A Descriptive Study on the Usage of Exploratory Laparotomy for Trauma Patients.

OBJECTIVE: Laparotomy is commonly indicated in patients presenting blunt or penetrating trauma. This cross-sectional study is designed to evaluate the frequency and the causes of laparotomy following abdominal trauma.
MATERIALS AND METHODS: The data of 71 patients who underwent laparotomy as a result of abdominal trauma in Shohada Ashayer Hospital, Khorramabad were evaluated and a questionnaire was completed for each patient. All the data were analyzed statistically using SPSS.
RESULTS: Of 71 patients, 61 underwent positive laparotomy whereas, negative laparotomy was performed in 10 patients. The results from this study showed that the most common organ of the injury was spleen (19.7%), followed by other solid organs. The small intestine (16.4%) was found more prone to injuries in penetrating trauma. Incidence of blunt trauma injury due to road accidents was the greatest 50.82% and 20% of penetrating traumas were the result of a firearm.
CONCLUSION: Abdominal trauma injury is common in our study population where spleen, small intestine and other solid organs are chiefly involved. Indications of laparotomy should be fully examined in order to avoid negative laparotomies and associated complications.

Introduction

Trauma injuries are one of the main challenges in emergency surgeries.1 Abdominal injuries contribute to one of the most significant trauma injuries that require special consideration and protocol for management.2,3 Exploratory laparotomy is one of the most commonly performed surgical procedures to determine abdominal injuries.4

Blunt trauma injuries are estimated to account for 78.6–95.6% of all the injuries globally whereas, about 9–15% of trauma injuries are reported in the abdominal region,5 with a high range of morbidity.6 It is the most susceptible region to blunt injury and early diagnosis is important in order to prevent fatality.7,8 Detailed anamnesis and clinical examination are usually recommended for the identification of the injury.9 Nonetheless, nonoperative management is associated with a lower rate of success and increased risk of mortality.7,10

Patients presenting with hemodynamic instability, hemorrhage-mediate hypotension, organ damage and peritonitis as a result of a penetrating injury to the abdomen or diaphragm are commonly known candidates of emergency laparotomy due to the injury.11 Management of blunt trauma injury can be demanding. The identification of intra-abdominal injuries is difficult through imaging modalities, therefore, careful consideration should be taken for the indications of laparotomy.12

A great number of early postoperative morbidities and mortalities are associated with laparotomy for trauma.13,14 Furthermore, negative laparotomies also account for complications and prolonged hospitalization.15,16

This study is, thereby, designed to identify the pattern of abdominal injuries requiring laparotomy and the usefulness of the procedure to aid diagnosis.

Methods

This is a cross-sectional (retrospective) study that was conducted on all the patients referred to the Emergency Department of Shohada Ashayer Hospital of Khorramabad. Patients who underwent emergency laparotomy due to abdominal trauma were included in this study. Patients who were managed nonoperatively were exempted from the study along with those who were hemodynamically stable and had a history of multiples traumas.

Records of all the patients were entered into the system and a questionnaire was filled out based on the available information, such as the findings from the laparotomy, cause of the injury, organs involved and demographic data. Laparotomy was considered negative in the case where no injury was identified. The abdomen was examined in the following regions: the large bowel, the small bowel from the cecum to the ligament of Treitz, stomach, diaphragm, liver, spleen, retroperitoneum and lesser sac.

To analyze the data obtained, SPSS 25.0 was used and the frequency and relative frequency tables were expressed as percentages. The study was approved by the ethical committee of Lorestan University of Medical Sciences (REC.LUMS.1381.WI900).

Results

In this study, 71 patients who underwent emergency laparotomy due to trauma at Shohada Ashayer Hospital were studied. Of these, 61 patients underwent positive laparotomy, 50.82% of patients had blunt trauma due to accident, 6.6% of patients had blunt trauma due to combat, 19.7% of penetrating traumas were due to sharp objects, and 23% underwent emergency laparotomy (Table 1). In patients with blunt trauma, the spleen and liver were the most commonly involved organs, 34% and 14%, respectively. Whereas, in penetrating trauma 35% of injuries were in the other organs and the small intestine with 23% (Table 2). Males were 6.6% more likely to present injury than females, where also, the spleen was the most commonly injured organ, 38%. Similarly, in the age group of 15 years and less, 57% of the injuries were reported in the spleen and in 15–30 aged patients, liver and associated organs and small intestine were the most frequently injured organs, 19.3% and 16.3%, respectively (Table 3). Among patients aged 31–45 years, spleen (12.9%) and other organs (41.6%) had the greatest prevalence of the injury whereas, among the patients aged 45 and above, the small intestine was the target of trauma injury in 45% cases (Table 4).

Table 1

Frequency of Trauma Mechanism in Positive Laparotomy Subjects

The Trauma Mechanism	Frequency	Frequency Relative to Percent
Blunt trauma due to accident	31	50.81
Blunt trauma due to conflict	4	6.6
Penetrating trauma with a sharp object	12	19.7
Penetrating trauma with a firearm	14	23
Total	61	100

Table 2

Frequency of Damaged Organs in Positive Laparotomies Based on Trauma Mechanism

The Trauma Mechanism	Blunt Trauma Due to Accident		Blunt Trauma Due to Conflict			Total			Penetrating Trauma with a Sharp Object		Penetrating Trauma with a Firearm			Total
Damaged organs	Frequency	Frequency Relative to Percent	Frequency		Frequency Relative to Percent	Frequency	Frequency Relative to Percent		Frequency	Frequency Relative to Percent	Frequency		Frequency Relative to Percent	Frequency	Frequency relative to Percent
Liver	4	12.9	1		25	5	14.2		0	0	2		14.2	2	7.6
Spleen	12	38.7	0		0	12	34.2		0	0	0		0	0	0
Small intestine	2	6.4	2		50	4	11.4		5	41.6	1		7.1	6	23
Colon	0	0	0		0	0	0		0	0	2		14.2	2	7.6
Kidneys	1	3.2	0		0	1	2.8		0	0	0		0	0	0
Other organs	4	12.9	0		0	4	11.4		3	25	6		42.8	9	34.6
Liver and associated organs	4	12.9	1		25	5	14.2		3	25	1		7.1	4	15.4
Spleen and associated organs	4	12.9	0		0	4	11.4		1	8.3	2		14.2	3	11.5

Table 3

Frequency of Damaged Organs in Gender-based Positive Laparotomies

Gender Damaged Organs	Gender
	Female		Male
	Frequency	Frequency Relative to Percent	Frequency	Frequency Relative to Percent
Liver	1	12.5	6	11.3
Spleen	3	37.5	9	17
Small intestine	0	0	10	18.9
Colon	1	12.5	1	1.9
Kidneys	0	0	1	1.9
Other organs	1	12.5	12	22.6
Liver and associated organs	1	12.5	8	15.1
Spleen and associated organs	1	12.5	6	11.3
Total	8	100	53	100

Table 4

Frequency of Damaged Organs in Age-based Positive Laparotomies

AgeDamaged Organs	≥15 years		15–30 years		31–45 years		≤45		Total
	Frequency	Frequency Relative to Percent	Frequency	Frequency Relative to Percent	Frequency	Frequency Relative to Percent	Frequency	Frequency Relative to Percent	Frequency	Frequency Relative to Percent
Liver	1	14.3	5	16.3	1	8.3	0	0	7	11.5
Spleen	4	57.1	3	9.7	3	25	2	18.2	12	19.7
Small intestine	0	0	5	16.3	0	0	5	45.4	10	16.4
Colon	0	0	1	3.2	1	8.3	0	0	2	3.3
Kidneys	0	0	1	3.2	0	0	0	0	1	1.6
Other organs	0	0	6	19.3	5	41.6	2	18.2	13	21.3
Liver and associated organs	0	0	6	19.3	2	16.6	1	9.1	9	14.7
Spleen and associated organs	2	28.6	4	12.9	0	0	1	9.1	7	11.5

Of all patients who had positive laparotomy and died, 14.3% had liver involvement, 16.7% presented injury to the spleen, 11% had liver and associated organs and 14.3% had a spleen and associated organ injuries (Table 5). Eight point two percent of our patients died where the highest incidence of fatality was associated with the spleen, 16.7%. In positive laparotomy patients, 11% had an underlying disease of the small intestine and 12.5% had an underlying disease of the liver and other organs (Table 6). In the study of patients who underwent laparotomy, 86% were positive for laparotomy and 14% negative, where no abdomen-related injury was found (Table 7).

Table 5

Frequency of Damaged Organs in Death-based Positive Laparotomies

AgeDamaged Organs	All Items	Death	Percentage Fatality
Liver	7	1	14.3
Spleen	12	2	16.7
Liver and associated organs	9	1	11
Spleen and associated organs	7	1	14.3
Total	35	5	56.3

Table 6

Frequency of Damaged Organs in Underlying Diseases-based Positive Laparotomies

Underlying DiseasesDamaged Organs	Total Case	Underlying Diseases
		Frequency	Frequency Relative to Percent
Small intestine	9	1	11
Liver and associated organs	8	1	12.5
Total laparotomy cases	71	2	2.8

Table 7

Frequency of Laparotomies Patients Due to Trauma in Terms of Positive and Negative Laparotomy

Performed Laparotomies	Frequency	Frequency Relative to Percent
Positive	61	86
Negative	10	14
Total	71	100

Discussion

Our study evaluates the pattern of laparotomy in patients with abdominal injuries and reports that spleen blunt traumas have the greatest prevalence and small intestine is commonly involved in penetrating injuries. A study by van Gool et al, reported that car accidents are the most common cause of trauma injury and stab wounds have the highest incidence of penetrating injury. Nonetheless, they also presented laparotomy-associated complications in these patients, which is one of the limitations of this study.13 Here we report, firearm and vehicle accidents as the most prevalent types of penetrating and blunt trauma injuries. In a recent case-report, it was reported that among the cases of blunt trauma injuries where three patients had spleen and kidney injury, and two of them had herniation injuries.11 We did not find any hernial injury in our study, and spleen injury was the most prevalent blunt injury in this study.

However, recent findings have also indicated that in the modern period, imaging modalities and several biomarkers can be used to detect trauma, and the use of laparotomy is not mandated, owing to its complications.17 Moreover, Simon et al18 reported that laparoscopy for penetrating wound management can reduce the need for negative laparotomy. Discrepancies in the studies are reported regarding the complications associated with negative laparotomy.6,15,19 Studies have also shown that in the cases of penetrating stab wound trauma, nonoperative management might fail in 56% of the cases and laparotomy is likely to be mandatory.20 In a study conducted in 1998 at a Russian university, 572 patients with penetrating abdominal injuries were studied where 185 patients with unstable hemodynamic status underwent emergency laparotomy of which 183 had intraperitoneal organ damage. The most common organs involved were the intestines, the spleen, and the liver, respectively. The remaining 387 patients with a negative clinical examination underwent a physical examination for fasciitis rupture, and 151 patients had a negative response to physical examination.14 Similarly, the small intestine was among the most affected organ (23%) in the penetrating trauma in our study. In a study in Ghana, Ohene-Yeboah et al21 reported that stab wounds were the most common cause of abdominal penetrating injury and the small bowel was the most affected organ. Moreover, the firearm was the leading cause of penetrating trauma in our study. Laparotomy is usually performed in gunshot victims, with hemodynamic instability and peritonitis. In the recent findings, cases where patients are stable and do not present with peritonitis, they can be exempted for laparotomy. Furthermore, negative laparotomy is associated with the risk of complications in about 41% cases.22 In a study conducted at the University of Nigeria on 67 patients with blunt and penetrating trauma, 36 suffered from penetrating abdominal injuries, of which 15 (44.4%) were bullet-injured. The most common organ involved was spleen in the case of blunt trauma (58.8%) and the most common organ involved in penetrating trauma was the small bowel (52.8%). It should be noted that the study was focused on male gender only and the average age of the patients was 29. In our study of 61 patients who had a positive laparotomy, 35 patients had blunt trauma with 34.2% spleen injuries, followed by penetrating trauma of small intestinal trauma (23%). In our study, 14% of laparotomies were negative, which is consistent with similar studies in different countries.

Conclusion

Our descriptive retrospective study identifies the frequencies of trauma, organ involvement, the use of diagnostic laparotomy and mortality among patients with penetrating and blunt trauma injuries. However, the study lacks the comparison with control groups, therapeutic data and the complications associated with laparotomy, particularly in negative laparotomy patients. Future studies with detailed analysis and additional parameters are therefore recommended in this area.