The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy

Abstract

Background: To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. Study Design:We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n=60) to recent historic controls (n=78) that would have met protocol inclusion criteria. The protocol includes low volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure.Results: Baseline characteristics, including age, ASA class and postoperative lactate levels were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p=0.044) and exhibited higher serum osmolarity (303 vs. 293 mosm/kg, p=0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p=0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p=0.045, number needed to treat: 8.3). Complication rates were similar between groups.

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

“…In 2012, Burlew et al found that those patients undergoing DCS who required multiple re-laparotomies and those who had a subsequent delay of abdominal wall closure presented with a higher incidence of complications 37 . These findings have been confirmed by recent publications in which the rate of adverse events significantly diminishes when patients are closed prior to 72 hours 38 .…”

“…En el 2012, Burlew et al ., reportaron que pacientes sometidos a cirugía de control de daños y que requirieron múltiples laparotomías con cierre tardío de la pared abdominal presentaron un mayor número de complicaciones 37 . Estos hallazgos fueron igualmente confirmados en publicaciones recientes donde se demostró que lograr el cierre de la pared abdominal antes de las 72 horas disminuía significativamente los eventos adversos de este grupo de pacientes 38 .…”

Dynamic closure techniques for treatment of an open abdomen: an update

“…In total, 13 studies fulfilled the criteria [12][13][14][15][16][17][18][19][20][21][22][23][24]. All included studies are observational cohort studies, and no studies reported on the use of either the Wittmann patch or the ABRA system.…”

“…Two studies reported on the ABRA system in combination with NPWT [12,13], while 9 reported on meshmediated fascial traction (MMFT) combined with NPWT [14][15][16][17][18][19][20][21][22]. Other types of fascial traction, either by dynamic suture lines [23] or by a self-made silastic tube system, and NPWT [24] were reported in 2 studies.…”

What's new in critical illness and injury science? Management of the open abdomen: Getting it together!

“…[15] This was further described in a protocol-based approach in 2019. [16] These studies underscore the benefits of avoiding excessive crystalloid infusion and using hypertonic saline-based resuscitation to improve the rates of fascial closure.…”