INTRODUCTION

Background

Trauma remains a significant global public health challenge and is an important cause of morbidity and mortality [1–3]. Abdominal trauma is highly challenging, and because such cases are often accompanied by significant hemorrhage, they require rapid clinical assessment and immediate surgical intervention to prevent life-threatening complications [4,5]. Because of this reason, the term “golden hour” was coined. Currently, the treatment of hemodynamic unstable abdominal injuries involves damage control laparotomy (DCL), damage control resuscitation, resuscitative endovascular occlusion of aorta (REBOA), or angioembolization [6,7]. The concept of “damage control” emphasizes prompt hemostasis. For this, expeditious hemostasis of the main bleeder is crucial, and it is often achieved via laparotomy. Indeed, prognosis varies significantly as time progresses following injury and it can range from full recovery to irreversible organ damage or fatality [4]. However, patients with severe blood loss may not be stable enough to be transferred to the operating room (OR).

To overcome these challenges, the strategy of direct-to-OR (DOR) resuscitation has been proposed [8]. This approach seeks to expedite critical intervention by eliminating potential delays at the emergency department (ED). However, bypassing the ED may not be feasible at many hospitals because of the cooperation between anesthesiologists and nursing staff in the OR. At many hospitals, performing laparotomy at the ED without anesthesiologists may be more appropriate. Few studies have reported the use of ED laparotomy to treat severely unstable patients and its efficacy and safety are unclear [9–12]. Moreover, ED environments are not always set up for such surgical procedures because the specialized facilities, essential instruments, and requisite personnel, including anesthesiologists and surgical nursing staff, are often not provided in these settings. This limitation underscores the urgent need for structured protocols and resources dedicated to managing such cases.

Despite such limitations, a protocol for performing ED laparotomy at the trauma bay was instituted at our trauma center in 2020. This approach was specifically meant to cater to cases of severely unstable abdominal injuries.

Objectives

Here, we investigated the mortality after ED laparotomy and time taken from admission to ED laparotomy.

METHODS

Ethics statement

This study was approved by the Institutional Review Board of Cheju Halla General Hospital (No. 2023-L14-01). The requirement for informed consent was waived due to the retrospective nature of the study.

Study design and patients

Data for the study was obtained from the Korean Trauma Database by reviewing entries made by Jeju Regional Trauma Center (Jeju, Korea) between January 2020 and December 2022 and retrieving the records on patients who underwent laparotomy because of abdominal trauma. Patients who underwent laparotomy more than 8 hours following admission, those who underwent laparoscopy, or those who underwent preperitoneal pelvic packing only, were excluded from the study.

Patient demographic and clinical data, including injury mechanism, age, sex, laboratory findings, vital signs, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) score, transfusion, postoperative outcomes, the place where the laparotomy was performed, bedside procedures (such as resuscitative endovascular balloon occlusion of the aorta [REBOA]), and ED thoracotomy, were collected and analyzed.

Laparotomies performed at the trauma bay or the ED were classified as ED laparotomy, whereas those done at the OR, were classified as OR laparotomy. Because patients undergo two or more surgeries in damage control settings, we divided the patients into the ED laparotomy or the OR laparotomy group based on where the first laparotomy was done. Our trauma center has two dedicated trauma bays, two ORs and one interventional radiology room close to the trauma bay. These facilities are equipped with point-of-care ultrasonography, a REBOA kit, a portable x-ray, and surgical equipment for ED laparotomy and thoracotomy, for use by a dedicated trauma staff. For the treatment of hemodynamically unstable patients, we have protocols for carrying out REBOA, ED thoracotomy, and ED laparotomy. The indications for REBOA are unstable vital signs (systolic blood pressure [SBP], <90 mmHg) and severe intra-abdominal or pelvic hemorrhage [13]. Patients with impending cardiac arrest (before or after REBOA), underwent ED thoracotomy. After the return of spontaneous circulation, the aortic clamp used during the thoracotomy was converted into REBOA. In cases requiring hemostasis but transfer to the OR was expected to be delayed, ED laparotomy was performed appropriately (Fig. 1). This study’s primary and secondary outcomes were in-hospital mortality and the length of time between admission and the first laparotomy, respectively.

Statistical analysis

Continuous data are presented as median and interquartile range (IQR). Categorical data are presented as proportions. Statistical differences between continuous variables were compared using the Mann-Whitney U-test, whereas differences between proportions were compared using the chi-square test or Fisher exact test, as appropriate. A P-value of <0.05 indicates statistically significant differences. All statistical analyses were performed using R ver. 4.3.1 (R Foundation for Statistical Computing).

RESULTS

Between January 2020 and December 2022, 105 trauma patients underwent emergency laparotomy within 8 hours of admission at our hospital. Table 1 summarizes the comparison between the patients who underwent OR laparotomy versus those who received ED laparotomy. Of the total 105 patients, 99 patients (94.3%) underwent OR laparotomy, whereas six (5.7%) received ED laparotomy. The mortality rate in the ED laparotomy group (four patients, 66.7%) was significantly higher than in the OR laparotomy group (18 patients, 17.1%; P=0.006). In the ED laparotomy group, all six patients (100%) underwent DCL, and the number of patients who underwent REBOA (four patients, 66.7%) was significantly higher than in the OR laparotomy group (10 patients, 10.1%; P<0.001). SBP was significantly lower in the ED laparotomy group than in the OR laparotomy group (40.5 mmHg [IQR, 0–105 mmHg] vs. 123 mmHg [IQR, 99–144 mmHg]; P=0.005). Heart rate was significantly lower in the ED laparotomy group than in the OR laparotomy group (30 beats/min [IQR, 0–95 beats/min] vs. 89 beats/min [IQR, 79.5–103 beats/min]; P=0.038). GCS score was significantly lower in the ED laparotomy group than in the OR laparotomy group (5.5 [IQR, 3–12] vs. 15 [IQR, 13–15]; P=0.004). Abdominal AIS score was significantly higher in the ED laparotomy group than in the OR laparotomy group (4 [IQR, 3–5] vs. 3 [IQR, 2–3.5]; P=0.013). Patients in the ED laparotomy group received significantly more packed red blood cell (PRBC) than those in the OR laparotomy group (8 U within 4 hours [IQR, 5–13 U] vs. 2 U within 4 hours [IQR, 0–5 U]; P=0.038). Notably, the time between patient admission and the first laparotomy was significantly shorter for patients in the ED laparotomy group than those in the OR laparotomy group (28.5 minutes [IQR, 14–59 minutes] vs. 104 minutes [IQR, 88–151 minutes]; P<0.001).

To minimize selection bias, we compared the patients who underwent ED laparotomy with those who underwent OR laparotomy and received more than 4 U of PRBCs within 4 hours after admission (Table 2). The time between admission and the first laparotomy was also shorter in the ED laparotomy group than in the group that underwent OR laparotomy and received over 4 U of PRBCs within 4 hours (28.5 minutes [IQR, 14–59 minutes] vs. 100 minutes [IQR, 88–133.5 minutes]; P=0.004).

The characteristics of the patients who underwent ED laparotomy are summarized in Table 3. One patient had a penetrating injury, whereas five patients had blunt injuries. All patients underwent DCL. However, only the two patients with massive mesenteric bleeding, which was controlled via ligation during ED laparotomy, survived. The other four patients, who had liver laceration, kidney rupture, spleen injury, and pancreas avulsion, underwent pad packing, followed by OR laparotomy, but they did not survive their injuries. In three patients (50.0%), ED laparotomies were performed within 30 minutes of admission.

DISCUSSION

In this study, we found that the mortality rate of patients who underwent ED laparotomy was 66.7%. Although only two patients survived, we believe that ED laparotomy is not always futile. Expeditious hemostasis can be achieved through ED laparotomy, especially in cases of mesenteric massive bleeding. We managed to ligate mesenteric bleeding during ED laparotomy. However, ED laparotomy was ineffective in patients with liver laceration, pancreatic avulsion, spleen injury, and kidney rupture. Although ED laparotomy appears to be effective in controlling mesenteric bleeding, more complicated procedures, such as nephrectomy, splenectomy, or controlling lacerated liver bleeding, were less feasible during ED laparotomy. Nonetheless, larger datasets and prospective studies are needed to estimate the effect size of ED laparotomy.

In 1979, Mattox et al. [11] reported the performance of 51 laparotomies at an ED, which underwent concurrent ED thoracotomy. However, only 11 of the 51 patients reached the OR, and none of the 51 patients survived, leading to the conclusion that although ED laparotomy was technically possible, it did not improve survival. In 2011, Lund et al. [10] described 44 ED laparotomies, which were associated with a 41% survival rate after 30 days. Notably, they reported that blunt trauma patients admitted with a blood pressure of <60 mmHg were associated with poor outcomes (15% survival) when compared with those who had penetrating trauma (60% survival). In our study, the survival rate was very poor (33.3%) and our cohort had only one patient with a penetrating injury. A retrospective study by Groven et al. [14], which involved 87 OR laparotomies and 80 ED laparotomies, reported a tendency of decreasing ED laparotomy but not increasing mortality. They noted a dedicated trauma OR. Although our trauma center has two dedicated trauma ORs, it generally takes 30 to 60 minutes to prepare the equipment and staff. Moreover, some patients may be too unstable to survive this short duration. Thus, ED laparotomy may benefit a subset of unstable patients. A retrospective study by Ito et al. [12], which involved 50 ED laparotomies and 55 OR laparotomies, reported that ED laparotomy was associated with a shorter duration between admission and operation when compared with OR laparotomy (median, 43 minutes vs. 109 minutes). In our study, we found that ED laparotomy was associated with a markedly shorter duration between admission and the operation when compared with OR laparotomy (28.5 minutes [IQR, 14.0–59.0 minutes] vs. 104.0 minutes [IQR, 88.0–151.0 minutes]). Ito et al. [12] observed higher infectious complications in the ED laparotomy group when compared with the OR laparotomy group (14.0% vs. 7.3%), although the difference was not statistically significant. In our study, we did not observe infectious complications, such as pneumonia or surgical site infection. However, because our study has a small sample size, this requires further investigation.

Expeditious bleeding control is most crucial in patients with significant intra-abdominal hemorrhage, which requires laparotomy. A recent retrospective analysis of the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study [4] analyzed data from patients who underwent laparotomy within 90 minutes of admission and had a Focused Assessment with Sonography for Trauma (FAST) performed. That study found that delayed operation was associated with increased early and late in-hospital mortality in patients with FAST positive finding. Several early intervention strategies, such as directly moving the patient to the OR have been proposed, and several studies have reported direct resuscitation in the OR [8,15,16]. Some hospital designs contain ORs within the emergency department, directly next to the trauma bay’s entrance (EDOR) [16]. A retrospective study involving 120 patients compared with data on 120 patients from the National Trauma Data Bank (NTDB) using propensity score matching, found that EDOR was associated with a shorter time to incision when compared with the NTDB dataset (25.5 minutes vs. 40.0 minutes). However, it was reported that the staff involved in trauma activation included trauma surgeons, attending anesthesiologists, and OR nurses in the EDOR system [16]. In our country, it is not easy to set up an OR in a trauma bay because of infection prevention regulations. Thus, in situations with limited facilities and human resources, ED laparotomy might be a practical alternative.

In our study, only two patients survived, and both had mesenteric bleeding injuries. This type of injury is relatively easy to control using clamp and packing. However, in ED laparotomy settings, more sophisticated procedures like liver bleeding control, nephrectomy, splenectomy, or major vessel injury control, may be inappropriate. Such procedures are more time-consuming and require more support from anesthesiologists to manage the patients’ vitality. In this study, after reaching the OR, patients with liver, kidney, spleen, or major vessel injuries underwent definite hemostasis, such as nephrectomy or splenectomy. However, attempting ED laparotomy might be valuable because accurate diagnosis is often difficult in hemodynamically unstable patients.

Limitations

This study has some limitations. First, because it is retrospective, it may have substantial selection and survival bias. Second, the number of patients who underwent ED laparotomy was small. Thus, multivariable analysis could not be done. In the future, larger studies may include propensity score matching for ED laparotomy to compare patients with similar severities. Here, we compared patients who had received more than 4 U of PRBC. Third, we did not report the result of FAST because 45.7% of patients had missing FAST results in our dataset. Finally, despite our ED laparotomy protocol, OR laparotomy might still be done if it is preferred by the surgeon, which may represent selection bias. Indeed, only 5.7% of laparotomies were done in the ED.

Conclusions

Although ED laparotomy was associated with a higher mortality rate, when compared with OR laparotomy it had a markedly shorter duration between admission and laparotomy. Thus, ED laparotomy allows quicker hemostasis. Notably, major mesenteric hemorrhages were effectively managed using ED laparotomy. Thus, in situations of delayed OR laparotomy, ED laparotomy might be a valuable alternative.

ARTICLE INFORMATION

Author contributions

Conceptualization: YJL, WSK; Data curation: all authors; Formal analysis: YJL, WSK; Methodology: YJL, WSK; Project administration: WSK; Supervision: WSK; Visualization: WSK; Writing–original draft: YJL, WSK; Writing–review and editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

Wu Seong Kang is an Editorial Board member of the Journal of Trauma and Injury, but was not involved in in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

Emergency department laparotomy for prompt hemostasis.

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Figure & Data

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