Tag Archives: laparotomy

Best Of AAST 2021: Individual Surgeon Outcomes In Trauma Laparotomy

Trauma programs use a number of quality indicators and PI filters to evaluate both individual and system performance. The emergent trauma laparotomy (ETL) is the index case for any trauma surgeon and is performed on a regular basis. However, this is one procedure where individual surgeon outcome is rarely benchmarked.

The trauma group in Birmingham AL performed a retrospective review of 242 ETLs performed at their hospital over a 14 month period. They then excluded patients who underwent resuscitative thoracotomy prior to the laparotomy. Rates of use of damage control and mortality at various time points were studied.

Here are the factoids:

The chart shows the survival rates after ETL at 24 hours (blue) and to discharge (gray) for 14 individual surgeons.

  • Six patients died intraoperatively and damage control laparotomy was performed in one third.
  • Mortality was 4% at 24 hours and 7% overall
  • ISS and time in ED were similar, but operative time varied substantially (40-469 minutes)
  • There were significant differences in individual surgeon mortality and use of damage control

The authors concluded that there were significant differences in outcomes by surgeon, and that more granular quality metrics should be developed for quality improvement.

Bottom line: I worry that this work is a superficial treatment of surgeon performance. The use of gross outcomes like death and use of damage control is not very helpful, in my opinion. There are so, so many other variables involved in who is likely to survive or the decision-making to consider the use of damage control. I am concerned that a simplistic retrospective review without most of those variables will lead to false conclusions.

It may be that there is a lot more information here that just couldn’t fit on the abstract page. In that case, the presentation should clear it all up.  But I am doubtful.

We have already reached a point in medicine where hospitals with better outcomes for patients with certain conditions can be identified. These centers should be selected preferentially to treat stroke or pancreatic cancer, or whatever there benchmark-proven expertise is. It really is time for this to begin to trickle down to individual providers. A specific surgeon should be encouraged to do what they are demonstrated to be really good at, and other surgeons should handle the things the first surgeon is only average at.

But I don’t think this study can provide the level of benchmarking to suggest changes to a surgeon’s practice or the selection of a specific surgeon for a procedure. A lot more work is needed to identify the pertinent variables needed to develop legitimate benchmarks.

Here are my questions for the presenter and authors:

  • Show us the details of all of the variables you analyzed (ISS, NISS, time in ED, etc) and the breakdown by surgeon.
  • Are there any other variables that influence the outcome that you wish you had collected?
  • There were an average of 17 cases per surgeon in your study. Is it possible to show statistical significance for anything given these small numbers?

The devil is in the details, and I hope these come out during the presentation!

Reference: IT’S TIME TO LOOK IN THE MIRROR: INDIVIDUAL SURGEON OUTCOMES AFTER EMERGENT TRUMA LAPAROTOMY. AAST 2021, oral abstract #38.

Incidental Appendectomy During Trauma Laparotomy?

The debate over incidental appendectomy has waxed and waned over the years. And for the most part, it has nearly permanently waned in general surgical cases for now. But every once in a while, I am asked about incidental appendectomy during trauma laparotomy. Is it a good idea? What reasons could there possibly be for doing it?

In the old days, we would frequently do an incidental appendectomy because… well, just because we were there. The surgeon was in the midst of a general surgical case, typically an open one, and this normal little appendix was just staring us in the face. The justification was usually, “we’ll save him another operation in the future in case he develops acute appendicitis.”

Legitimate reason? It took many years for the literature to develop, but it finally did. Here were the reasons we figured out not to do it:

  • Despite how innocuous a procedure it seems to be, there is a measurable uptick in complication rates. This is true in the usual clean contaminated general surgery cases. Some papers also noted an increased mortality when the appendectomy was added to a cholecystectomy case. In a trauma procedure with bowel injury and contamination, it’s a bit harder to see the correlation. But any time we cut or staple something out, there is always the possibility that it might break down.
  • Cost increases in laparoscopic cases if additional ports and/or equipment is needed for the appendectomy. This doesn’t really apply to major trauma cases, since we better not be doing them laparoscopically!
  • The appendix is not the useless vestigial structure we originally thought. There is evidence that it is a repository for the gut microbiome, which can help repopulate the colon with bacteria after a serious insult like prolonged antibiotic administration. Unnecessary removal may ultimately interfere with gut health and disease.

Can acute appendicitis develop after trauma laparotomy? Sure, at any time. Thankfully, it’s not very common. The presenting complaints are the same as we learned in the doctor books. However, the location of the pain and tenderness may not be in the classic location depending on the post-trauma anatomy and presence of adhesions.

Bottom line: Incidental appendectomy is no longer indicated for just about anything, including trauma laparotomy. If one of your patients presents with abdominal pain at any time, both post-traumatic and other causes must be considered. CT has become the standard for appendicitis workup, and is extremely helpful in sorting out causes in the post-op trauma patient. Use it, and if it is one of the rare cases where appendicitis is actually present, then proceed with the usual and appropriate operative on nonoperative management.

References:

  • Incidental appendicectomy with laparotomy for trauma. Br J Surg 62(6):487-9, 1975
  • Appendicitis following blunt abdominal trauma. Am J Emerg Med 35(9):1386.e5-1386, 2017.
  • Systematic review of blunt abdominal trauma as a cause of acute appendicitis. Ann R Coll Surg Engl 92(6):477-82, 2010.

Best of AAST #8: Complications After Trauma Laparotomy

With the introduction of damage control laparotomy (DCL) in the early 1990s, the trauma literature has focused on the nuances of this procedure. A significant amout of research has looked at patient selection, techniques, optimum time to closure, and complications afterwards. Studies on the single-look trauma laparotomy (STL) seem to have fallen behind. When compared to DCL, it seems to have relatively few complications.

But is that really so? A paper from the 1980s showed a nearly 50% complication rate after STL, but this included some trivial things like atelectasis which padded the numbers. A group at Scripps Mercy in San Diego looked at long-term complications after  STL in a state-wide California database. They were able to identify patients who underwent STL who were then readmitted for complications at a later date. They studied this data over an 8-year period.

Here are the factoids:

  • A total of 2,113 patients had a STL during the study period
  • One third (712) were readmitted at least once, with a median time to first readmission of 110 days
  • 30% of these patients had a surgery-related complication:
    • bowel obstruction 18%
    • infection 9%
    • incisional hernia 7%
  • Mechanism of injury was not related to development of complications

Bottom line: More than 10% of patients undergoing single-look trauma laparotomy develop significant complications. This is much higher than the complication rate seen after typical general surgical procedures. The difference between these groups and the reasons are not clear. Additional work must be done to tease out the risk factors, and our patients should be counseled on these potential complications and when to return for evaluation. Finally, the trauma surgeon should always use their best judgment to avoid an unnecessary trauma laparotomy.

Reference: Long-term outcomes after single-look trauma laparotomy: a large population-based study. Session IV Paper 14, AAST 2018.

Prone Positioning After Trauma Laparotomy

Patients with serious abdominal injury may require a laparotomy, and a subset of these may need a temporary closure for damage control surgery. Concomitant spine injury may have your spine surgeons asking “is it safe to prone the patient who is postop with a midline incision or an open abdomen.” What to tell them?

There’s not much guidance out there in the literature. One paper from 2000 looked at four patients who were proned for severe ARDS and found that one suffered a wound dehiscence. However, this patient had severe generalized edema and was on several pressor agents. 

The use of temporary abdominal closure techniques has revolutionized the early management of severely injured trauma patients and has greatly decreased the incidence of complications from abdominal compartment syndrome. Several authors have now demonstrated that putting those patients in the prone position is well tolerated. 

As far as patients who have a closed laparotomy, proning appears to be well tolerated as well. One caveat: consider carefully if the patient is having wound complications or if they are morbidly obese.

The bottom line: Consider the risks and benefits carefully in any post-laparotomy patient you are considering prone positioning for. Other than in morbidly obese, it is generally considered safe, even in patients with damage control dressings in place. However, make sure the trauma surgeon re-evaluates the wound again as soon as the patient is returned to the supine position.

References: 

1. The “open abdomen” is not a contra-indication to prone positioning for severe ARDS (abstract). Schwab, et al. Chest. 1996;110:142S.

2. Complications of Prone Ventilation in Patients with Multisystem Trauma with Fulminant Acute Respiratory Distress Syndrome. Offner et al. Journal of Trauma-Injury Infection & Critical Care. 48(2):224-228, February 2000.

3. The Management of the Open Abdomen in Trauma and Emergency General Surgery: Part 1-Damage Control. Diaz et al. Journal of Trauma-Injury Infection & Critical Care. 68(6):1425-1438, June 2010.

Tips For Surgeons: Abdominal Packing

One of the tenets of trauma surgery, handed down for generations, is that we should pack the abdomen to help manage major abdominal hemorrhage. “All four quadrants were packed” reads the typical operative note. But how exactly do you do that? Sounds easy, right?

Well, there are nuances not found in the surgery textbooks. Here are some practical tips for the trauma surgeon:

  • Prepare. Have your scrub nurse fluff up about 20 laparotomy pads in advance. The point of packing is two-fold: soak up blood and stop bleeding. Fluffed up pads work better than the flat, rolled up pads shown above. And you will need them fast, so have a supply ready.
  • Do you really need to pack? Your patient is hypotensive, and you are convinced the abdomen is the source. You run to the OR, open it and… no blood. So don’t pack. It won’t slow down the (lack of) bleeding, but it is possible to cause serosal tears or worse. Just figure out where the bleeding is really coming from.
  • Be careful. Don’t just jam them in there. Carefully place pads over and under the liver. Carefully place a hand on the spleen and push toward the hilum so you can place pads between spleen and body wall. Try not to cause more damage than is already there.
  • Penetrating trauma: Pack where you know (or think) the penetrations are first. Basically, if it’s not bleeding there, don’t pack there.
  • Blunt trauma: Pack the upper quadrants first. This is where the money is, because the liver and spleen are the top culprits. Then pack the lower quadrants to soak up shed blood.
  • Once packed, check for successful control. If bleeding has stopped (or at least decreased significantly) stop and wait for anesthesia to catch up and continue your massive transfusion protocol. If bleeding continues, remove packs from the offending area and try to obtain definitive control. This is now the patient’s only chance, since you can’t stop the bleeding with packing.
  • Remove packs in the proper order. In blunt trauma, remove the lower quadrant packs first. They’re not doing anything and just take up valuable space. In penetrating trauma remove the packs in the area of the injury first. 
  • Get an xray to confirm that all packs are out at the end of the case. Self explanatory. It’s easy to lose a few in the heat of the moment. I’ve seen two bundles (10 pads) left over the liver in one case decades ago!