Mini-laparotomy in emergency general surgery in a second-level hospital in Zambia: a prospective cohort study

Abstract

Background Being an integral part of the Enhanced Recovery After Surgery methodology, the mini-invasive surgical technique is an important factor in attenuating surgical stress and minimising the risk of postoperative complications. Here we present our experience of utilising the mini-laparotomy (ML) approach in emergency surgery.Methods This prospective clinical study included adult patients operated on for acute abdominal conditions at a second-level hospital in Zambia. Thirty-four patients were explored through ML, and another 34 participants had a standard laparotomy (SL) incision. The size of ML ranged from 6 to 12 cm, with the median being 10.5 cm. ML was not attempted in abdominal malignancy, generalised peritonitis, and as an approach for the relaparotomy procedures. Length of hospital of stay (LOS) and morbidity/mortality were primary endpoints. Secondary outcomes of interest included operating time (OT) and post-operative pain control. Continuous variables were presented as mean with standard deviation or median with ranges; categorical data were given as proportions and percentages. Associations between data were estimated using the t-test and chi-square analysis, as appropriate. LOS was compared by log-rank test and presented graphically by Kaplan-Meier survival curves. A p-value < 0.05 was considered statistically significant.Results The most common procedures performed through ML were resection of the small bowel or colon, closure of hollow viscus perforation or rupture, and adhesiolysis. Employment of ML was associated with reduced LOS (p = 0.0002), shorter OT (p = 0.0003), and minimised need for opioid analgesia (p = 0.01); however, the difference in postoperative complications was not statistically significant (ML: 21% versus SL: 27%, p = 0.57), and mortality was similar (6% in each group).Conclusions As our data showed, ML is a feasible and safe technique that could be used in emergency visceral surgery and abdominal trauma in well-selected patients. Having comparable postoperative morbidity with the SL approach, it might lead to reduced pain and enhanced recovery after the procedure. We proposed an algorithm for the selection of exploration method in patients presented with acute abdominal conditions that could be of help to acute care surgeon operating in a resource-limited setting.