Urgent and emergent re-laparotomy in trauma. A preventable cause of increased mortality?

In a 2-year period, 96 patients required laparotomy for trauma at the University of Kansas Medical Center. Fifteen patients required a total of 25 emergent and urgent reexplorations. Six patients required reoperation for bleeding, eight for intra-abdominal sepsis, and 3 for inadequate initial operation or missed injury. Forty per cent of patients undergoing multiple laparotomies died, versus 16 per cent for single operations. Factors predisposing to complications requiring re-laparotomy include multi-system trauma, blunt abdominal injury, and inadequate or delayed initial resuscitation and operation. Recognition of these factors and resuscitation and operation by personnel experienced in trauma care should lead to lower reoperation rates, and decreased morbidity and mortality when reoperation is necessary.     

Management of splenic trauma: the Durban experience

In a retrospective survey of splenic trauma managed at a teaching hospital, the data of 127 patients during a 2 year period have been analysed. Splenic conservation was achieved in 47 laparotomies (38.8 per cent). Six patients with blunt abdominal trauma (4.7 per cent of all patients) were managed non-operatively. Splenic conservation by suture with or without packing with omentum or oxidized cellulose was successful in 27 out of 37 attempts. Failure of this technique was easily recognized during laparotomy and no patient required re-operation for continued splenic bleeding after splenorrhaphy. There was no significant difference between successful conservation of the spleen at laparotomy of patients below the median age (28 years) and older patients. Wound sepsis was increased after splenectomy (P less than 0.05). Splenic conservation is not appropriate for all types of splenic injury. Where conservation is not possible splenectomy and re-implantation is recommended.     

Fascial dehiscence after trauma laparotomy: a sign of intra-abdominal sepsis

Fascial dehiscence (FD) after trauma laparotomy is associated with technical failure, wound sepsis, or intra-abdominal infection (IAI). The association of IAI with FD is inadequately evaluated. Knowing about its presence is essential to guide clinical diagnosis and management. Our objective was to identify the incidence and risk factors of IAI in patients with FD. We performed a medical record review of 55 trauma patients with FD. Patients with IAI were compared to patients without IAI and FD patients to all trauma laparotomy patients during the same period. Statistical significance was at P < 0.05. Thirty-nine (71%) FD patients had IAI, significantly higher than all trauma laparotomies (4.6%, P < 0.0001). Only 31 per cent of patients underwent laparotomy and drainage while 69 per cent received CT-guided percutaneous drainage followed by expectant management. Similarly, 33 per cent of the non-IAI group had operative management. No differences were found between the two groups in any of the examined factors. The majority of trauma patients with FD have IAI. No clinical or laboratory factors help identify FD patients likely to have IAI. Therefore, FD should be viewed as a sign of possible underlying IAI. Appropriate radiographic imaging or direct visualization of the entire abdominal cavity should be pursued before managing the dehisced fascia.     

Emergency laparotomy for abdominal trauma

We have retrospectively reviewed our experience of 153 consecutive patients who underwent emergency laparotomy for suspected intraabdominal injury over a 10-year period.

The commonest cause of injury was road traffic accidents (61 per cent), and the commonest indication for operation was signs of peritoneal irritation (35 per cent). Peritoneal lavage was performed in 62 patients (41 per cent). The liver was the organ most frequently injured (52 patients, 34 per cent) and 52 per cent of these patients died. Splenic injuries occurred in 46 patients (30 per cent). The negative laparotomy rate was 16 per cent. Forty-five patients died (29 per cent) and five of these had negative laparotomies. The Injury Severity Score (ISS) of all patients who died was > 16.     

Predicting the outcome of exploratory laparotomy in ICU patients with sepsis or organ failure

Critically ill patients with sepsis and/or organ failure are difficult to assess. They are often comatose or on steroids and many nonspecific findings such as fever, positive blood cultures, or septic shock which may suggest intra-abdominal sepsis are far from diagnostic. To determine whether decision making regarding the use of laparotomy in these patients could be improved upon, we reviewed our experience with consecutive intensive care unit patients who had laparotomy and we related laparotomy outcome to clinical signs and symptoms. Seventy-three per cent of the 100 laparotomies reviewed were positive for intra-abdominal sepsis. A discriminant function analysis revealed that eight factors in combination predicted laparotomy outcome. However, the overall accuracy of the discriminant function prediction (76.8%) offered little improvement over the policy in place for performing laparotomies in this group of patients at the participating hospitals during the time period of our investigation.     

Multiple laparotomies are a predictor of fascial dehiscence in the setting of severe trauma

The purpose of this study was to determine the incidence of wound dehiscence after repeat trauma laparotomy. We performed a retrospective analysis of adult trauma patients who underwent laparotomy at an urban level 1 trauma center during the past 5 years. Patients were divided into single (SL) and multiple laparotomy (ML) groups. Demographic, clinical, and outcome data were collected. Data were analyzed using chi2, t testing, and ANOVA. Overall dehiscence rate was 0.7 per cent. Multiple laparotomy patients had damage control, staged management of their injuries, or abdominal compartment syndrome as the reason for reexploration. SL and ML patients had similar age and sex. ML patients had a higher rate of intra-abdominal abscess than SL patients (13.7% vs 1.2% P < 0.0001), but intra-abdominal abscess did not predict wound dehiscence in the ML group (P = 0.24). This was true in spite of the fact that ML patients had a significantly higher Injury Severity Score (ISS) than SL patients (21.68 vs 14.35, P < 0.0001). Interestingly, wound infection did not predict dehiscence. Patients undergoing repeat laparotomy after trauma are at increased risk for wound dehiscence. This risk appears to be associated with intraabdominal abscess and ISS, but not wound infection. Surgeons should leave the skin open in the setting of repeat trauma laparotomy, which will allow serial assessment of the integrity of the fascial closure.     

Nontherapeutic laparotomies revisited

A wide variability exists in the reported incidents of complications following nontherapeutic laparotomy for trauma. We undertook this study to examine the decision-making leading to and complication rates related to the use of nontherapeutic laparotomy in an era of nonoperative management. We conducted a retrospective chart review of all nontherapeutic laparotomies as defined by the operating surgeon performed between May 1998 and May 2001. A total of 50 patients (6%) underwent nontherapeutic laparotomies predominantly for penetrating injury. The most frequent preoperative reason for nontherapeutic laparotomy was the question of hollow viscous or diaphragmatic injury on preoperative studies. Peritoneal signs on examination and peritoneal penetration on wound exploration were also frequent indications for surgery. Significant complication rates were low at approximately 12 per cent. Total length of stay was 7.3 days and 5 days if patients with significant other associative injuries were excluded. Overall morality was 4 per cent and unrelated to the nontherapeutic laparotomy in all cases. Overall incidence of nontherapeutic laparotomy has decreased with the use of abdominal helical CT and triple-contrast CT to evaluate penetrating injuries. Despite these advances diaphragmatic and hollow viscous injuries remain a concern. Although overall serious complication rates were low the use of nontherapeutic laparotomy adds significantly to length of stay and complications.     

腹部创伤患者腹腔镜探查术的适应证和中转开腹手术的指征

作者通过７例腹部创伤患者施行腹腔镜探查术的经验，探讨腹腔镜探查术的适应证和手术指征。作者认为急症电视腹腔镜探查术适用于高度怀疑且无法排除腹腔内脏器损伤，或已经证实有腹腔内脏器损伤，而且血液动力学相对稳定的腹部创伤者；因腹腔内大出血致血液动力学极不稳定者直立即行急症开腹探查（止血）术。中转开腹手术的指征是：（１）术中腹腔内大出血不止，致血压不稳发生休克者。（２）腹腔镜下难以完全明确诊断者。（３）腹腔镜下处理腹腔内脏器损伤困难者。     

Non-directed relaparotomy for intra-abdominal sepsis. A futile procedure

Over a 50-month period, 2,657 primary laparotomies were performed; 192 patients underwent urgent relaparotomy for complications of primary laparotomy. Forty-seven relaparotomies were performed for Type I intra-abdominal sepsis (IAS-1) with a 12.8 per cent mortality, and 46 for Type 2 IAS with a 82.6 per cent mortality (P less than 0.001). Of the 46 IAS-2 patients, 31 relaparotomies were "directed" by positive peritoneal signs (CAT/ultrasound/PIPIDA examinations) with 94 per cent (29/31) yielding positive findings. Fifteen were "non-directed" in an effort to uncover an occult source of continuing sepsis of MOSF and yielded a 13 per cent (2/15) positive rate (P less than 0.001), and a 93 per cent (14/15) mortality. Relaparotomy for sepsis directed by positive radiologic or clinical findings can be reliably expected to demonstrate a surgical focus whose correction may yield patient survival; non-directed relaparotomy, however, seldom demonstrates a focus and does not contribute to survival.     

Incisional hernia in re-opened abdominal incisions: an overlooked risk factor

Many patients undergoing laparotomy will have had a previous incision in the abdominal wall which offers a convenient and logical route for reexploration. This study aims to examine the risk of subsequent incisional herniation in incisions made through previous scar tissue compared with incisions made through fresh tissues. Out of a total of 1022 laparotomies performed in a 5-year period on one surgical unit, the incisional hernia rates were available for assessment in 699 freshly made incisions, 142 reincisions and 36 incisional hernias. The incidence of incisional hernia was 6 per cent after freshly made incisions and this incidence was increased after both re-incision (12 per cent, P less than 0.05) and incisional hernia repair (44 per cent, P less than 0.01). With the exception of jaundice, none of the other commonly accepted risk factors for incisional herniation were significantly increased in those patients with re-incised wounds who subsequently developed a hernia, when compared with patients who did not develop a hernia. An increased risk of incisional herniation is present when laparotomy is performed through a previous abdominal incision.     

Reexploration for complications after esophagectomy for cancer

Among 316 patients who underwent resection for esophageal cancer, 23 required reexploration for complications and 10 died. The commonest reason for reexploration was leakage (eight patients). Development of leakage necessitating reexploration was associated with a hospital mortality rate of 75%. Other reasons for reexploration were postoperative bleeding (n = 7), chylothorax (n = 2), burst abdomen (n = 2), diaphragmatic herniation (n = 1), bile peritonitis (n = 1), bowel gangrene (n = 1), and tracheal perforation (n = 1). Definite or presumed technical error could be identified in 18 of the 23 patients requiring reexploration and indicated that the majority of reexplorations were for complications that appeared to be potentially avoidable. When reexploration became necessary, early intervention offered the best chance of survival.     

Nonoperative management of solid abdominal organ injuries from blunt trauma: impact of neurologic impairment

The role of nonoperative management of solid abdominal organ injury from blunt trauma in neurologically impaired patients has been questioned. A statewide trauma registry was reviewed from January 1993 through December 1995 for all adult (age >12 years) patients with blunt trauma and an abdominal solid organ injury (kidney, liver, or spleen) of Abbreviated Injury Scale score > or =2. Patients with initial hypotension (systolic blood pressure <90 mm Hg) were excluded. Patients were stratified by Glasgow Coma Score (GCS) into normal (GCS 15), mild to moderate (GCS 8-14), and severe (GCS < or =7) impairment groups. Management was either operative or nonoperative; failure of nonoperative management was defined as requiring laparotomy for intraabdominal injury more than 24 hours after admission. In the 3-year period 2327 patients sustained solid viscus injuries; 1561 of these patients were managed nonoperatively (66 per cent). The nonoperative approach was initiated less frequently in those patients with greater impairment in mental status: GCS 15, 71 per cent; GCS 8 to 14, 62 per cent; and GCS < or =7, 50 per cent. Mortality, hospital length of stay, and intensive care unit days were greater in operatively managed GCS 15 and 8 to 14 groups but were not different on the basis of management in the GCS < or =7 group. Failure of nonoperative management occurred in 94 patients (6%). There was no difference in the nonoperative failure rate between patients with normal mental status and those with mild to moderate or severe head injuries. Nonoperative management of neurologically impaired hemodynamically stable patients with blunt injuries of liver, spleen, or kidney is commonly practiced and is successful in more than 90 per cent of cases. No differences were noted in the rates of delayed laparotomy or survival between normal, mild to moderately head-injured, and severely head-injured patients.     

The open peritoneal cavity: etiology correlates with the likelihood of fascial closure

The use of laparostomy in damage control surgery and uncontrolled intra-abdominal infection has been well described. We examined 71 patients who required laparostomy to see if trends in management and outcome could be identified based on the underlying disease state. The underlying etiology included gastrointestinal sepsis (n = 25), pancreatitis (n = 21), or trauma (n = 25). Pancreatitis patients required more operations per patient (P < 0.05). The likelihood and type of closure (fascial, mesh, or none) was related to the underlying etiology: trauma patients were more likely to have fascial closure (P < 0.02), patients with GI sepsis were more likely to require mesh closure, and pancreatitis patients were more likely to have no formal closure (P < 0.02). Only 29 per cent of patients achieved definitive fascial closure. Mortality in trauma patients was 20 per cent, 36 per cent for GI sepsis, and 43 per cent in patients with pancreatitis. Complications of laparostomy included enterocutaneous fistula (16.9%) and abscess formation (7%). Though the use of laparostomy has become more prevalent, it is still associated with significant hospital stay, morbidity, and mortality. In our study, the number of operations and likelihood of abdominal closure appears to correlate with the etiology of the underlying disease requiring use of laparostomy.     

Incidental appendicectomy with laparotomy for trauma.

Incidental appendicectomy was performed in 83 of 206 patients undergoing laparotomy for abdominal trauma. No organs were injured in 42 per cent of the appendicectomy patients and in 17 per cent of the non-appendicetomy patients, thus making comparison between the groups unreliable. While the incidence of intestinal perforation was 21 per cent in the appendicectomy patients, the rate of wound infection was only 7 per cent. One complication (pelvic abscess) was possibly attributable to incidental appendicetomy. Since males below the age of 50 face a significant risk of future appendicitis and represent the majority of patients with abdominal trauma, it may be advisable to perform incidental appendicectomy with laparotomy for trauma in such patients. Specific indications for incidental appendicectomy during laparotomy for trauma are suggested.     

Penetrating abdominal stab wounds: a plea for a more conservative policy

This is a retrospective study of 107 penetrating abdominal stab wounds which have been reviewed on the basis of the clinical indications for surgery. Eighty-four patients underwent laparotomy. The unnecessary laparotomy rate was 35 per cent and the mortality 2.4 per cent. Important complications developed in 44 per cent of those undergoing surgery. Evaluation of clinical variables is presented and it is suggested that in the absence of shock, generalized peritonitis or evisceration, careful initial assessment, monitoring and regular re-examination would be a satisfactory method of treatment for many cases. This would result in a decrease in unnecessary laparotomies and associated excess morbidity.     

Survival after palliative surgery for advanced intraabdominal cancer.

The clinical course of 300 patients with known intraabdominal neoplasm requiring surgical exploration was analyzed. The most common primary tumor sites were the gastrointestinal tract (60 per cent), female reproductive organs (17 per cent), and urinary tract (6 per cent). Gastrointestinal and extrahepatic biliary obstruction, gastrointestinal bleeding, and peritonitis were the most common indications for surgery. The overall operative mortality was 26 per cent, and the mean survival time was 6.6 months. Small bowel fistulas, intraabdominal abscesses, and cardiopulmonary and renal failure were the leading causes of death. Palliative procedures in patients less than sixty years old with single site of obstruction or with tumor of gastrointestinal origin were associated with a low operative mortality and prolonged survival. On the other hand, surgical intervention in patients more than seventy years old undergoing chemotherapy, with multiple sites of obstruction, peritonitis, or primary tumor originating outside the gastrointestinal tract, was associated with high operative mortality and seldom benefited from palliative intervention. Surgical intervention to relieve a distressing symptom in a patient with advanced neoplasm is a well established procedure, but the risks and benefits of such intervention should be carefully weighed against the expected mortality and the quality of survival.     

Medical admission of elderly trauma patients with isolated injuries

We sought to evaluate the outcomes of trauma patients admitted to medical services rather than to the general trauma team, particularly those elderly patients with isolated injuries of a specialty nature. Over the 2-year retrospective study period, 3017 trauma patients were admitted. The trauma service directed care in 2740 (90.8%) of this group versus the 277 (9.2%) admitted to medical services (MS). The patients in each group were then classified according to age younger than 55 years or older than 55 years (elderly). Of the 277 patients admitted to the MS, 177 (63.8%) were elderly compared with only 13 per cent of the trauma service group. Smaller proportions (16.9%) of the elderly medical patients were admitted to the intensive care unit as compared with the trauma group (22.1%). There was a higher morbidity rate, 41.9 per cent, in the trauma service group as compared with the MS group, 20 per cent. No patients on the MS underwent a laparotomy for intraabdominal injuries nor were there any missed injuries of a general surgical nature. Allowing elderly trauma patients with isolated specialty injuries to be managed by the MS is not associated with increased morbidity or mortality.     

Acalculous cholecystitis in critically III patients

Acute acalculous cholecystitis is a treacherous and potentially fatal complication of severe trauma and prolonged intensive care. The present study reviews seventeen patients seen between June 1974 and August 1977. Although specific causes have been suggested—transfusions, fractures with immobilization, central hyperalimentation, respirators, and “refeeding”—there was no common denominator among our patients. Refeeding was a feature in 30 per cent of our cases, 50 per cent received more than 10 units of blood, 65 per cent had prolonged gastric suction, and 60 per cent had mechanical ventilation. Thus, although all suggested causes were seen, no single factor was dominant.Clinical presentation in this civilian group resembles that of other reports, but differs in remarkable areas. Only 65 per cent of our group presented with one or more of the classic symptoms of cholecystitis—pain, tenderness, or mass. Sixty-five per cent of patients had elevated bilirubin levels. However, the same incidence of hyperbilirubinemia was seen in another group of traumatized patients who did not develop acalculous cholecystitis. The smoldering and nonclassic presentation frequently delayed diagnosis for several days. It was correctly made in 65 per cent, discovered at autopsy in one patient, and found at laparotomy for “sepsis” in the rest. The present report is unique because 88 per cent of the patients had cholecystostomy as initial therapy. Although five patients who underwent operation ultimately succumbed, cholecystitis could be implicated in only one. This patient died of sepsis at 24 hours but also had multiple unrelated intraabdominal abscesses at surgery. Clinical presentation is more complex than previously reported and simple cholecystostomy is an effective mode of therapy in these critically ill patients.     

Protocol for bedside laparotomy in trauma and emergency general surgery: a low return to the operating room

Bedside laparotomy (BSL) was introduced as a heroic procedure in trauma patients too unstable for safe transport to the operating room (OR). We hypothesize a BSL protocol would maintain patient safety while reducing OR use. Patients were prospectively entered into a BSL protocol from July 2002 to June 2003 and retrospectively reviewed. Protocol indications for BSL were abdominal compartment syndrome, decompensation due to hemorrhage, washout/closure, and sepsis in a patient too unstable for safe transport to the OR. Primary outcomes were mortality, emergent return to OR, and primary fascial closure (PFC). Trauma operating room charges and OR time were analyzed. One hundred thirty-three BSL were performed on 60 patients with an overall mortality of 23.3 per cent (14/60). There was an average of 2.2 BSL per patient (range 1-8). Indications for BSL were 1) explore/washout (n = 100, 75.2%), 2) decompression (n = 14, 10.5%), 3) infection/abscess (n = 12, 9.0%), 4) hemorrhage (n = 7, 5.3%). Five of 133 BSL (5.8%) were emergently returned to the OR because of perforation or compromised bowel. Trauma OR charges were dollar 5,300 per cases with 2.12 hours per cases. The protocol standardized the conduct of BSL procedure to allow for a low return to OR rate of 5.8 per cent and had an overall in-hospital mortality rate of 23.3 per cent. Primary fascial closure of the abdomen had a significantly reduced hospital stay. BSL allowed trauma OR charges of dollar 5,300 per cases with 2.12 hours per cases savings.     

The dominant role of paracentesis technics in the early diagnosis of blunt abdominal trauma

A simplified method of diagnostic abdominal paracentesis and lavage is described. Liberal application of this method as part of the initial physical examination of blunt trauma patients resulted in identification at first examination of 94 per cent (61 of 65) of those who were to have laparotomy. No case in the series was brought to laparotomy as the result of findings at arteriography, radionuclide imaging, or sonarography, and no intraabdominal problem was missed because of failure to use one of these organ-imaging technics. The very limited role of these imaging procedures in early management of blunt abdominal trauma is discussed.