferior (caudad) and
posterior. Note that the goal to have the catheter tip resting anterior
to the rectum (the most dependent portion of the peritoneum). The closed
technique employs the Seldinger technique in which an introducer needle
is passed through intact skin and fascia into the peritoneal cavity and
the DPL catheter is positioned into the cavity over a guidewire. The
semi-open technique is similar to the closed technique except that the
skin is incised and the fascia exposed before the introducer needle is
used to puncture the fascia into the peritoneum.
05 For lavage, the syringe is removed and a 1-liter bag of warm IV
fluid (NS or LR) is connected to the DPL catheter using primed, sterile
IV tubing. (The tubing should not have a 1-way valve as this prevents
the return of fluid after lavage.) The IV fluid is allowed to flow into
the peritoneal cavity (approximately 1 liter in adults, 10-15 ml/kg in
children). If possible, the patient should be gently rocked from side to
side as the fluid is infusing. Note that the IV bag should not be
allowed to empty completely as this disrupts the siphon effect required
to evacuate the effluent.
The DPL effluent should be sent for red blood cell count, white blood
cell count and gram stain. A grossly positive result includes: immediate
aspiration of 10 ml or greater of gross blood, aspirate containing
gross enteric contents or vegetable matter. Although some disagreement
exists, most studies quote a positive DPL result as one of the following
criteria: red blood cell count > 100,000/mm3 or white blood cell
Some studies advocate checking lavage amylase and alkaline
phosphatase, as they have higher specificity for small bowel injuries.
Although, no consensus on cut-off values exists, > 19 IU/L and > 2
IU/L respectively has been suggested.
06 The catheter is connected to a 12 cc (or larger) syringe and
aspirate obtained. If 10 ml of gross blood or enteric matter is
obtained the DPL is considered grossly positive and the patient should
be prepared for laparotomy. (Note that if < 10 ml of blood is
obtained, the aspirate is returned to the peritoneal cavity before
proceeding to lavage).
Our patient had an asymptomatic anterior abdominal stab wound that
violated the peritoneum and an equivocal CT scan and no
contraindications to a DPL. In order to avoid a potentially harmful and
unnecessary exploratory laparotomy in combination with the concern for a
small hollow viscus injury, a DPL was performed. The DPL was not
grossly positive on aspirate so a lavage was performed. The effluent
analysis was negative and the patient remained asymptomatic. So after
the catheter was removed and the wound repaired, the patient was
discharged home and was continuing to do well on follow up several weeks
07 When nearly all of the fluid has infused, lower the bag to
the ground and allow the effluent to drain out by gravity. At least 30%
of the original infusate must be obtained for an adequate lavage sample.
The effluent is sent for analysis; if negative, the catheter should be
removed. The wound is irrigated and the fascia is closed with 1-2 simple
interrupted absorbable sutures. Semi-open or closed technique does not
require fascial closure. In all techniques the skin is closed using
suture or skin staples.
- Schultz DJ, Weigelt JA: Diagnostic Peritoneal Lavage. In Operative
Techniques in General Surgery Volume 5. Issue 3 Edited by: VanHeerden
JA, Farley DR. Philadelphia, PA: WB Saunders; 2003:139-144.
- Sarin E, Kashuk JL, Cothren CC, et al. Diagnostic peritoneal lavage
remains a valuable adjunct to modern imaging techniques. J Trauma.
- Biffl WL, Kaups KL, Cothren CC, et al. Management of patients with
anterior abdominal stab wounds: a Western Trauma Association Multicenter
trial. J Trauma. 2009;66:1294-1301.
- Jansen JO, Logie JR. Diagnostic peritoneal lavage—an obituary. Br JSurg. 2005;92:517–518.
- McAnena OJ, Marx JA, Moore EE. Contributions of peritoneal lavage
enzyme determinations to the management of isolated hollow visceral
abdominal injuries. Ann Emerg Med. 1991; 20:834-837.
Dr. Lina Tran is a 3nd year Emergency Medicine Resident at the
Denver Health Emergency Medicine Residency Program. Dr. Peter Pryor is a
faculty member at Denver Health, an Assistant Professor of Emergency
Medicine at the University of Colorado School of Medicine and has an
academic focus in medical photography.