Bedside laparotomy for trauma: are there risks?
BACKGROUND
Critically ill trauma patients are often too unstable for safe transfer to the operating room. Damage control laparotomy patients frequently require early reoperation and have a reported mortality of 50-60%. As a result, many of these patients must undergo laparotomy in the intensive care unit. We hypothesized that patients undergoing bedside laparotomy (BSL) and managed with the abdomen left open would have an unacceptably high mortality or intra-abdominal complications.


METHODS
We performed a retrospective chart review of our Trauma Registry. Of the 11,096 consecutive trauma admissions from March 1, 1996 to May 20, 2000, 75 patients underwent 95 BSL. Patients were stratified according to injury severity score (ISS), base deficit (BD), lactic acid (LA), total transfusion (TRBC) requirements, indication for BSL, mechanism of injury, infectious complications (intra-abdominal abscess (IAA), fistula), and length of hospital stay.


RESULTS
Seventy-five patients underwent 95 BSL. Mean ISS was 50.6 +/- 18.9, mean BD was -11.9 (+/- 5), and the mean LA was 5 +/- 5 for the study group. The TRBC for the group was 43.7 +/- 42.6 units. Indications for the 95 BSL were (1) abdominal compartment syndrome (n = 47, 49.5%); (2) suspected intra-abdominal infection (n = 18, 19.0%); (3) washout/pack removal (n = 14, 14.7%); (4) washout with fascial closure (n = 12, 12.6%); and (5) other (n = 4, 4.2%). Twenty-nine of 75 patients (39.2%; ISS 52.3 +/- 18.8) died within 72 h of operation. Of the 46 remaining patients, an additional eight died 72 h or more after operation, for a late mortality rate of 17.4% and a total mortality rate of 49%. None of these deaths were attributable to either the operation or to post-operative IAA or fistula formation; all late deaths were secondary to multiple organ failure. Intra-abdominal abscesses developed in three of 46 patients (6.5%), each of whom had a TRBC of >100 units (mean, 160 units). Five of 46 patients (10.9%) developed enterocutaneous fistulae. None of these eight patients died. Thirty-eight of 75 patients (50.7%) survived to discharge, with a mean ISS of 40 (+/- 11.9).


CONCLUSIONS
Despite the high acuity of the population undergoing BSL, 50.7% of patients survived. Moreover, during BSL, IAA and fistula formation occurred at low rates.
Diaz
Jose J
JJ
Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA. jose.diaz@vanderbilt.edu
Mauer
Adele
A
May
Addison K
AK
Miller
Richard
R
Guy
Jeffery S
JS
Morris
John A
JA
D000007:Abdominal Injuries / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D000328:Adult; D002423:Cause of Death; D016638:Critical Illness / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015601:Injury Severity Score; D007813:Laparotomy / Q000379:methods* / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems; D011183:Postoperative Complications / Q000401:mortality; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D014193:Trauma Centers; D016896:Treatment Outcome