Trauma Laparotomy: A Surgical Odyssey

Surgical Health Collective

*Corresponding Author: Mark L Walker, M.D., F.A.C.S. Surgical Health Collective, 1691 Phoenix Boulevard Suite 120 Atlanta, Georgia 30349, USA, Phone: 404-761-7482, E-mail: [email protected]

Received Date: January 02, 2025

Published Date: February 18, 2025

Citation: Walker ML. (2025). Trauma Laparotomy: A Surgical Odyssey. Mathews J Surg. 8(1):35.

Copyrights: Walker ML. © (2025).

ABSTRACT

A retrospective analysis of 203 trauma patients undergoing laparotomy over an 18-year period by a single surgeon at a level 1 trauma center was performed. These were young (mean age=33.84+/-14.74) seriously injured (mean ISS=22.32+/-11.61) patients who sustained a mix of blunt (52%) and penetrating injury (48%). Many of these patients were in shock at the time of admission (mean base deficit 7.30+/-5.06). Patients requiring a massive transfusion protocol (MTP) were stratified. Those with a single laparotomy and MTP had more balanced resuscitation when compared to those with MTP and damage control. The overall mortality was 5.4%. A damage control laparotomy was performed in 34 patients with a mortality of 23.5%(8 patients). 4 patients received ultra-massive transfusion (more than 20 units of Packed red cells) during their initial operation. 3 of these patient survived. A stepwise regression analysis yielded GCS (Glasgow Coma Score) as the sole predictor of outcome. Individual trauma surgeons can continue the search for better outcomes by reviewing their overall care.

Keywords: Trauma Patients, Laparotomy, Hemodynamic Stability, Surgical Infection.

INTRODUCTION

Trauma laparotomy is increasingly viewed as an index procedure that reflects quality of trauma care. Comprehensive global data covering trauma laparotomy remains inadequate but an international study seeks to close this deficit [1]. Busy trauma centers have reported mortality rates varying from 5% to 40% based on the need for damage control procedures [2,3]. Goals of initial care include restoring hemodynamic stability and limiting peritoneal contamination.

This paper will review one surgeons 18-year experience with trauma laparotomy. It will delineate the role of damage control intervention in the setting of a massive transfusion protocol (MTP) and contrast this outcome data with a subset of patients who had MTP implemented during a single laparotomy (SL).

METHODS

203 patients managed by one surgeon at a Level1trauma center over an eighteen-year period were reviewed. Patients that survived for more than 4 hours were included in this review. Medical charts containing initial labs, vital signs, imaging studies, anesthesia operative flow sheets, operative reports, pathology reports, post-operative notes and laboratory values were reviewed. Electronic Medical Records were utilized in addition to paper charts. Records of patients seen on an outpatient basis were also assessed.

Categorical and continuous variables were cataloged. Demographic variables included age, sex, type of trauma (blunt vs. penetrating), Injury severity score, Glasgow Coma Scale, blood pressure, pulse, respiration, base deficit, lactate, INR, estimated blood loss and operative transfusions. These variables were described for the group as a whole and for designated subsets. Specific organ injuries were determined for each patient and graded by the AAST organ injury scale. The use of preoperative FAST and or an abdominal CT scan was also documented.

Means plus standard deviations were determined. An analysis of variance was performed comparing subsets. A T-test was used for continuous variables. Outcomes were defined including mortality and morbidity. A step-wise regression analysis was used to determine those factors associated with mortality. Post-operative complications were cataloged. Deep space surgical infection, wound infection, sepsis, pneumonia, urinary tract infection, catheter related infections, acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI) were assessed. MedCalc Statistical Software version 22.066 was used for the general statistical analysis. StatSoft, Inc.,2011 Statistica Version 10 was used for the regression analysis.

RESULTS

A total of 4500 patients were cared for during the study period. 230 of this group had a laparotomy during their hospital admission. 203 patients fulfilled the study criteria. 27 patients either did not have charts available for review or did not fulfill the study criteria. These were young (mean age 33.84 +/- 14.74) seriously injured (mean ISS-22.32 +/- 11.61) patients who sustained blunt trauma (52%) and stayed in the hospital for a mean of 15 +/-16.035 days. Table 1 describes the group as a whole. Many of these patients were in shock at the time of admission with the initial mean base deficit of 7.30 +/- 5.06 and a mean baseline lactate of 3.76 +/-2.25. Mortality was 5.4% (11 patients). Table 2 depicts post-operative complications for the group as a whole.

Table 3 depicts the damage control laparotomy group. Patients treated with DCL had high injury severity scores and base deficits along with very large blood loss during operative intervention. The low GCS in this group reflects either severe closed head injury or in field intubation. Intensive care unit and hospital length of stay were both prolonged in the DCL group. Table 4 depicts the SL/MTP cohort. SL/MTP patients were then compared to DCL/MTP patients (Table 5). Balanced resuscitation was evident in both but achieved (1:1= PRBC: FFP) in the SL/MTP group. As expected DCL/MTP patients had higher ISS (mean 33.14+/-12.0), lower GCS (7.53+/-5.45), chemical evidence of shock (base deficit=11+/-6.36) and greater blood loss (mean of 4 liters+). These differences were statistically significant. 4 patients received ultra-massive transfusion (more than 20 units of blood during initial operative care). Three of these patients survived.

All patients with SL/MTP were survivors. Of the 34 patients with DCL, 8 did not survive (23.5%).

Overall there were 11 deaths. Exsanguination occurred in 6 patients. Fatal brain injury was causative in 2 patients. 1 patient succumbed from multi-organ failure and sepsis. 1 from a massive pulmonary embolus and a final patient from ARDS. Using step-wise regression GCS emerged as the sole factor associated with survival. ISS, base deficit, lactate and EBL did not correlate with outcome.

Regarding specific injuries; there were 56 patients with liver injuries (5 with grade V and 14 with grade IV). There were 68 patients with spleen injuries (21 grade V and 23 grade IV). There were 27 kidney injuries (6 with grade V and 8 with grade IV). There were 20 patients with pancreas injuries (1 Grade IV and 5 with Grade III). There were 76 patients with colon trauma. There were 23 grade I, 7 Grade II, 19 Grade III, 19 Grade IV and 8 Grade 5 injuries. Colon repair was performed in 33 and colon resection was performed in 34. 21 patients had a colostomy. There was overlap between the repair, resection and colostomy groups. There were 36 small bowel resections and 28 small bowel repairs. There were 11 Pringle maneuvers, 9 finger fractures and ligation and one hepatic lobectomy. 65 splenectomies, 14 nephrectomies and 9 pancreatectomies performed, 17 patients with named vascular injuries were cared for 3 aorta, 4 inferior vena cava, 4 retrohepatic cava/hepatic venous injuries, 1 portal vein, 1 middle sacral artery, 1 inferior mesenteric artery, 1 right hepatic artery, 2 internal iliac vein and 1superior mesenteric vein near the origin of the portal vein. All aortic injury patients recovered. 2 were related to stab wounds and 1 was from a gunshot wound. Three of 4 IVC injured patients survived. One retrohepatic caval injury was combined with a right hepatic artery injury and this patient succumbed from hemorrhage. Two patients with a retrohepatic caval wounds from blunt trauma survived with packing. One patient had a Grade V liver injury associated with atrio-caval rupture from blunt trauma. He survived with packing and an atrio-caval repair.

The most common post-operative complication was sepsis (17%). More than half of these patients had documented bacteremia. The most common source of infection was pneumonia. Wound infection occurred in 5.4% and deep space infection in 6%. 4 patients developed an enterocutaneous fistula and 2 of these closed spontaneously prior to discharge to home.

Table 1. Group as a whole N=203

PRBC = Packed Red Blood Cells

INR = International Normalized Ratio

BPS = Blood Pressure Systolic

LOS = Length of Stay

FFP = Fresh Frozen Plasma

BPD = Blood Pressure Diastolic

Table 2. Complications

IAA = Intraabdominal Abscess

ECF = Enterocutaneous Fistula

AKI = Acute Kidney Injury

ARDS = Acute Respiratory Distress Syndrome

UTI= Urinary Tract Infection

Table 3. Damage Control Laparotomy

GCS= Glasgow Coma Scale

EBL=Estimated Blood Loss

INR=Internationalized Normative Ratio

LOS=Length of Stay

ICU LOS= Intensive Care Unit length of stay

Table 5. Massive Transfusion n=17 & SL vs. DCL n=22

Table 6. Pre-Operative Imaging

This report illustrates some of the current principles of trauma care and highlights areas that require improvement. First a rapid assessment in the trauma bay involves searching for occult sources of hemorrhage [4]. The expeditious use of the focused abdominal ultrasound for trauma has been a mainstay in this regard. Alerting the trauma team (including anesthesiology) that a massive transfusion protocol should be instituted early when 2 or more ABC (assessment of blood consumption) criteria have been met is necessary [5]. In this series PRBC: FFP was more balanced in the single laparotomy/MTP group. All of these patients survived. In contrast the DCL/MTP group received a 2:1 ratio of PRBC: FFP. The PROPPR trial data did not reveal a difference in overall outcome between a 1:1:1 vs. 1:2:1 ratio. However, a post-hoc analysis suggested that exsanguination occurred more often in the 1:2:1 group [6]. This may be a factor in the outcome difference noted although some of our patients likely had non-survivable injuries (retrohepatic cava + right hepatic artery bleeding is an example). Time to hemorrhage control has been documented as a quality indicator by several groups [7-9]. We did not report complete data herein but a subset analysis of the most critically injured revealed a mean time of 44 minutes to hemorrhage control. The liberal use of FAST in this series (128 patients 63%) likely has some bearing on this. FAST was positive in 52 patients and no CT scanning was done in this group. A preoperative CT was performed in 96 patients. 14 of these patients had a positive FAST (Table 6). One of the difficult issues in trauma care decision making involves when to go to the scanner as opposed to the operating room. In a cohort of 383 patients from the United Kingdom a preoperative CT was performed for the majority of patients but FAST was performed in only 57 patients (16%). If CT had been omitted, the time to hemorrhage control may have been shortened. More than half of the patients who died in that series had a preoperative CT [10]. CT remains an important part of the work up of patients with tangential penetrating trauma in the setting of normal hemodynamics [11-13]. CT provides useful information that might allow the clinician to follow a course of observation instead of abdominal exploration. Sensitivity of the modern generation scanners for detecting bowel injury in blunt trauma has improved to 95% [14].

There was one missed bowel injury in our series. This patient had a normal admission CT scan and mild tenderness in the region of a seat belt contusion on examination. He had a femur fracture and was cleared for orthopedic intervention. A repeat CT post-operatively detected the mesenteric and bowel injury. A small bowel resection and ileostomy was performed. Full recovery followed.

Common causes for acute trauma mortality include hemorrhage and traumatic brain injury [15-17]. 11 patients succumbed after admission. 6 died from exsanguination, 2 from severe TBI (one patient with a basilar skull fracture was also bleeding) one from a massive pulmonary embolus, another from ARDS and a final patient from multi-organ failure and sepsis. These results are depicted in Table 7. Using a step-wise regression analysis, GCS was the only independent predictor of mortality.

In a mature trauma network patients are now making it to the hospital with injuries that they may have succumbed to decades earlier. Newer tools including resuscitative endovascular balloon occlusion (Reboa) may help us salvage more of these patients in the setting of non-compressible truncal hemorrhage [18-21]. We did not use Reboa in any of the patients described and this likely represents a quality improvement area.

Another concern is the utilization frequency of damage control laparotomy. The 17% rate reported in our study does not seem excessive given the high grade of liver injuries and the estimated blood loss (4 liters) reported in the DCL group. Quality improvement efforts have successfully reduced the application of damage control laparotomy at one level 1 US trauma center from 30% to 17% with no adverse consequences regarding outcome [22]. A large range exists between institutions and individual surgeons for the application of damage control laparotomy [23-25]. It is clear based on this study that the mere implementation of a massive transfusion protocol does not mandate a damage control approach.

The open abdomen exposes the patient to significant risks of infection, fistula formation and ventral hernia. The significant rate of infection reported in our patients (sepsis in 17%, wound infection 5.4% and intraabdominal abscess 6%) is consistent with what is often described in damage control observational studies [26-28]. All four patients with an enterocutaneous fistula had open abdomens in the damage control setting. 3 with colon and small bowel wounds requiring resection and anastomosis. Colon injuries requiring resection and repeated re-explorations are two clear risk factors for fistula formation in the setting of an open abdomen [29,30].

Fortunately, 2 closed prior to discharge and one was repaired after several months. The final patient had a low output fistula that was managed with local wound care. It has been closed and his colostomy has been reversed. He is tolerating oral intake.

SUMMARY AND CONCLUSIONS

We report a retrospective series of 203 patients managed by one surgeon over an 18-year period in a Level I trauma center. These young severely injured patients had significant base deficits and elevated lactates reflecting compromised flow on admission. Patients treated with a massive transfusion protocol and a single laparotomy were compared to those treated with damage control laparotomy and massive transfusion. ISS, blood loss, base deficit and lactate were greater in the damage control group. GCS was significantly lower in the DCL group. Balanced resuscitation was evident in those patients managed with a massive transfusion protocol and a single laparotomy. Mortality was 5.4% with most patients succumbing to hemorrhage. Although not utilized in this cohort, we remain hopeful that the application of Reboa may allow us to salvage patients in the future from non-compressible truncal hemorrhage.

ACKNOWLEDGMENTS

None.

CONFLICTS OF INTEREST

The author declares that there is no conflicts of interest.

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