Index Laparotomy Research Articles

Early placement of a non-invasive, pressure-regulated, fascial reapproximation device improves reduction of the fascial gap in open abdomens: a retrospective cohort study

BackgroundSince current fascial traction methods involve invasive procedures, they are generally employed late in the management of the open abdomen (OA). This study aimed to evaluate early versus late placement...

Different but Equal: Outcomes of Prolonged Postanesthesia Care Unit Stay After Trauma Laparotomy

IntroductionHospital overcrowding is common and can lead to delays in intensive care unit (ICU) admission, resulting in increased morbidity and mortality in medical and surgical patients. Data on delayed ICU admission are limited in the postsurgical trauma cohort. Damage control laparotomy with temporary abdominal closure (DCL-TAC) for severely injured patients is often followed by an aggressive early resuscitation phase, usually occurring in the ICU. We hypothesized that patients who underwent DCL-TAC with initial postanesthesia care unit (PACU) stay would have worse outcomes than those directly admitted to ICU. MethodsA retrospective chart review identified all trauma patients who underwent DCL-TAC at a level 1 trauma center over a 5 y period. Demographics, injuries, and resuscitation markers at 12 and 24 h were collected. Patients were stratified by location after index laparotomy (PACU versus ICU) and compared. Outcomes included composite morbidity and mortality. Multivariable logistic regression was performed. ResultsOf the 561 patients undergoing DCL-TAC, 134 (24%) patients required PACU stay due to ICU bed shortage, and 427 (76%) patients were admitted directly to ICU. There was no difference in demographics, injury severity score, time to resuscitation, complications, or mortality between PACU and ICU groups. Only 46% of patients were resuscitated at 24 h; 76% underwent eventual primary fascial closure. Under-resuscitation at 24 h (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.31-0.95, P = 0.03), increased age (AOR 1.04; 95% CI 1.02-10.55, P < 0.0001), and increased injury severity score (AOR 1.04; 95% CI 1.02-1.07, P < 0.0001) were associated with mortality on multivariable logistic regression. The median time in PACU was 3 h. ConclusionsPACU hold is not associated with worse outcomes in patients undergoing DCL-TAC. While ICU was designed for the resuscitation of critically ill patients, PACU is an appropriate alternative when an ICU bed is unavailable.

EGS P27 Twice Recurrent Gallstone Ileus Requiring 3 Laparotomies – A Case Report

Abstract Background Gallstone ileus is a well-known and not an uncommon complication of gall stone disease, with standard management being an enterotomy and extraction of the obstructing gallstone with management of the gallbladder and the billio-enteric fistula being deferred to an interval procedure if indicated. Recurrent gallstone ileus are not unheard of, but are quite rare and are the reason cited by the proponents of a single stage procedure. While a single stage procedure is possible - involving an enterotomy as well as a challenging cholecystectomy and the management and closure of a duodenal fistula – more commonly than not it is not performed. Methods Twice recurrent gallstone ileus is extremely rare and on performing a literature review only 1 published case report has been identified. Here we present the case of an 87-year-old Caucasian female, presenting with 3 incidences of gall stone ileus in a 30 day period requiring 3 laparotomies. Initial presentation to our institution was in November 2022 with a CT proven localised Gallbladder perforation. The first presentation with gallstone ileus was on 21/03/2023 with symptoms of bowel obstruction and CT proven obstructing 23mm gallstone 8 cm from the ileocaecal valve as well as pneumobillia and two other stones in the gallbladder. Results The index laparotomy was performed and no transition point was found, and bowel run-through from DJ to ICV revealed no intraluminal gall stones and the caecum was full of fluid. The gallstone had passed into the colon spontaneously and no enterotomy was performed. Two subsequent laparotomies were required due to CT proven incidence of recurrent Gallstone ileus on 30/03/2023 and 20/4/2023, were enterotomies were performed and the obstructing stones extracted each time. An informed decision not to tackle the gallbladder and the duodenal fistula was taken by a consensus of 3 consultant surgeons due to the frailty of our patient. Conclusions Our patient made a meaningful recovery after developing an entero-cutaneous fistula that resolved with conservative management and was discharged home on 15/05/2023. While our patient's frailty and previous gallbladder perforation made the decision not proceed with a cholecystectomy and repair of the duodenal fistula a straightforward one, the incidence of twice recurrent gallstone ileus in the span of a month raises questions as to whether other techniques should be considered in a more fit patient such as a single stage operation or a Cholecystolithotomy.

The Efficacy of VAMMFT Compared to "Bogota Bag" in Achieving Sheath Closure Following Temporary Abdominal Closure at Index Laparotomy for Trauma

IntroductionThe open abdomen (OA) is a necessary component of damage control surgery and closure is often challenging. Our aim was to review our ten-year experience with OA in trauma patients and to compare the success of a dual closure technique termed vacuum-assisted, mesh-mediated fascial traction (VAMMFT) to an exclusively Bogota Bag (BB) approach.MethodsA retrospective analysis was performed using the HEMR database from 2012 to 2022, comparing demographics, mechanism of injury, admission vitals and biochemistry between patients with BB and VAMMFT applications. Rate of secondary abdominal closure and complications were assessed in both groups. Logistic regression was used to find predictors of closure.ResultsOA was required by 348 patients at index laparotomy. Of these, 133 (38.2%) were managed with VAMMFT and 215 (61.8%) exclusively with a BB. There were no statistical differences between the BB and VAMMFT groups in terms of demographics, injuries, admission vitals and biochemistry. The VAMMFT group achieved a closure rate of 73% compared to 54.9% in the BB group (OR of 2.2 [1.4–3.7]). There was no significant difference in fistulation rate between the two groups (p = 0.103). Length of hospital stay was 30 versus 17 days in the VAMMFT and BB groups, respectively (OR 1.41 [1.30–1.54]). There were no independent predictors of closure identified in the VAMMFT group. Older patients were less likely to achieve closure when BB was used (OR 0.97 [0.95–0.99]). VAMMFT failure was commonly due to lack of stock (39%) and protocol violations (33%).ConclusionThe VAMMFT approach to the OA is efficacious and safe. VAMMFT achieves a much higher rate of secondary closure than BB alone with a low rate of enteric fistula formation.

Invited Commentary: The Efficacy of VAMMFT Compared to "Bogota Bag" in Achieving Sheath Closure Following Temporary Abdominal Closure at Index Laparotomy for Trauma.

Invited Commentary: The Efficacy of VAMMFT Compared to "Bogota Bag" in Achieving Sheath Closure Following Temporary Abdominal Closure at Index Laparotomy for Trauma.

The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania

BackgroundDamage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. MethodsWe analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for “reopening of recent laparotomy” or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. ResultsIn total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. ConclusionThere is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.

The “weekend effect” does not impact on outcome of trauma laparotomy – Experience from a level 1 trauma centre in New Zealand

PurposeTrauma centres have been proven to provide better outcomes in developed countries for overall trauma, but there is limited literature on the systematic factors that describe any discrepancies in outcomes for trauma laparotomies in these centres. This study was conducted to examine and interrogate the effect of systematic factors on patients undergoing a trauma laparotomy in a developed country, intending to identify potential discrepancies in the outcome. MethodsThis was a retrospective study of all laparotomies performed for trauma at a level 1 trauma centre in New Zealand. All adult patients who had undergone an index laparotomy for trauma between February 2012 and November 2020 were identified and laparotomies for both blunt and penetrating trauma were included. Repeat laparotomies and trauma laparotomies in children were excluded. The primary clinical outcomes reviewed included morbidity, length of hospital stay, and mortality. All statistical analysis was performed using R v.4.0.3. ResultsDuring the 9-year study period, 204 trauma laparotomies were performed at Waikato hospital. The majority (83.3%) were performed during office hours (170/204), and the remaining 16.7% were performed after hours (34/204). And 61.3% were performed on a weekday (125/204), whilst 38.7% were performed on the weekend/public holiday (79/204). Most of the parameters in office hours and after hours groups had no statistically significant difference, except lactate (p = 0.026). Most of the variables in weekday and weekend groups had no statistically significant difference, except pH, lactate, length of stay, and gastrointestinal complications (p = 0.012, p < 0.001, p = 0.003, p = 0.020, respectively). ConclusionThe current trauma system at Waikato hospital is capable of delivering care for trauma laparotomy patients with the same outcome regardless of working hours or after hours, weekday or weekend. This confirms the importance of a robust trauma system capable of responding to the sudden demands placed on it.

Systemic Review of Open Abdomen versus Primary Closure after Emergency Laparotomy for Peritonitis: Experience in Qazi Hussain Ahmed Medical Complex, Nowshera, Pakistan.

Objective: In secondary peritonitis patients, optimal management after index laparotomy is poorly defined. Although an open abdomen or temporary abdominal closure with planned relaparotomy is used to reassess bowel viability or contamination severity, recent studies show that primary abdominal closure has comparable morbidity and mortality. The differences between Open Abdomen (OP) and Primary Closure (PC) after emergent laparotomy are examined in this study.&#x0D; Material and Methods: A systemic review on open abdomen versus primary closure after emergency laparotomy for peritonitis from January 2017 to December 2021 were analyzed. This systemic review was conducted in the department of surgical Qazi Hussain Ahmad Medical complex, Nowshera, Pakistan with approval from the hospital ethical and research committee. The study enrolled 200 patients who met the eligibility requirements. A lottery method was used to divide the patients into two groups at random. Patients with secondary peritonitis requiring emergent laparotomy were identified (N = 200) using the Premier database at a quaternary level. Mannheim Peritonitis Index, lactate, and vasopressor requirement were used to perform propensity matching for PC (n = 100; 65%) or OA (n = 100; 35%). A total of 200 closely matched pairs (PC: OA) were examined.&#x0D; Results: About 65 percent of the 200 women patients enrolled in the study had an emergency laparotomy (mean age of 52.2 years). Only one relaparotomy was performed on 100 (65.0%) of the (O.A) patients, while 35 (35.0%) had multiple reoperations. Overnight (4 pm–4 am) laparotomies had more temporary closures with O.A (35.0 percent OA vs. 65.0 percent PC, p = 0.05) than daytime laparotomies. Surgical subspecialties performed PC in 82.1 percent of laparotomies, compared to 35.0 percent (p 0.0002) of acute care surgeons. Postoperative complications and n-100 (65.0 percent vs. 35.0 percent, p = 0.0002), mortality (18.0 percent vs. 09.2 percent, p = 0.005), and a longer median length of stay (12 vs. 12 days p = 0.0001) were all higher in OA patients.&#x0D; Conclusion: The study's systemic review revealed that compared to PC, the complications, mortality rates, and costs associated with OA were significantly higher. Given these findings, more research is needed to determine appropriate OA indications.

Laparotomy for penetrating gastric trauma - A South African experience

IntroductionPenetrating gastric injury (PGI) is common and although primary repair is sufficient for most injuries, several areas surrounding the peri-operative management remain contentious. This study reviews our experience in the management of PGI and review the clinical outcome at a major trauma centre in South Africa. Materials and methodsA retrospective study was conducted from January 2012 to April 2020 at a major trauma centre in South Africa. Results210 cases were included (184 male, median age: 30 years). Mechanism of injury was 59% stab wounds (SWs) and 41% gunshot wounds (GSWs). The AAST grade was predominantly (92%) grade 2 for all cases. 20% (41/210) were isolated gastric injuries. All cases underwent primary repair and there were no cases of suture line failure. Eleven cases (5%) had one or more injuries not identified at the index laparotomy: 7 were unidentified gastric injuries and the remaining 4 were unidentified non gastric injuries. There was no association between unidentified injuries and mechanism of injury or outcome. Fifty-seven (27%) cases experienced one or more complications. Eighty-two cases (39%) required intensive care unit admission. The overall median length of hospital stay was 7 (IQR 4-11) days. The overall mortality was 14%. GSW injuries were more likely to have additional organ injury, higher ISS and PATI scores, longer length of hospitalization, higher likelihood of ICU stay, greater morbidity and mortality than SW injuries. There was a slight increase in the wound sepsis rate as number of associated extra gastric injuries increased but this was not statistically significant. There was no difference in wound overall sepsis rate between SW and GSW injuries (2% vs 8%, p=0.121). ConclusionsPrimary repair alone is sufficient for most PGI, but laparotomy is associated with high incidence of unidentified injury and surgeons must to be cognisant of the likelihood of these occult injuries.

Damage Control Surgery may be a Safe Option for Severe Non-Trauma Peritonitis Management: Proposal of a New Decision-Making Algorithm.

Damage control surgery (DCS) has emerged as a new option in the management of non-traumatic peritonitis patients to increase survival in critically ill patients. The purpose of this study was to compare DCS with conventional strategy (anastomosis/ostomies in the index laparotomy) for severe non-traumatic peritonitis regarding postoperative complications, ostomy rate, and mortality and to propose a useful algorithm in the clinical practice. Patients who underwent an urgent laparotomy for non-trauma peritonitis at a single level I trauma center in Colombia between January 2003 and December 2018, were retrospectively included. We compared patients who had DCS management versus definitive initial surgical management (DISM) group. We evaluated clinical outcomes and morbidities among groups. 290 patients were included; 81 patients were treated with DCS and 209 patients underwent DISM. Patients treated with DCS had a worse critical status before surgery with higher SOFA score [median, DCS group: 5 (IQR: 3-8) vs. DISM group: 3 (IQR: 1-6), p < 0.001]. The length of hospital stay and overall mortality rate of DCS group were not significant statistical differences with DISM group. Complications rate related to primary anastomosis or primary ostomy was similar. There is not difference in ostomy rate among groups. At multivariate analysis, SOFA > 6 points and APACHE-II > 20 points correlated with a higher probability of DCS. DCS in severe non-trauma peritonitis patients is feasible and safe as surgical strategy management without increasing mortality, length hospital of stay, or complications. DCS principles might be applied in the non-trauma scenarios without increase the stoma rate.

Patient's characteristics, management practices and outcome of re-laparotomies in a tertiary hospital in Tanzania

BackgroundRelaparotomy is an important indicator of the safety and quality of laparotomy in any surgical setting. Despite this, its measure in many low- and middle-income countries is scarce, Tanzania included. Understanding its existence will help curb it and mitigate its adverse outcomes by systematic improvement strategies. This study, therefore, aimed to examine characteristics of patients undergoing on-demand relaparotomy and their management outcomes at a tertiary level hospital in Tanzania. MethodsA cross-sectional descriptive study was carried out in the department of surgery of Muhimbili National Hospital for one year in 2017–2018. All patients (of all ages and sex) who required an on-demand relaparotomy within 60 days of their index laparotomy were identified for inclusion into the study. Data were collected regarding patient's demography, clinical characteristics, index surgical procedure, indication for relaparotomy, number of re-laparotomies, complications during re-laparotomy, ICU admission, and mortality. Data were entered into SPSS version 23 for analysis where continuous variables were summarized as means with standard deviations and categorical variables summarized as the frequency with proportions. Ethical approval for the audit was obtained from the Muhimbili University of Health IRB. ResultsA total of 101 patients had undergone relaparotomy, with a relaparotomy rate among those primarily operated at our hospital of 7.6%. Their mean age was 37 years with equal sex distribution. The leading primary procedure had involved bowel resection and anastomosis (47.5%) with anastomotic leak being the leading reason for relaparotomy (37.6%) followed by intra-abdominal collection (29.7%), bowel fistula (19.8%) and wound dehiscence (18.8%). Electrolyte imbalance was the leading complication among the patients (22.9%) followed by anemia (21.5%), wound infection (18.9%) and Septicemia (11%). The overall mortality of rate was 39.6%. ConclusionOn-demand relaparotomy carries a high mortality and morbidity at Muhimbili National Hospital in Tanzania. Addressing predictors and improving post-operative services are urgently needed.

Vacuum Assisted Mesh Mediated Fascial Traction Is Effective at Achieving Secondary Closure of Open Abdomens Following Emergency Laparotomy in a Developing World Setting

Introduction: We have previously described our initial experience with a combination approach known as Vacuum Assisted Mesh Mediated Fascial Traction (VAMMFT). This project reviews our two-year experience with the use of VAMMFT following TAC in patients undergoing an emergency laparotomy. Methods: All patients who could not undergo primary closure at index laparotomy and who required a TAC and subsequently a VAMMFT were identified from Hybrid Electronic Medical Registry (HEMR) and retrieved for analysis. Results: Over the two year period January 2017- January 2019, a total of 77 patients required a VAMMFT following an emergency laparotomy. Of this cohort 15 (19%) died and 62 survived. Of the 15deaths two achieved SFC prior to death and 13 died with a VH. Of the 62 who survived SFC was achieved in 46/62 (74%) and 16/62 (25%) were left with a VH. The overall rate of SFC was 48/77(62%). The median length of stay was 29 days, the median number of repeat laparotomies was4, and median time to first repeat laparotomy was 3 days. A total of 19 patients (32,2%) required ICU admission. The VH group had a significantly longer length of hospital stay than the SFC group. The following morbidities were recorded, anastomotic failure, intra-abdominal sepsis(13), acute kidney injury (8), hospital acquired pneumonia (6) and enteric fistulae (7). Conclusion: VAMMFT seems to both safe and efficacious in our environment. There are no absolute or well defined contraindications to its use. We must continue to audit it’s use to better refine our management strategies going forward.

Relaparotomy—the Surgeons Nightmare

The term relaparotomy (RL) refers to operations performed within 60 days of an initial laparotomy, for complications arising following the primary surgery. Our study aims to determine the incidence, indications, and outcome of RLs and identify factors affecting outcomes of RLs in Indian population. A prospective nonrandomized observational study was conducted at a tertiary care Medical College Hospital. Planned elective RL, those undergoing index laparotomy in other hospital were excluded. Demographic features, nutritional status, initial diagnoses, elective/emergency initial surgery, postoperative complications leading to RL, presence of diffuse peritonitis, average interval to RL, associated co morbidity, duration of hospital stay, outcome, and factors associated with outcome of RL were analyzed. Of 622 laparotomies in the study period, 30 underwent RL with incidence of 4.8%. The mean age was 52.2 years. RL was more common in emergency surgeries (80% vs 20%). The mean hospital stay among patients undergoing RL was 25.8 days. The mean interval between first laparotomy and RL was 12.3 days and the average gap between the time of detection of the complication and RL was 3.96 days. The mortality rate in the study was 20%. Five of the six mortality patients had underwent emergency primary surgery. The mean serum albumin level was 3.4 g/dL while that associated with mortality was 3.01 g/dL. All laparotomies have potential for RL. RL is associated with high morbidity and mortality. Careful surgical techniques and patient optimization help reduce RL rate. Intensive postoperative monitoring and early RL when indicated reduce mortality associated with RL.

Closed Or Open after Source Control Laparotomy for Severe Complicated Intra-Abdominal Sepsis (the COOL trial): study protocol for a randomized controlled trial

BackgroundSevere complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment include early antibiotic administration and operative source control. A further therapeutic option may be open abdomen (OA) management with active negative peritoneal pressure therapy (ANPPT) to remove inflammatory ascites and ameliorate the systemic damage from SCIAS. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise.MethodsThe Closed Or Open after Laparotomy (COOL) study will constitute a prospective randomized controlled trial that will randomly allocate eligible surgical patients intra-operatively to either formal closure of the fascia or use of the OA with application of an ANPTT dressing. Patients will be eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR a Predisposition-Infection-Response-Organ Dysfunction Score ≥ 3 or a World-Society-of-Emergency-Surgery-Sepsis-Severity-Score ≥ 8. The primary outcome will be 90-day survival. Secondary outcomes will be logistical, physiologic, safety, bio-mediators, microbiological, quality of life, and health-care costs. Secondary outcomes will include days free of ICU, ventilation, renal replacement therapy, and hospital at 30 days from the index laparotomy. Physiologic secondary outcomes will include changes in intensive care unit illness severity scores after laparotomy. Bio-mediator outcomes for participating centers will involve measurement of interleukin (IL)-6 and IL-10, procalcitonin, activated protein C (APC), high-mobility group box protein-1, complement factors, and mitochondrial DNA. Economic outcomes will comprise standard costing for utilization of health-care resources.DiscussionAlthough facial closure after SCIAS is considered the current standard of care, many reports are suggesting that OA management may improve outcomes in these patients. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only.Trial registrationClinicalTrials.gov, NCT03163095.

The State of Prophylactic Mesh Augmentation

Prophylactic mesh augmentation (PMA) is the implantation of mesh during closure of an index laparotomy to decrease a patient's risk for developing incisional hernia (IH). The current body of evidence lacks refined guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to summarize the literature and identify areas of research needed to foster responsible and appropriate use of PMA as an emerging technique. We conducted a comprehensive review of Scopus, Cochrane, PubMed, and <ext-link ext-link-type="uri" xlink:href="http://clinicaltrials.gov">clinicaltrials.gov</ext-link> for articles and trials related to using PMA for IH risk reduction. We further supplemented our review by including select papers on patient-reported outcomes, cost utility, risk modeling, surgical techniques, and available materials highly relevant to PMA. Five-hundred-fifty-one unique articles and 357 trials were reviewed. Multiple studies note a significant decrease in IH incidence with PMA compared with primary suture-only-based closure. No multicenter randomized control trial has been conducted in the United States, and only two such trials are currently active worldwide. Evidence exists supporting the use of PMA, with practical cost utility and models for selecting high-risk patients, but standard PMA guidelines are lacking. Although Europe has progressed with this technique, widespread adoption of PMA requires large-scale pragmatic randomized control trial research, strong evidence-based guidelines, current procedural terminology coding, and resolution of several barriers.

Early Definitive Fracture Fixation is Safely Performed in the Presence of an Open Abdomen in Multiply Injured Patients.

To investigate the safety and feasibility of performing definitive fracture fixation in multiply injured patients in the presence of an open abdomen after laparotomy. Retrospective observational cohort study. Level-I academic trauma center. Adult polytrauma patients with the presence of an open abdomen after "damage control" laparotomy and associated major fractures of long bones, acetabulum, pelvis, or spine, requiring surgical repair (n = 81). Timing of definitive fracture fixation in relation to the timing of abdominal wall closure. Incidence of orthopedic surgical site infections. During a 15-year time window from January 1, 2000 until December 31, 2014, we identified a cohort of 294 consecutive polytrauma patients with an open abdomen after laparotomy. Surgical fixation of associated fractures was performed after the index laparotomy in 81 patients. In group 1 (n = 32), fracture fixation occurred significantly sooner despite a concurrent open abdomen, compared with group 2 (n = 49) with abdominal wall closure before fixation (mean 4.4 vs. 11.8 days; P = 0.01). The incidence of orthopaedic surgical site infections requiring a surgical revision was significantly lower in group 1 (3.1%) compared to group 2 (30.6%; P = 0.002). Definitive fracture fixation in the presence of an open abdomen is performed safely and associated with a significant decrease in clinically relevant surgical site infections, compared with delaying fracture fixation until abdominal wall closure. These data suggest that the strategy of imposing a time delay in orthopaedic procedures while awaiting abdominal wall closure is unjustified. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Open abdomen with vacuum-assisted wound closure and mesh-mediated fascial traction in patients with complicated diffuse secondary peritonitis: A single-center 8-year experience.

Open abdomen (OA) treatment in patients with peritonitis is increasing worldwide. Various temporary abdominal closure devices are being used. This study included patients with complicated diffuse secondary peritonitis, OA, and vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). The aim of this study was to describe mortality and major morbidity in terms of delayed primary fascial closure and enteroatmospheric fistula rates. This was a single-academic-center retrospective study of consecutive patients with diffuse peritonitis, OA, and VAWCM between years 2008 and 2016. Descriptive and univariate analyses were performed. Forty-one patients were identified and analyzed. Median age was 59 years, preoperative septic shock was diagnosed in 54% (n = 22), and 59% (n = 24) had a postoperative peritonitis. Mortality was 29% (n = 12), and 76% (n = 31) of patients were admitted in the intensive care unit. The median duration of OA was 7 days with a median of two dressing changes. Delayed primary fascial closure rate among survivors was 92% (n = 33), and enteroatmospheric fistulas developed in 7% (n = 3). In a subgroup analysis, patients with OA in the primary laparotomy for peritonitis (n = 27) were compared with patients with OA in the subsequent laparotomies (n = 14). There were no significant differences between groups. The VAWCM technique in patients with complicated secondary diffuse peritonitis and OA yields excellent results in terms of delayed primary fascial closure rate and a low number of enteroatmospheric fistulas. It seems to be safe to close the abdomen at the index laparotomy, if possible, even if there is a risk of a need of OA later. Therapeutic/care management study, level IV.

Damage control laparotomy for abdominal trauma in children.

Damage control laparotomy (DCL) is not well studied in the pediatric trauma population. The purpose of this study was to develop a surrogate definition of DCL compatible with national and administrative data sources so that the rate and outcomes of DCL in pediatric trauma patients could be determined. Using the 2010-2014 National Trauma Data Bank, children ≤18 with an abdominal AIS ≥ 3 who underwent a laparotomy within 3h of arrival were identified (n = 2989). DCL was defined as occurring in children who underwent a second laparotomy within 5-48h from the index laparotomy (n = 360). Children meeting these criteria were compared to those children who had the initial definitive operative management (n = 2174) and those who died prior to 48h (n = 455). DCL occurred in 12% of children with operative abdominal trauma. Children who underwent DCL had a greater median ISS (25 vs 18) and heart rate (112 vs 100), lower systolic blood pressure (104 vs 113), and GCS (12 vs 13), and were more likely to receive a preoperative blood transfusion (19 vs 11%) than those who had definitive initial operative management (all p < .05). Median length of stay (17 vs 8 days) and mortality (9 vs 2%) were greater following DCL than definitive initial operative management (p < .001). No differences in rate of DCL were seen based on ACS pediatric verification (p = .07). Few children with operative abdominal trauma undergo DCL. DCL was associated with worse physiology rather than anatomic injury severity in this study. As expected, outcomes were worse following DCL.

Intra-abdominal packing with laparotomy pads and QuikClot™ during damage control laparotomy: A safety analysis

BackgroundIntra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage control in critically injured patients. Combat Gauze™ and Trauma Pads™ ([QC] Z-Medica QuikClot®) are kaolin impregnated hemostatic agents, that in addition to LP, may improve hemorrhage control. While QC packing has been effective in a swine liver injury model, QC remains unstudied for human intra-abdominal use. We hypothesized QC packing during damage control laparotomy (DCL) better controls hemorrhage than standard packing and is safe for intracorporeal use. MethodsA retrospective review (2011–2014) at a Level-I Trauma Center reviewed all patients who underwent DCL with intentionally retained packing. Clinical characteristics, intraoperative and postoperative parameters, and outcomes were compared with respect to packing (LP vs. LP+QC). All complications occurring within the patients’ hospital stays were reviewed. A p≤0.05 was considered significant. Results68 patients underwent DCL with packing; (LP n=40; LP+QC n=28). No difference in age, BMI, injury mechanism, ISS, or GCS was detected (Table 1, all p>0.05). LP+QC patients had a lower systolic blood pressure upon ED presentation and greater blood loss during index laparotomy than LP patients. LP+QC patients received more packed red blood cell and fresh frozen plasma resuscitation during index laparotomy (both p<0.05). Despite greater physiologic derangement in the LP+QC group, there was no difference in total blood products required after index laparotomy until abdominal closure (LP vs LP+QC; p>0.05). After a median of 2days until abdominal closure in both groups, no difference in complications rates attributable to intra-abdominal packing (LP vs LP+QC) was detected. ConclusionWhile the addition of QC to LP packing did not confer additional benefit to standard packing, there was no additional morbidity identified with its use. The surgeons at our institution now select augmented packing with QC for sicker patients, as we believe this may have additional advantage over standard LP packing. A randomized controlled trial is warranted to further evaluate the intra-abdominal use of advanced hemostatic agents, like QC, for both hemostasis and associated morbidity.

Costs of relaparotomy on-demand versus planned relaparotomy in patients with severe peritonitis: an economic evaluation within a randomized controlled trial

IntroductionResults of the first randomized trial comparing on-demand versus planned-relaparotomy strategy in patients with severe peritonitis (RELAP trial) indicated no clear differences in primary outcomes. We now report the full economic evaluation for this trial, including detailed methods, nonmedical costs, further differentiated cost calculations, and robustness of different assumptions in sensitivity analyses.MethodsAn economic evaluation was conducted from a societal perspective alongside a randomized controlled trial in 229 patients with severe secondary peritonitis and an acute physiology and chronic health evaluation (APACHE)-II score ≥11 from two academic and five regional teaching hospitals in the Netherlands. After the index laparotomy, patients were randomly allocated to an on-demand or a planned-relaparotomy strategy. Primary resource-utilization data were used to estimate mean total costs per patient during the index admission and after discharge until 1 year after the index operation. Overall differences in costs between the on-demand relaparotomy strategy and the planned strategy, as well as relative differences across several clinical subgroups, were evaluated.ResultsCosts were substantially lower in the on-demand group (mean, €65,768 versus €83,450 per patient in the planned group; mean absolute difference, €17,682; 95% CI, €5,062 to €29,004). Relative differences in mean total costs per patient (approximately 21%) were robust to various alternative assumptions. Planned relaparotomy consistently generated more costs across the whole range of different courses of disease (quick recovery and few resources used on one end of the spectrum; slow recovery and many resources used on the other end). This difference in costs between the two surgical strategies also did not vary significantly across several clinical subgroups.ConclusionsThe reduction in societal costs renders the on-demand strategy a more-efficient relaparotomy strategy in patients with severe peritonitis. These differences were found across the full range of healthcare resources as well as across patients with different courses of disease.Trial RegistrationISRCTN51729393