D. D. Coffey1, C. Spalding1, M. S. O’Mara1 1Grant Medical Center / Ohio University,Trauma And Acute Care Surgery / Ohio University Heritage College Of Osteopathic Medicine,Columbus, OHIO, USA
Introduction: Damage control laparotomy with temporary abdominal closure has become routine in trauma surgery with concern for abdominal compartment syndrome, or a planned second-look procedure. This technique is associated with complications including fluid/protein loss, enterocutaneous fistula, and ventral hernia. The increasing prevalence of this procedure has led to concern over too many abdomens being left open due to surgeon routine or surgeon fatigue. Fatigue is a concern with long surgeon shifts, and after 16 hours decision making capabilities may be impaired. We hypothesize that patient and physician factors other than physiologic parameters contribute to the decision to not close the initial trauma laparotomy.
Methods: This was a retrospective chart review comprising a total of 527 patients 5 years. Patients who underwent emergent damage control laparotomies with fascia not closed were included in the open abdomen group. No consistent criteria were defined to choose this course. Those patients who had fascia primarily closed after the first emergent laparotomy were included as closed abdomens and used as the control group. Patient demographics, injury factors, time of operation, and time to fascial closure were evaluated.
Results: Demographic and injury factors were predictive of the decision to leave the abdomen open (table), in particular injury severity, patient mass, and blunt mechanism predicted an open abdomen. Time of day was not predictive of the decision to leave a patient open. In a logistic regression model of these factors, only patient age (p=0.002), ISS (p<0.0001), and the number of abdominal organs with an injury grade of 3 or more (p=0.0014) predicted the abdomen would be left open. Of the patients with initially open abdomen, 84 (60%) survived and 67 of those achieved primary fascial closure. Mean time to closure was 2.4 (±1.6) days. None of the presenting demographic or injury factors predicted time to primary fascial closure by independent or model analysis (all p>0.1).
Conclusion: The decision to perform damage control surgery and leave an abdomen open appears to be consistent throughout the day and to be dependent upon patient factors as evaluated by the operating surgeon. Fatigue does not seem to be a contributing factor. This does not hold true for the fascial closure, which is done at approximately two days after the initial procedure, and does not vary based upon demographic or injury factors in the patients that survive. An opportunity may exist to identify a subset of the open abdomen patients that could return to the operating room for earlier definitive closure, thereby lowering the risk of complications.
