RESULTS

During the eight-year study period, 654 patients required OAD, of whom 452 patients (69%) achieved abdominal closure of some type, with 400 patients (61%) surviving to hospital discharge. Among those who achieved abdominal closure, 35 patients (7.7%) required relaparotomy during the initial hospitalization. Those requiring relaparotomy had lower APACHE-II (18 ± 5 vs. 22 ± 9; p<0.001), and SAPS-2 (37 ± 10 vs. 45 ± 17; p<0.00001) scores. Median days to initial OAD closure (4 vs. 7 days; p=0.016) were less among the relaparotomy patients. Etiologies prompting relaparotomy included: dehiscence/evisceration (37.1%), intra-abdominal abscess/anastomotic leak/visceral necrosis (28.6%), intraabdominal hypertension/abdominal compartment syndrome (22.9%), enteric fistula (8.6%), and gastrointestinal hemorrhage (2.9%). In the relaparotomy group, primary fascial closure (PFC) was possible in 86% following initial OAD, but decreased to 9% for the subsequent abdominal closure (p<0.0001). Patients were eight times more likely to require prosthetic mesh for definitive functional closure for their subsequent closure (24% vs 3%). Due to fascial necrosis and loss of abdominal domain, a significant percentage of patients were only able to achieve a skin-only closure for their second operation. .

Relaparotomy Following Initial Closure of the Open Abdomen:

Incidence and Etiologies

Christina Hsu BA

1, Michael L. Cheatham MD FACS FCCM

2

University of Central Florida School of Medicine, Orlando, Florida1

Department of Surgical Education, Orlando Regional Medical Center, Orlando, Florida2

INTRODUCTION

The life-saving potential of damage control surgery for critically injured patients has been well-discussed in trauma literature. Damage control laparotomy, followed by either open abdomen decompression (OAD) or temporary abdominal closure (TAC), has been proven to reduce morbidity and mortality among critically injured patients. Although the need for OAD following one of these clinical indications has been proven to enhance patient survival, failure to close the open abdomen within a reasonable amount of time has been linked to complications. Long-term open abdomen management is associated with significant morbidity including fistula formation, need for split thickness skin grafting, prolonged hospitalization, long-term disability, and mortality. Early definitive abdominal closure should be the objective once the need for an open abdomen has been resolved. While the majority of patients who required OAD will achieve definitive primary fascial closure (PFC) prior to discharge from the hospital, a small number of these patients will require reopening of their laparotomy for one of a variety of reasons. We sought to identify the incidence of and etiologic causes for relaparotomy during the initial hospitalization.

OBJECTIVE

The objective of our retrospective database review is to identify the incidence and etiology of relaparotomy following abdominal closure during the initial hospitalization.

METHODS

Study Design: Retrospective database review of patients requiring OAD/TAC over an eight year period was performed at Orlando Regional Medical Center (ORMC).

Inclusion Criteria: All patients requiring OAD/TAC (ages 16 and older) that were admitted to the surgical critical care team at ORMC between the years of 2002 and 2009.

Collected Variables: Patient demographics, mechanism and severity of injury, TAC method, duration of OAD, subsequent abdominal wall reconstruction technique, resource utilization, and survival to hospital discharge were recorded.

Statistical Evaluation: Patients requiring reopening of a recent laparotomy were compared to those who did not. Data are presented as either percentage or mean ± standard deviation. Categorical data was analyzed using Fisher’s Exact test. Continuous data were analyzed using the Mann-Whitney U-test for non-normally distributed data. Significance was defined as a p < 0.05.

CONCLUSIONS

Relaparotomy is a rare event following closure of the open abdomen for damage control. The most common etiologies for relaparotomy are fascial dehiscence/evisceration and pathologic conditions of the viscera. Whereas primary fascial closure was the most common method used during initial closure, it was infrequently achieved following relaparotomy. This required that other closing techniques, such as skin-only and use of prosthetic mesh, became necessary.

While this study did not collect consistent intra-abdominal pressure measurements, the high incidence of fascial dehiscence and necrosis raises the question of whether routine perioperative intra-abdominal pressure (IAP) monitoring may help avoid these potential complications. The patients who developed fascial necrosis in our study may very well have been patients who had been closed too tightly or developed intra abdominal pressure. Overall, identification of patients at high risk of relaparotomy after initial closure of the open abdomen has significant clinical value.

SUMMARY

Relaparotomy is a rare event following closure of the open abdomen for damage control. The most common etiologies for relaparotomy are fascial dehiscence/evisceration and pathologic conditions of the viscera. Subsequent PFC was infrequently achieved when relaparotomy was necessary.

RELEVANT PUBLICATIONS

* Hammond KL. Surgical hemorrhage, damage control, and the abdominal compartment syndrome. Clinics in colon and rectal surgery. Nov 2006;19(4):188-194.

* Cheatham ML, Safcsak K. Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival? Critical care medicine. Feb 2010;38(2):402-407.

* Diebel L, Saxe J, Dulchavsky S. Effect of intra-abdominal pressure on abdominal wall blood flow. The American surgeon. Sep 1992;58(9):573-575

* Germanos S, Gourgiotis S, Villias C, Bertucci M, Dimopoulos N, Salemis N. Damage control surgery in the abdomen: an approach for the management of severe injured pa-tients. Int J Surg. Jun 2008;6(3):246-252.

ACKNOWLEDGEMENTS

This paper was presented at the Fifth World Congress of Surgery in August 2011. I’d like to thank my mentor, Dr. Michael L. Cheatham, for his extensive help and support while undertaking this project. Many thanks to the University of Central Florida College of Medicine for their funding and support.

Author contact e-mail address: christinahsu09@gmail.com

Figure 1: Consort Statement

Images 1 and 2: Damage control laparotomy and open abdomen decompression (OAD) are surgical techniques used to manage critically ill patients

after major traumatic injury. [Credit: Michael Cheatham, Orlando Regional Medical Center]

TABLE 1: Demographics

Successful

closure Relaparotomy

Patients Significance

Age (years) 43 ± 18 46 ± 18 0.33

Gender (male) 73% 66%

Service 0.60

Trauma 80% 77%

General Surgery 15% 17%

Vascular Surgery 1% 3%

Obstetrics/Gynecology 1% 3%

Medicine 3% 0%

ISS 25 ± 13 23 ± 9 0.28

SAPS-2 45 ± 17 37 ± 10 <0.0001

APACHE-2 22 ± 9 18 ± 5 <0.001

Legend: ISS – Injury Severity Score; SAPS-2 – Simplified Acute Physiology Score, version 2; APACHE-2 - Acute Physiology and Chronic Health Evaluation, version 2

TABLE 3: Etiologies for reopening of recent laparotomy

Dehiscence/evisceration

37.1%

Infection/necrosis 28.6%

IAH/ACS 23%

Fistula 8.6%

Gastrointestinal hemorrhage 2.9%

Legend: IAH – intra-abdominal hypertension; ACS – abdominal compartment syndrome

TABLE 2: Resource Utilization

Successful closure

Relaparotomy Significance

Days to initial closure

13 ± 15 6 ± 5 <0.0001

Days to subsequent closure

- - - 9 ± 8 - - -

Hospital days

28 ± 28 38 ± 21 0.012

Legend: ISS – Injury Severity Score; SAPS-2 – Simplified Acute Physiology Score, version 2; APACHE-2 - Acute Physiology and Chronic Health Evaluation, version 2

Table 1: Demographics

Table 2: Resource Utilization

Table 3: Etiologies for reopening of recent

laparotomy