Delayed interventions and mortality in trauma damage control laparotomy

Abstract

In damage control laparotomy, operative principles include hemorrhage and contamination control. However, required components of initial damage control laparotomy are unknown, and nonemergency injury repair is sometimes delayed for resuscitation, angiography, or nonabdominal operations. The frequency and effects of delayed interventions are unknown. A retrospective review of patients undergoing damage control laparotomy at a single, urban trauma center was performed. Interventions initially performed at the second laparotomy were considered delayed interventions. In the study, 330 damage control laparotomy patients survived to reoperation. Of all interventions, 13.9% were first performed at the second laparotomy, including 11.9% of visceral interventions and 27.2% of vascular interventions. Overall, 29.7% of patients underwent an unplanned re-exploration, and 21.8% of patients underwent re-exploration for hemorrhage control. There was no significant increase in mortality (33.3% vs 23.9%, P=.09), intra-abdominal infection (37.9% vs 28.0%; P=.10), anastomotic leak (8.0% vs 5.8%, P=.45), or enterocutaneous fistula formation (9.2% vs 9.1%, P=1.00) with delayed interventions overall. However, mortality was increased in patients undergoing delayed vascular interventions (59.1% vs 22.8%, P=.003), unplanned re-exploration (45.9% vs 18.1%, P<.001) and re-exploration for hemorrhage control (50.0% vs 19.8%, P<.001). Delayed interventions are common in damage control laparotomy, with abdominal interventions often spread over multiple explorations. Mortality is increased in patients undergoing emergent re-exploration and with delayed repair of major vascular injuries. Ideal treatment of damage control laparotomy patients may include addressing injuries more completely at the first laparotomy instead of deferring care for other priorities.