Intraoperative Surgical Strategy in Abdominal Emergency Surgery

Abstract

Background Emergency abdominal surgery is associated with a high rate of postoperative complications and death. Pre‐ and immediate postoperative bundle‐care strategies have improved outcome, but so far, no standardized intraoperative strategies have been proposed. We introduced a quality improvement model of specific intra‐ and postoperative strategies for the heterogenous group of patients undergoing emergency abdominal surgery. The objective was to evaluate a quality improvement strategy, using an intraoperative, multidisciplinary time‐out model in emergency abdominal surgery to apply one of three surgical strategies; definitive–palliative–or damage control surgery. Methods All patients scheduled for any gastrointestinal emergency procedure were stratified dynamically according to standardized criteria for performing definitive–palliative–or damage control surgery. Pre‐ intra‐ and postoperative data were collected according to the intraoperative strategy applied. Postoperative complications were displayed according to the Clavien‐Dindo‐score and the CCI (Comprehensive Complication Index). 30–90‐day‐ and 1‐year mortality was presented. Results We included 436 consecutive patients undergoing emergency laparotomy or laparoscopy in 2019. Intraoperative strategy was definitive in 326(75%)–palliative in 90(21%) and damage control approach in 20(4%) patients. CCI was 21(0,45), 30(17,54) and 78(54,100) in the definitive–, the palliative–, and the damage control group, respectively. 30‐day mortality was; 11.7%, 26.7% and 30%, and the 1‐year mortality was 16.9%, 56.7% and 40% in the definitive– the palliative– and the damage control group, respectively. Conclusions We present a multidisciplinary, intraoperative decision‐making standard as a potential quality improvement tool of ensuring individualized intra‐ and postoperative treatment for every emergency surgical patient and for future research‐protocols.

Understanding early deaths after major emergency abdominal surgery: An observational study of 754 patients

“…The Herlev Hospital covers an area with approximately 450,000 inhabitants and has implemented a multidisciplinary perioperative protocol for patients with severe intra-abdominal conditions requiring major emergency abdominal surgery named AHA (acute high-risk abdominal surgery). 6 This protocol comprised of previously described elements of pre, 20 intra, 21 and postoperative 15,22 standards, including rapid clinical evaluation and resuscitation, initial prophylactic interventions upon suspicion, ondemand abdominal CT within 2 h, surgery within 6 h after arrival at the hospital, multidisciplinary intraoperative time-out and decision-making on the surgical strategy (definitive, palliative, or damage control surgery) as well as a standardized anesthesia protocol including perioperative goal-directed hemodynamic optimization, standardized postoperative highdependency wards, intermediate or intensive care, standardized rounds every day by dedicated consultant emergency surgeons, and a postoperative standard nursing care map with optimal pain treatment, dieticianregulated early nutrition, and physiotherapist-guided mobilization. Regular data audits and quality assessments are performed.…”

Non-technical skills and teamwork in trauma: from the emergency department to the operating room

“…While training and experience may attenuate the trend toward repetitive type 1 use, a helpful tool is the use of intra-resuscitation or intraoperative time-outs ( 11 , 17 ). These allow the entire team to reassess the situation and share concerns.…”

Structured Decision‐Making during Emergency Abdominal Surgery

“…The surgical community has recognized the need for strategies and a streamlined decision making tool to improve the outcome in abdominal emergencies. The study conducted at Copenhagen University Hospital Herlev [2] evaluated a quality improvement strategy, using an intraoperative, multidisciplinary time‐out model in emergency abdominal surgery.…”

“…The key advantage of the checklist proposed by the authors [2] for an intraoperative surgical strategy is that it ensures the exchange of relevant information among all OR team members. Additionally, it supplements rather than replaces existing communication practices within each discipline (for example, senior surgeon-surgical resident or nurse-nurse discussions).…”