Reasons for relaparotomies following operations on the biliary tract in nontumorous lesions

According to the authors' data the incidence of relaparotomies after 1500 operations for non-tumor diseases of bile ducts was 2.5%. Causes of relaparotomies at early and late terms of the postoperative period were different. The dependence of results of the treatment on the amount of relaparotomies and the presence of such complications as jaundice, cholangitis and pancreatitis has been established. In such complications and increased amount of relaparotomies lethality was considerably higher. General lethality after relaparotomies was 49%. Complex of prophylactic and curative measures of the complications resulting in relaparotomies has been developed.     

Indications for relaparotomy and its results

For the recent six years 6855 operations on abdominal organs have been performed which were followed by relaparotomies in 104 patients (1.5%). The authors show that the greatest amount of relaparotomies followed operations for ulcer disease, tumors and cholecystitis. The main causes of relaparotomies were peritonitis, intestinal obstructions and bleedings. The group of greater risk consisted of men aged 50-60. The amount of relaparotomies can be reduced due to unification of medical tactics, strict observation of the operation technique and responsible management of the patients in the postoperative period.     

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.     

Combined treatment of acute diffuse peritonitis]

Results of treatment in 199 patients were analysed. The patients were divided into 3 groups. In group 1 (80 patients) acute diffuse peritonitis was treated with conventional methods, in group 2 (62 patients) conventional treatment was supplemented by exchange plasmapheresis, in group 3 (57 patients) conventional treatment was used together with extracorporeal detoxication and elective relaparotomies. Plasmapheresis and elective relaparotomies resulted in increase of effectiveness of the treatment in acute diffuse peritonitis. The intervals between the elective relaparotomies and sessions of plasmapheresis depended on the stage and the course of peritonitis. Lethality rate in conventional method of treatment for acute diffuse peritonitis made up 39%, in plasmapheresis 29%, and in combined treatment--24.5%.     

Surgical treatment of complications after operations on the biliary tract

Causes of relaparotomies after operations for cholelithiasis are analyzed. The frequency of relaparotomies after cholecystectomies was 2.1%. Technical defects in performing operations were the cause of postoperative complications in 52.4% of the cases. Of 63 patients subjected to relaparotomy 23 patients died (36.5%). Prophylactics of complications after operations on bile ducts should be directed first of all to careful observation of the cholecystectomy technique.     

Early relaparotomy

An analysis of 14565 operations on organs of the abdominal cavity has shown that main causes of early relaparotomies were peritonites (47,4%), intestinal obstruction (33,3%), eventration of the abdominal organs (16,0%) and hemoperitoneum (3,3%). The highest lethality was after postoperative peritonitis (54,1%). For the recent 10 years the total lethality has become 31,6% lower due to better diagnosis and early relaparotomies.     

"Second-look" operations in patients with colorectal tumour

The diagnostic problems of metastases and recurrences in colorectal tumour patients are reviewed. The question and indications of relaparotomies are discussed in detail. The results of relaparotomies made for tumorous and nontumorous indications at the Department of Surgery of the National Cancer Institute are reported.     

Relaparotomy after appendectomy]

A result of 70 relaparotomies performed after the operative intervention for acute appendicitis has been analysed. The causes and indications for reoperation, an outcome, nature of complications which required performance of relaparotomy have been considered. A classification of relaparotomies depending on time of their performance is suggested.     

An analysis of the reasons for relaparotomy in the surgical clinic]

The results of surgical treatment of 4,078 patients who underwent operation in 1985-1989 were studied. Due to the occurrence of complications in the early postoperative period, 182 relaparotomies were carried out in 164 patients. The main indications for relaparotomies were advanced underlying disease, surgical errors (tactical, technical), changes of the patients' immune status. Early diagnosis, timely operation with the use of technically correct manipulations, and the application of a full complex of intensive therapy measures in the postoperative period are important in the prevention of complications.     

Programmed relaparotomy in generalized purulent peritonitis

Efficacy of programmed relaparotomy in combined treatment of 51 patients with generalized peritonitis is analyzed. Based on evaluation of surgical data, basic clinical and laboratory markers of endotoxicosis algorithm of programmed relaparotomy has been developed. Comparative analysis of the results of treatment of 36 patients after 1-2 programmed relaparotomies (1.6+/-0.5 surgeries) and 15 patients after repeated relaparotomies (3.4+/-0.3 surgeries) demonstrated that these methods were more effective before development of significant polyorganic disturbances. Nine (17.6%) patients died.     

Possibility of predicting and preventing postoperative complications leading to relaparotomy

The occurrence of relaparotomies is known to be 1,2% of operations on the abdomen organs. Pyo-inflammatory complications are responsible for more than half cases resulting in relaparotomies. Relaparotomies are divided into emergent and urgent, radical and palliative. A system for prognosis of complications and differential diagnosis of postoperative paresis of the gastro-intestinal tract and postoperative peritonitis is presented. Prophylactics of postoperative complications reduced lethality after relaparotomies from 79% to 56%.     

Relaparotomy. Problems of terminology

The authors discuss the term "relaparotomy" and such its definitions as "early", "delayed", "late", "elective", "targeted", analyze different classifications of relaparotomies, propose their own definition of this term based on objective criteria of general reaction to surgical stress in the form of Seli[symbol: see text] adaptation syndrome which has definite duration (60 days). This fact may be regarded as a clinical criterion of determination of relaparotomy's terms. Surgery may be named as relaparotomy when it is performed in terms of adaptation syndrome (60 days). If surgery is performed after the end of adaptation syndrome it must be regarded as repeated operation.     

Relaparotomy in abdominal injuries

Relaparotomies in the postoperative period were performed in 56 out of 529 patients (10,6%) operated upon for injuries of organs of the abdominal cavity. Twenty-two of them died. In most cases relaparotomies were caused by peritonitis, intraabdominal bleedings and abscesses.     

"Routine" versus "on demand" ultrasonography in the surgical intensive care patient. A prospective randomized study

Between May 1988 und March 1989 all patients who underwent elective or emergency surgery followed by intensive care were randomly assigned to group A (n = 149): routine sonography at the postoperative day 1, 3, 7 and 9, group B (n = 151): sonography on demand. In these two groups, the following parameters were compared: number of relaparotomies, lethality of relaparotomies, total lethality, moment of relaparotomy, period of hospitalisation, time spent with sonography. In the analyzed parameters, our examination showed no difference between the two groups. For this we state that the routine sonographical control of the surgical patient with intensive care being opposed to the sonography on demand shows no significant advantage. The demand for a routine sonography as a postoperative control can not be generally supported.     

Relaparotomie im Kindesalter

Zusammenfassung An der Kinderchirurgischen Universitätsklinik Mainz wurden vom 1. 1. 1976 bis 31. 12. 1983 1793 Laparotomien an Kindern im Alter bis zu 15 Jahren vorgenommen. Eine akute, nicht geplante Relaparotomie lag in 4,6% der Fälle vor. Die häufigste Indikation zur Relaparotomie war ein verwachsungsbedingter Ileus (53%); weniger häufige Ursachen waren Platzbauch, Peritonitis, Darmperforation, Anastomoseninsuffzienz und Sekundärblutung. 15% aller relaparotomierten Kinder mußten sich mehr als einer Relaparotomie unterziehen. Über 40% der akuten Relaparotomien wurden an Kindern innerhalb des ersten Lebensjahres vorgenommen. 56% aller Relaparotomien mußten innerhalb der ersten vier postoperativen Wochen durchgeführt werden, 87% innerhalb des ersten postoperativen Jahres. Die Letalitätsrate der akuten Relaparotomie betrug 15%. Sie war besonders hoch bei Kindern mit Anastomoseninsuffizienz und Platzbauch und erhöhte sich mit der Anzahl der Relaparotomien. Die Bedeutung der präoperativen Sonographie zur Diagnosestellung für eine akute, nicht geplante Relaparotomie wird diskutiert und an Hand von Beispielen dokumentiert.

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Relaparotomy in childhood

Summary From 1.1.1976 to 31.12.1983 1,793 laparotomies were performed on children up to the age of 15 years at the Hospital of Pediatric Surgery, Mainz University. The incidence of acute unplannend relaparotomies was 4.6%. The most frequent indication of acute relaparotomy was postoperative obstruction due to adhesions (in 53 % of all cases); burst abdomen, peritonitis, intestinal perforation, anastomotic insufficiency and secondary hemorrhage were less frequent causes of repeated abdominal procedures. 15% of all relaparotomised children underwent more than one repeat laparotomy. More than 40% of acute relaparotomies were performed on children within their first year of life. 56% of all relaparotomies had to be performed within the first four postoperative weeks, 87% within the first year. The lethality rate of acute relaparotomy was 15%. Lethality was especially high in children suffering from anastomotic insufficiency or burst abdomen; it increased with the number of relaparotomies. The significance of preoperative sonography for the diagnosis leading to acute unplanned relaparotomies is discussed and commented with examples.

Herrn Prof. Dr. S. Hofmann-v.Kap-herr zum 50. Geburtstag gemidwet.     

The effect of different temporary abdominal closure techniques on fascial wound healing and postoperative adhesions in experimental secondary peritonitis

Background Secondary peritonitis causes considerable mortality and morbidity. New strategies have been introduced like relaparotomy and temporary abdominal closure in the management of such persistent intra-abdominal infections. Materials and methods Rats were divided into five groups each having ten animals. After induction of peritonitis, relaparotomies were done, and the abdomen was closed by different temporary abdominal closure techniques. After performing two relaparotomies during a 48-h period, all fascias closed primarily and incisional tensile strengths, hydroxyproline contents, and adhesions were measured on the following seventh day. Results The median values of tensile strength and hydroxyproline concentrations were lowest in skin-only closure rats. Intraperitoneal adhesion scores were highest in Bogota bag closure group. Conclusion Primary, Bogota bag, and polyprolene mesh closures seem to be safe in terms of early fascial wound healing. Although it is easy to perform, skin-only closure technique has deleterious effects on fascial wound healing probably due to fascial retraction. Interestingly, Bogota bag has caused increased intraperitoneal adhesion formation.     

Laparoscopic "second-look" in the management of mesenteric ischemia

Mesenteric ischemia is a major cause of mortality in surgery. Despite the advances in medicine, considerable number of patients undergoes reoperations for a better assessment of intestinal viability. Although great majority of these second-look operations are "negative explorations," progressive nature of this devastating disease pushes surgeons to re-explore the abdomen. This study compares open and laparoscopic "second-look" procedures in patients with mesenteric ischemia. In the first group (n = 41), abdomen was closed and second-look laparotomy was performed to 23 patients. In the second group (n = 36), a 10-mm trocar was inserted before closing the abdomen and second-look intervention was performed by a telescope to 23 patients. Sixteen of relaparotomies in the first group (70%) revealed nothing and were unnecessary. Two patients (8%) in the laparoscopy group needed re-resection while 20 patients (87%) were rescued from unnecessary laparotomies. Conclusively, patients with mesenteric ischemia are "ill enough" to deserve the "minimal invasion" spirit of laparoscopic surgery.     

Relaparotomies following the creation of intestinal anastomoses in newborn infants]

An analysis of the immediate postoperative period in 295 newborns after putting intestinal anastomoses was made. Postoperative surgical complications were found in 38 children who required 47 relaparotomies. Surgical tactics was determined for the complications of the postoperative period as well as the indications for relaparotomy.     

Planned relaparotomies in the surgical treatment of severe generalized peritonitis from intestinal origin

The evolution of the septic state and the mortality rate are analyzed in a group of 42 selected patients presenting with severe peritonitis from small or large intestinal origin. All patients presented in a septic state with signs of generalized peritonitis for at least 24 hours. Planned relaparotomies are preferable to the conventional surgical approach of peritoneal lavage which frequently must be followed by demand relaparotomies in patients with recurring peritonitis. The mortality rate in the planned relaparotomy group (29%) was significantly lower than in the conventional treatment group (73%). The poor prognosis of persistent or recurrent multisystem failure complicating septic shock is confirmed. The planned relaparotomy tactic should be considered a valuable alternative approach to the treatment of severe forms of peritonitis.     

Elective relaparotomy as a method of treatment and prevention of complications of diffuse suppurative peritonitis

The results of treatment of 41 patient with diffuse purulent peritonitis, who underwent 2 and more relaparotomies are analysed. It has been proved that performance of the elective relaparotomy for preventing the development of intraabdominal complications of peritonitis were superior to the existing methods of treatment. It permitted to reduce lethality in diffuse purulent peritonitis 3.6-fold.