59.08 Skin Closure Techniques Following Trauma Laparotomy: Is Secondary Closure as Beneficial as We Think?

Posted on January 31, 2019

C. A. Fitzgerald1, B. C. Morse1, R. N. Smith1, J. Nguyen2, O. Danner2, R. B. Gelbard1  1Emory University School Of Medicine,Surgery,Atlanta, GA, USA 2Morehouse School of Medicine,Surgery,Atlanta, GA, USA

Introduction:

Trauma laparotomy incisions are often left open in the setting of enteric injuries to reduce the risk of wound infection, but there are limited data to support this practice. The purpose of this study was to determine if primary or delayed skin closure after trauma laparotomy is associated with an increased incidence of surgical site infections (SSI) and other wound complications.  

Methods:

Retrospective review of all patients who underwent a trauma laparotomy at a Level I trauma center from 2015-2017. Patients were separated into three groups: Group 1: fascia and skin both closed, Group 2: fascia closed, skin open for secondary closure, Group 3: delayed primary skin closure.

Results:

A total of 819 patients were included. Most patients were male (81.8%) and had penetrating injuries (66.4%). There were 556 (67.9%) patients in Group 1, 244 (29.8%) in Group 2 and 19 (2.3%) in Group 3. The incidence of hollow viscus injury (HVI) was 256 (46%), 222 (90.9%) and 18 (94.7%) in Groups 1, 2 and 3, respectively. There were 25 (4.5%) damage control laparotomies in Group 1, 57 (23.4%) in Group 2, and 1 (5.2%) in Group 3. Group 2 had longer ICU and hospital lengths of stay (10.4±14.8 vs. 5.8±9.3 vs. 6.2±12.0, p<0.001, and 25.1±24.1 vs. 15.2±14.5 vs. 17.8±12.2, p<0.001). Group 2 had a higher rate of organ space infections compared to Groups 1 and 3 (40/244, 16.4% vs. 35/556, 6.3%, vs. 1/19, 5.2%, p=0.0003) while Group 3 was associated with a significantly higher rate of fascial dehiscence and enterocutaneous fistula (ECF) among patients with HVI. There was no difference in the incidence of superficial or deep SSI or overall mortality between groups (Table 1).

Conclusion:
Leaving skin incisions open following trauma laparotomy appears to be associated with higher morbidity without reducing the rate of surgical site infections. Closing skin at the time of initial laparotomy should be considered to reduce hospital stays and lower the risk of fascial dehiscence and ECF.