Surgeon decision-making is consistent in trauma patients despite time of day and patient injury

Abstract

Background: Damage control laparotomy with temporary abdominal closure has become routine in trauma surgery. This technique is associated with complications. Increasing prevalence of this procedure leads to concern over abdomens being left open due to decision points other than patient factors, such as routine, time of day, or surgeon fatigue. We hypothesize that time of day contributes to the decision to leave the initial trauma laparotomy open.Materials and Methods: This was a retrospective chart review of 527 patients over 5 years. Patients with emergent damage control laparotomies with fascia not closed were included in the open abdomen group. Those patients who had fascia primarily closed were used as the control group. Patient demographics, injury factors, time of operation, and time to fascial closure were evaluated.Results: Time of day was not predictive of the decision to leave a patient open. In a logistic regression model of these factors, only patient age (P = 0.002), injury severity score (P < 0.0001), and the number of abdominal organs with an injury grade of three or more (P = 0.0014) predicted the abdomen would be left open. Of the patients with initially open abdomen, 101 (72.1%) survived and 77 (76.2%) of those achieved primary fascial closure. Mean time to closure was 3.7 days.Conclusion: The decision to perform damage control surgery and leave an abdomen open appears to be consistent throughout the day and to be dependent on the patient factors. Time of day does not seem to be a contributing factor. Fascial closure, done on average 3.7 days after the initial procedure, does not vary based on the demographic or injury factors. It appears that closure occurs as part of a routine or on convenience. An opportunity may exist to identify a subset of the open abdomen patients that could return to the operating room for earlier definitive closure, thereby lowering the risk of complications.The following core competencies are addressed in this article: Patient care, Practice based learning and improvement, and Systems-based practice.