Skin closure after trauma laparotomy in high-risk patients: opening opportunities for improvement.
BACKGROUND
Although many surgeons leave laparotomy incisions open after colon injury to prevent surgical site infection (SSI), other injured patient subsets are also at risk. We hypothesized that leaving trauma laparotomy skin incisions open in high-risk patients with any enteric injury or requiring damage control laparotomy (DCL) would not affect superficial SSI and fascial dehiscence rates.


METHODS
Patients who underwent trauma laparotomy (2004-2008) at two Level I centers were reviewed. To ensure a high-risk sample, only patients with transmural enteric injuries or need for DCL surviving 5 days or more were included. SSIs were categorized by the CDC (Centers for Disease Control and Prevention) criteria and risk factors were analyzed by skin closure (open vs. any closure). Significant (p < 0.05) univariate variables were applied to two multivariate analyses examining superficial SSI and fascial dehiscence.


RESULTS
Of 1,501 patients who underwent laparotomy, 503 met inclusion criteria. Patients were young (median, 28.0 years; range, 22.0-40.0 years) with penetrating (74%) or enteric (80%) injuries, and DCL (36%) and SSI (44%; superficial, 25%; deep, 3%; organ/space, 25%) were common. While no difference in superficial SSI after loose (n = 136) or complete skin closure (n = 224) was detected (p = 0.64), superficial SSIs were less common with open skin incisions (9.8%), despite multiple risk factors, than with any skin closure (31.1%, p < 0.001). Predictors of superficial SSIs and fascial dehiscence were each evaluated with multiple-variable logistic regression analysis. After adjusting for multiple potential confounding variables, any skin closure increased the risk of superficial SSIs approximately nine times (odds ratio, 8.6; p < 0.001) and fascial dehiscence six times (odds ratio, 5.7; p = 0.013).


CONCLUSIONS
Management of skin incisions takes careful consideration like any other step of a laparotomy. Our results suggest that the decision to leave skin open is one simple method to improve outcomes in high-risk patients.


METHODS
Therapeutic study, level III.
Division of Trauma and Surgical Critical Care, Department of Surgery, Cooper University Hospital, Camden, New Jersey 08103, USA. seamon-mark@CooperHealth.edu
Mark J
MJ
Seamon
Brian P
BP
Smith
Lisa
L
Capano-Wehrle
Abdulla
A
Fakhro
Nicole
N
Fox
Michael
M
Goldberg
Niels M
NM
Martin
Abhijit S
AS
Pathak
Steven E
SE
Ross
D000007:Abdominal Injuries / Q000601:surgery; D000328:Adult; D005260:Female; D006801:Humans; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D013529:Surgical Wound Dehiscence / Q000517:prevention & control; D013530:Surgical Wound Infection / Q000517:prevention & control*; D055815:Young Adult