MSS13: UPDATED ANALYSIS OF NON-THERAPEUTIC LAPAROTOMIES IN MILITARY TRAUMA
Patrick F Walker, MD1; Joseph D Bozzay, MD2; David W Schectman, MD3; Faraz Shaikh, MS4; Laveta Stewart, PhD, MSc, MPH4; David Tribble, MD, DrPH4; M L Carson, MS4; Carlos J Rodriguez, DO, MBA5; Matthew J Bradley, MD, MS2; 1University of Maryland R Adams Cowley Shock Trauma Center; 2Department of Surgery, Uniformed Services University; 3San Antonio Military Medical Center; 4Uniformed Services University Infectious Disease Clinical Research Program; 5Department of Surgery, John Peter Smith Hospital
Objectives: Combat casualties are frequently injured in austere settings where modern imaging modalities are unavailable. Exploratory laparotomies are often performed whenever a suspicion for intra-abdominal injury exists. Prior studies have demonstrated non-therapeutic laparotomy (NTL) rates as high as 30% in combat. Given advances in combat casualty care, as well as changes in resources available in theater, we sought to determine if a change in NTL has occurred as the recent conflicts in Iraq and Afghanistan have progressed.
Methods: Military personnel with combat-related injuries requiring laparotomy sustained in Iraq and Afghanistan from June 2009 to May 2014 were included if they required a laparotomy and were evacuated to Landstuhl Regional Medical Center (LRMC, Germany) before being transferred to participating U.S. military hospitals. Indications for laparotomy and operative findings were identified in addition to demographics and outcomes.
Results: Of 4304 combat casualties, 341 patients underwent a total of 1053 laparotomies during the course of their care, of which 244 were performed for concern for abdominal injury. NTL occurred in 16.8% of patients. Those with NTL were more likely to have a computed tomography scan concerning for injury (48.8 vs 27.1%; p=0.006), non-penetrating injury mechanism (56.1 vs 28.1%; p<0.001), and lower Injury Severity Score (26 vs 33; p=0.003). Patients with NTL were less likely to be admitted to the intensive care unit (70.7 vs 89.2%; p=0.007) compared to patients who underwent therapeutic laparotomy (TL). NTL was associated with a 0% surgical site infection (SSI) rate compared to 16.8% for TL (P=0.002).
Conclusions: The NTL rate has decreased over the course of the recent conflicts in Iraq and Afghanistan. No SSI was identified in patients who had NTL. Surgeons should continue to have a low threshold for exploratory laparotomy in military patients in austere settings with concern for intra-abdominal injury.