Failed Primary Abdominal Closure in the Trauma Patient
Failed Primary Abdominal Closure in the Trauma Patient
After receiving institutional review board approval from the University of Texas Southwestern Medical Center, all of the patients undergoing exploratory laparotomy for trauma between January 1, 2006 and December 31, 2008 were identified in the Parkland Memorial Hospital trauma database. This group was cross-referenced with the Department of Surgery coding database for "reopening of recent laparotomy" to obtain a list of all of the trauma patients who had an open abdomen. Although an institutional protocol exists that provides guidance in making the choice to perform damage-control laparotomy, the decision to perform a damage-control procedure with an open abdomen is ultimately at the discretion of the attending surgeon. A vacuum-based dressing is our initial temporary abdominal covering of choice. Patients surviving their resuscitation are returned to the operating room 24 to 48 hours after termination of their index laparotomy for definitive management of their injuries and attempted abdominal closure. If closure at first take back is impossible or believed to be ill advised, then the choice of vacuum- or fascial-based open abdomen management is left to the discretion of the attending surgeon staffing the case, as are all of the future choices surrounding timing of return trips to the operating room and open abdomen management techniques to be used. Exclusion criteria were age younger than 18 years, performance of only a single abdominal operation, and performance of initial damage-control laparotomy >24 hours after presentation. Data pertaining to demographics, the presenting clinical status, and outcomes were collected, with categorical values listed as percentages and continuous variables as mean ± standard deviation. All of the operative reports were then reviewed to ascertain the number of abdominal operations performed, surgical techniques used to manage open abdomens, and number of days with an open abdomen. In addition to standard assessments of injury severity, further information on the severity of abdominal injury was ascertained through the calculation of a Penetrating Abdominal Trauma Index (PATI) score on all of the patients, regardless of injury mechanism.
For the purpose of this study, an open abdomen was defined as an explored abdominal cavity without fascial closure. Based on a review of operative notes, subjects were classified into two groups: those in whom primary fascial closure was obtained before discharge from index admission (successful closure group [SC]) and those with a discharge plan of delayed ventral hernia repair (failed closure group [FC]). Surgical techniques for managing the open abdomen were divided into two groups: fascial-based management and vacuum-based management. Subjects who had both fascial- and vacuum-based management at different times in their convalescence had an a priori decision made after review of all of their operative records as to which method constituted the preponderance of their care and were classified as such.
To identify independent risk factors for failure to achieve definitive fascial closure, a univariate analysis was initially conducted of all of the covariates. Those with a P value ≤0.20 were considered in the logistic regression model using several variable selection procedures. A parsimonious model was selected that included those variables that produced the best area under the curve and Hosmer-Lemeshow results. Adjusted odds ratios (OR) with 95% confidence intervals (CIs) and adjusted P values were derived. Bivariate analyses were performed using the chi square or Fisher exact test (two-sided) as appropriate to test differences in proportions. The unpaired Student t test was used to compare differences between means. SAS software version 9.2 (SAS Institute, Cary, NC) was used for all of the calculations.
Methods
After receiving institutional review board approval from the University of Texas Southwestern Medical Center, all of the patients undergoing exploratory laparotomy for trauma between January 1, 2006 and December 31, 2008 were identified in the Parkland Memorial Hospital trauma database. This group was cross-referenced with the Department of Surgery coding database for "reopening of recent laparotomy" to obtain a list of all of the trauma patients who had an open abdomen. Although an institutional protocol exists that provides guidance in making the choice to perform damage-control laparotomy, the decision to perform a damage-control procedure with an open abdomen is ultimately at the discretion of the attending surgeon. A vacuum-based dressing is our initial temporary abdominal covering of choice. Patients surviving their resuscitation are returned to the operating room 24 to 48 hours after termination of their index laparotomy for definitive management of their injuries and attempted abdominal closure. If closure at first take back is impossible or believed to be ill advised, then the choice of vacuum- or fascial-based open abdomen management is left to the discretion of the attending surgeon staffing the case, as are all of the future choices surrounding timing of return trips to the operating room and open abdomen management techniques to be used. Exclusion criteria were age younger than 18 years, performance of only a single abdominal operation, and performance of initial damage-control laparotomy >24 hours after presentation. Data pertaining to demographics, the presenting clinical status, and outcomes were collected, with categorical values listed as percentages and continuous variables as mean ± standard deviation. All of the operative reports were then reviewed to ascertain the number of abdominal operations performed, surgical techniques used to manage open abdomens, and number of days with an open abdomen. In addition to standard assessments of injury severity, further information on the severity of abdominal injury was ascertained through the calculation of a Penetrating Abdominal Trauma Index (PATI) score on all of the patients, regardless of injury mechanism.
For the purpose of this study, an open abdomen was defined as an explored abdominal cavity without fascial closure. Based on a review of operative notes, subjects were classified into two groups: those in whom primary fascial closure was obtained before discharge from index admission (successful closure group [SC]) and those with a discharge plan of delayed ventral hernia repair (failed closure group [FC]). Surgical techniques for managing the open abdomen were divided into two groups: fascial-based management and vacuum-based management. Subjects who had both fascial- and vacuum-based management at different times in their convalescence had an a priori decision made after review of all of their operative records as to which method constituted the preponderance of their care and were classified as such.
To identify independent risk factors for failure to achieve definitive fascial closure, a univariate analysis was initially conducted of all of the covariates. Those with a P value ≤0.20 were considered in the logistic regression model using several variable selection procedures. A parsimonious model was selected that included those variables that produced the best area under the curve and Hosmer-Lemeshow results. Adjusted odds ratios (OR) with 95% confidence intervals (CIs) and adjusted P values were derived. Bivariate analyses were performed using the chi square or Fisher exact test (two-sided) as appropriate to test differences in proportions. The unpaired Student t test was used to compare differences between means. SAS software version 9.2 (SAS Institute, Cary, NC) was used for all of the calculations.