Exploratory Laparotomy Following Penetrating Abdominal Injuries From the Battle of Mosul: a Cohort Study From a Referral Hospital in Erbil, Kurdistan Region in Iraq
Conditions: Penetrating Abdominal Trauma, War Injury
Sponsor: Vrinnevi Hospital

 
 
  
 
 
 
 
 
 
 
Exploratory laparotomy following penetrating 
abdominal injuries: a cohort study from a referral 
hospital in Erbil, Kurdistan region in Iraq 
 
 
 
 
 
 
 
 
Research protocol 
 
1 November 2017 
 
FINAL version 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 

 
2
Table of Contents 
Protocol Details .............................................................................................................. 3 
Signatures of all Investigators Involved in the Study .................................................... 4 
Summary ........................................................................................................................ 5 
List of Abbreviations ..................................................................................................... 6 
List of Definitions .......................................................................................................... 7 
Background .................................................................................................................... 8 
Justification .................................................................................................................... 9 
Aim of Study .................................................................................................................. 9 
Investigation Plan ......................................................................................................... 10 
Study Population .......................................................................................................... 10 
Data .............................................................................................................................. 11 
Statistical Analyses ...................................................................................................... 12 
Safety and Monitoring ................................................................................................. 13 
Ethical Considerations ................................................................................................. 13 
Conflict of Interest ....................................................................................................... 13 
Dissemination .............................................................................................................. 13 
References .................................................................................................................... 14 
Appendix 1: Penetrating Abdominal Trauma Index .................................................... 15 
Appendix 2: Clavien-Dindo’s Classification of Surgical Complications .................... 18 
Appendix 3: Surgical Site Infection defined by WHO ................................................ 19 
Appendix 4: Case Report Form ................................................................................... 20 
 
 
 

 
3
Exploratory laparotomy following penetrating abdominal injuries: a 
cohort study from a referral hospital in Erbil, Kurdistan region in 
Iraq 
Principal Investigator  
Måns Muhrbeck, MD, Department of Surgery, Vrinnevi County Hospital, Linköping 
University, Norrköping, Sweden, e-mail: mans.muhrbeck@me.com, mobile: +46-
(0)70 333 88 52 
 
 
Co-investigators 
Andreas Älgå, MD, Centre for Research on Health Care in Disasters, Department of 
Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; Rawand Musheer 
Haweizy, Lecturer, MBChB, MRCS, Emergency Hospital, Erbil, Iraq; Peter 
Andersson, MD, PhD, Associate Professor, Centre for Teaching and Research in 
Disaster Medicine and Traumatology, Linköping University, Linköping, Sweden; 
Andreas Wladis, MD, PhD, Professor, Centre for Teaching and Research in Disaster 
Medicine and Traumatology, Linköping University, Linköping, Sweden; Johan von 
Schreeb, MD, PhD, Associate Professor, Centre for Research on Health Care in 
Disasters, Department of Public Health Sciences, Karolinska Institutet, Stockholm, 
Sweden 
 
 
Protocol Details 
Version 1.9 
Final 
1 November 2017 
 
 

 
4
Signatures of all Investigators Involved in the Study 
 
 
 
 
 
___________________________ 
 
___________________________ 
Måns Muhrbeck, MD  
 
 
Peter Andersson, MD, PhD  
Principal investigator  
 
 
Co-investigator 
 
 
 
___________________________ 
 
___________________________ 
Rawand Musheer Haweizy, MD 
 
Johan von Schreeb, MD, PhD  
Co-investigator 
 
 
 
Co-investigator 
 
 
 
 
___________________________ 
 
___________________________ 
Andreas Wladis, MD, PhD 
 
 
Andreas Älgå, MD  
Co-investigator 
 
 
 
Co-investigator 
 
 
 
 
 

 
5
Summary 
Study Rationale 
The battle of Mosul was characterized by the use of improvised explosive devices, 
human shields and suicide bombers in an urban setting. It is unclear whether this type 
of warfare cause more extensive abdominal injuries to civilians than combatants. 
Understanding of the correlation between the severity of abdominal injuries, type of 
warfare and population affected is of importance when planning for surgical care in a 
conflict setting.  
 
 
Aim 
To assess whether civilians obtain more extensive abdominal injuries than combatants 
in an urban battle characterized by the use of indiscriminate weapons.  
 
 
Study Design  
An observational retrospective cohort study with longitudinal data collection.  
 
All patients admitted with penetrating abdominal injury subjected to an exploratory 
laparotomy at Emergency Hospital, Erbil, between October 17, 2016 and July 16, 
2017 will be included. Differences in demographics, injury mechanism, time since 
injury, clinical status on arrival, intraoperative findings, postoperative complications 
and outcome will be analysed. 
 
 
Primary Objective 
Differences in injury mechanism, organs injured, surgical treatment given, 
postoperative complications and outcome between civilians and combatants. 
 
 
Secondary Objectives 
Differences in surgical treatment given, postoperative complications and outcome 
between patients with prior surgical treatment of their injury and patients without 
prior surgical treatment. 
 
Differences in surgical treatment given, postoperative complications and outcome 
between patients who receive surgical treatment less than 24 hours from injury and 
patients who receive surgical treatment more than 24 hours from injury will be 
analysed. 
 
 
Statistical methods 
Differences between groups will be analysed using t-test and regression models. 
 
 

 
6
List of Abbreviations 
EH 
 
 
 
Emergency Hospital, Erbil, Iraq 
 
Ex-lap  
 
 
Exploratory laparotomy 
 
ICRC  
 
 
International Committee of the Red Cross  
 
IED 
 
 
 
Improvised Explosive Device 
 
ISg 
 
 
 
Islamic State Group 
 
WHO  
 
 
World Health Organization 
 
 

 
7
List of Definitions 
Civilians 
Children <16 years, all women and men ≥50 
years. 
 
Combatants 
  
Men 16-50 or combatants by own admission. 
 
Exploratory laparotomy 
Surgical incision through the abdominal wall 
into the abdominal cavity 
 
PATI 
  
Penetrating Abdominal Trauma Index 
Assess the severity of injury in patients with 
knife, gunshot or other penetrating wounds to 
the abdomen (appendix 1). 
 
Penetrating abdominal injury 
An injury penetrating the peritoneum into the 
abdominal cavity 
 
Peritonitis 
Rigid involuntary general tenderness of the 
abdominal wall. 
  
Postoperative complication 
Any deviation from the ideal postoperative 
course that is not inherent in the procedure and 
does not comprise a failure to cure. 
Classification of Surgical complications will be 
done according to Clavien-Dindo (appendix 2). 
 
SSI 
Surgical Site Infection is present when one of 
the following criteria are meet: 
i. Purulent discharge from surgical site 
ii. Positive culture 
iii. Surgical site requires reopening 
iv. SSI is present as judged by attending 
physician 
Severity according WHO guidelines  
(appendix 3). 
 
 
 
 
 
 
 

 
8
Background 
Trail location 
In 2014, Islamic State Group (ISg) made significant territorial gains in several 
governorates in Iraq and captured key cities, including Fallujah and Mosul1. ISg is 
unique among terrorist groups in that it employs a combination of conventional 
maneuverer warfare with tactics such as human shields, improvised explosive devices 
(IED’s), suicide bombers and drones in order to capture and hold territory. These 
tactics are indiscriminate, leading to excessive civilian casualties2. 
Emergency Hospital (EH) is one of two trauma hospitals in Erbil, a major 
metropolitan area in Kurdistan Region of Iraq. Erbil is located 94 kilometres east of 
the city of Mosul. Mosul is the provisional capital of the Nineveh region of Iraq. In 
mid-October 2016, the offensive to liberate Mosul from the ISg was initiated. EH 
was assigned by the Governate to exclusively provide care to injured from the armed 
conflict in and around Mosul. Since late December 2016 treatment facilities, run by 
other emergency care providers, have opened closer to Mosul. EH since then mainly 
served as a referral hospital.  
The battle of Mosul formally ended on 10 July, 2017. The admission of causalities 
from Mosul to EH has since then diminished significantly. NGOs and other 
emergency care providers have also decreased their activities since. 
Previous reports on exploratory laparotomy in conflict settings 
Outcome of exploratory laparotomy (ex-lap) following war-related injuries has 
previously been extensively studied and reported on3-7. These reports have mainly 
concentrated on causes for and findings at ex-lap, and postoperative mortality (table 
1). Few studies have focused on the differences in injury mechanism, complexity of 
injuries and outcome between civilians and combatants, especially in urban conflicts 
where IED’s, human shields and suicide bombers are used2. 
 
Table 1. Findings at ex-lap and postoperative mortality in different conflicts  
Conflict 
Nb. 
of 
Ex-
laps 
Negative 
explorations 
Small 
intestinal 
injuries 
Colon 
injuries 
incl. 
rectum 
Other 
injuries 
Postoperative 
mortality 
Chad,19803 
210 
4,8% 
33,0% 
21,1% 
32,7% 
22,5% 
Lebanon 
1975-854 
1314 
9,7% 
24,7% 
21,2% 
55,0% 
9,5% 
Former 
Yugoslavia 
1991-955 
93 
4,3% 
30,0% 
28,4% 
41,5% 
10,8% 
Gaza 2000-
036 
230 
6,5% 
26,7% 
17,9% 
55,3% 
7,4% 
Mosul, 
Iraq, 20067 
153 
15% 
23,7% 
18,7% 
57,6% 
33,3% 
 

 
9
Justification  
There is a need for better understanding of demographics and outcome of ex-lap 
following abdominal injuries sustained in urban conflicts where IEDs, human shields 
and suicide bombers are used. The use of these indiscriminate weapons could affect 
civilians to a greater extent than combatants8. We therefore hypothesis that the use of 
indiscriminate weapons in an urban setting causes more extensive abdominal injuries 
to the civilian population than to combatants. The knowledge gained from this study 
could be crucial when planning surgical staffing and facility needs in similar contexts. 
 
Potential Risks and Benefits 
Since this is an observational retrospective cohort study without any interventional 
methods it poses little to no harm for the participants. A potential benefit for future 
patients would be an increase understanding among health care providers regarding 
what kind of abdominal injuries indiscriminate weapons causes. Furthermore, a better 
understanding on what impact the use of indiscriminate weapons have on the civilian 
population.  
 
Aim of Study 
To assess whether civilians have more complex abdominal injuries than combatants in 
an urban battle characterized by the use of indiscriminate weapons.  
 
Primary Measure 
Differences in injury mechanism, organs injured, surgical treatment given, 
postoperative complications and outcome between civilians and combatants. 
 
 
Secondary Measures 
Comparison of surgical treatment given, postoperative complications and outcome 
between patients with prior surgical treatment of their injury and patients without 
prior surgical treatment. 
 
Differences in surgical treatment given, postoperative complications and outcome 
between patients who receive surgical treatment less than 24 hours from injury and 
patients who receive surgical treatment more than 24 hours from injury will be 
analysed. 
 
See chapter Data, patient files, for detailed primary and secondary measurements. 
 
 
 

 
10
Investigation Plan 
Study Design 
A cohort study with retrospective longitudinal data collection using routinely 
collected clinical data.  
 
Study Period 
Consecutive patients presenting at EH between October 17, 2016 and July 16, 2017 
that meet eligibility criteria will be included. Patient history information preceding 
hospital admission will be included. 
 
Study Location 
Emergency Hospital, Erbil, Kurdistan Region, Iraq. 
 
Study Duration for Participants 
Participants will be followed from admission until discharged from EH. 
 
Study Population 
Recruitment Methods 
Patients will be included from the surgical ledger at the Surgical Department of EH. 
 
Inclusion Criteria 
• All patients treated with ex-lap due to conflict-related penetrating injury presenting 
at EH between October 17, 2016 and July 31, 2017 will be included. 
 
Exclusion Criteria 
• Patients who received treatment several times during the study period will only be 
counted as one patient.  
 
Information for Patients and Consent 
Since this study is based on data from routine care participants will not be informed, 
nor will consent be asked of participation, as this could introduce bias and 
confounding factors. There are moreover no risks or potential gains involved for 
participants. No incentives or inducements will be provided to any participant or staff 
involved.  
 
 
 

 
11
Data 
Data Sources 
Data was routinely prospectively collected on paper based patient forms in the clinical 
setting at EH. A patient database with consecutive patients treated between October 
17, 2016 and July 31, 2017 was created. It is expected that the database will contain a 
total of 1,800 patients to produce approximately 160 evaluable subjects. Paper based 
patient files will be queried for demographic information, combatant or civilian status, 
admission dates, discharge dates, whether the injury was conflict-related or not, 
geographical site for injury, cause and mechanism of injury, prehospital data, medical 
history, vital signs at hospital admission, anatomical data and details regarding extent 
of abdominal injury, number and type of surgeries, details on surgery, need for ICU 
care, in hospital complications, re-admission including cause of re-admission, 
outcome including death and cause of death. Paper based data will be entered into a 
computer database using Epidata entry software (The Epidata Association, Odense, 
Denmark). 
 
Patient Files 
• Time of admission (specified) 
• Age in years (specified) 
• Sex (Male/Female/Unknown) 
• Ethnicity (Arabic/Kurdish/Other/Unknown) 
• Civilian/Combatant (Iraqi/Peshmerga/ISg/Unknown/Other) 
• Time of injury (specified) 
• Geographical location where injury occurred (specified) 
• War-related injury (Yes/No/Unknown) 
• Cause of injury (Bullet/Shell/Mie/IED/Unknown/Other) 
• Mechanism of injury (Gunshot/Stab/Blast/Crush/Fragment/Burn/Traffic 
accident/Unknown/Other) 
• Care prior to admission to EH (First Aid/Medical/Surgery/None 
given/Unknown) 
• Provider of care prior to EH (MSF/Aspen/ICRC/Samaritan Purse/DoH/None) 
• Mode of transport to EH (Military/Private 
car/Motorcycle/Ambulance/Unknown) 
• Medical history (Healthy/Prior surgery/ Prior medical/Unknown) 
• Body temperature (specified in Celsius) 
• Heart rate (specified in beats/min) 
• Blood pressure (specified in systole/diastole mmHg) 
• Pregnant (Yes/No/Unknown) 
• Pregnancy status based on (Lab/Question/Status/Unknown) 
• Site and extent of abdominal wound (specified) 
• Other injuries (Yes/No/Unknown, specified) 
• Preoperative haemoglobin (specified in g/dL) 
• Preoperative transfusions (Yes/No/Unknown, specified) 
• Use of preoperative radiology (Yes/No/Unknown, specified) 
• Time and date of procedure (specified) 
• Duration of procedure (specified in hours and minute) 

 
12
• Antibiotics prophylaxis (Yes/No/Unknown, specified) 
• Procedure done (appendix 1 for definition of findings) 
• Perioperative complication (Yes/No/Unknown, specified) 
• Postoperative antibiotic prophylaxis (Yes/No/Unknown, specified) 
• Postoperative infection (Yes/No/Unknown, appendix 3 for definition) 
• Other postoperative complication (Yes/No/Unknown, appendix 2 for 
definition) 
• Need of postoperative intensive care (Yes/No/Unknown, specified) 
• Postoperative transfusions (Yes/No/Unknown, specified) 
• Use of postoperative radiology (Yes/No/Unknown, specified) 
• Further surgery done (Yes/No/Unknown, specified) 
• Discharge (Yes/No/Unknown, specified) 
• Follow-up scheduled (Yes/No/Unknown, specified) 
• Re-admission (Yes/No/Unknown, specified) 
• Deceased during hospital stay (Yes/No/Unknown, specified) 
• Remarks 
 
 
Statistical Analyses 
Sample Size  
Due to the nature of the study, the sample size will be a convenience sample of the 
available cases during the study period. It is expected that approximately 160 subjects 
will be enrolled.  
  
Statistical Methods 
Analysis will be done by as treated. A 5% significance level will be used. The 
difference in dichotomous, such as postoperative complication (primary outcome), 
and categorical outcomes with more than two categories will be tested using chi-
square or Fisher test. For differences in continuous variables t-test will be used. In 
order to adjust our analysis for possible confounders and effect modifiers we will then 
use linear, logistic, ordinal or multinomial regression models, according to the nature 
of the outcome (continuous, binary, ordinal or nominal) with injury mechanism as the 
dependent variable and civilian/combatant as the main explanatory variable. 
Important demographic and injury specific parameters such as geographical location, 
date, age, sex, and injured organs, will then be included in the model as potential 
confounders.  
 
 
 

 
13
Safety and Monitoring 
Participant Confidentiality 
The use of identification numbers will ensure anonymity in the data analysis. The 
participant’s age, gender and demographic characteristics will be used as identifying 
features for analysis. The research team will ensure the ethical principles of 
beneficence, non-maleficence, justice and respect of patients are adhered to 
throughout the study. 
 
Data Collection and Management 
All data will remain anonymous throughout the data entry and analysis process. 
Nominal data will not be distributed outside the study location, or appear in any report 
or publication. Participant names will only be known by the research team. 
Identification codes will be safeguarded at EH facilities for the duration of the study. 
 
Ethical Considerations 
Ethics 
The study will be conducted according to ethical principles stated in the Declaration 
of Helsinki9. 
 
Ethical Review Board Approval 
An approval from the Ethics Review Committee of the Directorate of Health, 
Department of Health, Erbil, Kurdistan Regional Governate will be obtained before 
initiating the study. 
 
Conflict of Interest 
This is an investigator-initiated study. No company has had any influence over study 
design. There are no known conflicts of interest with other parties. 
 
Dissemination 
Printed and electronic versions of the final report will be provided to all partners 
involved in this research. Main findings will be presented orally to hospital staff at 
EH. The research methodology and results will be presented at scientific conferences 
and published in peer-reviewed journals. 
 
 
 

 
14
References 
1. Cockburn P. The rise of Islamic state : ISIS and the new Sunni revolution. London ; 
New York: Verso 2015. 
2. Affairs UNOfD. Improvised Explosive Devices (IEDs) [WWW]. New York, 
USA2016 [Available from: https://www.un.org/disarmament/convarms/ieds2/ 
accessed 28 May 2017. 
3. Dumurgier C WR, Durette D, Jancovici R, Suc L, Mechineau Y. Plaies de 
l’abdomen par projectiles de guerre: expérience du détachement médical de 
Kousseri- Riggil – 15.07.80 au 15.12.80. [Abdominal wounds by the 
projectiles of war: experience of the medical detachment in Kousseri-Riggil – 
15.07.80 to 15.12.80.] Médecine et Hygiène 1992;40:2984-92. 
4. Nassoura Z, Hajj H, Dajani O, et al. Trauma management in a war zone: the 
Lebanese war experience. The Journal of trauma 1991;31(12):1596-9. 
5. Sikic N, Korac Z, Krajacic I, et al. War abdominal trauma: usefulness of 
Penetrating Abdominal Trauma Index, Injury Severity Score, and number of 
injured abdominal organs as predictive factors. Military medicine 
2001;166(3):226-30. 
6. Giannou C, Baldan M, Comité international de la Croix-Rouge. War surgery : 
working with limited resources in armed conflict and other situations of 
violence. Geneva: ICRC 2009. 
7. Borhan MS A-NH. Analysis of Abdominal Missile Injuries: Prospective Study in 
Mosul. , 2008. 
8. Coupland RM, Samnegaard HO. Effect of type and transfer of conventional 
weapons on civilian injuries: retrospective analysis of prospective data from 
Red Cross hospitals. BMJ 1999;319(7207):410-2. 
9. World Medical Association Declaration of Helsinki: ethical principles for medical 
research involving human subjects. JAMA 2000;284(23):3043-5. 
10. Moore EE, Dunn EL, Moore JB, et al. Penetrating abdominal trauma index. The 
Journal of trauma 1981;21(6):439-45. 
11. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a 
new proposal with evaluation in a cohort of 6336 patients and results of a 
survey. Ann Surg 2004;240(2):205-13. 
12. Mentula PJ, Leppaniemi AK. Applicability of the Clavien-Dindo classification to 
emergency surgical procedures: a retrospective cohort study on 444 
consecutive patients. Patient Saf Surg 2014;8:31. doi: 10.1186/1754-9493-8-
31 
13. Leaper DJ, Edmiston CE. World Health Organization: global guidelines for the 
prevention of surgical site infection. J Hosp Infect 2017;95(2):135-36. doi: 
10.1016/j.jhin.2016.12.016 
 
 
 
 

 
15
Appendix 1: Penetrating Abdominal Trauma Index10 
Overview 
The Penetrating Abdominal Trauma Index (PATI) can be used to assess the severity 
of injury in patients with knife, gunshot or other penetrating wounds to the abdomen. 
The index can be used to compare performance of different emergency care settings. 
 
Patient evaluation 
1. 14 organs are examined 
2. The risk associated with injury to each organ is graded from 1 to 5. 
3. The estimated severity of each type of injury is graded from 1 to 5. 
Organ Injured 
Risk 
Factor 
Injury 
Injury 
Estimate 
Duodenum 
5 
single wall 
1 
≤ 25% wall 
2 
>25% wall 
3 
duodenal wall and blood supply 
4 
pancreaticoduodenectomy 
5 
Pancreas 
5 
tangential 
1 
through-and-through (duct intact) 
2 
major debridement or distal duct injury 
3 
proximal duct injury 
4 
pancreaticoduodenectomy 
5 
Liver 
4 
nonbleeding peripheral 
1 
bleeding, central or minor debridement 
2 
major debridement or hepatic artery ligation 
3 
lobectomy 
4 
lobectomy with caval repair or extensive bilobar 
debridement 
5 
Large intestine 
4 
serosal 
1 
single wall 
2 
≤ 25% wall 
3 
>25% wall 
4 
colon wall and blood supply 
5 

 
16
Major vascular 
4 
≤ 25% wall 
1 
>25% wall 
2 
complete transection 
3 
interposition grafting or bypass 
4 
ligation 
5 
Spleen 
3 
nonbleeding 
1 
cautery or haemostatic agent 
2 
minor debridement or suturing 
3 
partial resection 
4 
splenectomy 
5 
Kidney 
3 
nonbleeding 
1 
minor debridement or suturing 
2 
major debridement 
3 
pedicle or major calyceal 
4 
nephrectomy 
5 
Extrahepatic 
biliary 
2 
contusion 
1 
cholecystectomy 
2 
≤ 25% common duct wall 
3 
>25% common duct wall 
4 
biliary enteric reconstruction 
5 
Small bowel 
2 
single wall 
1 
through-and-through 
2 
≤ 25% wall or 2-3 injuries 
3 
>25% wall or 4-5 injuries 
4 
wall and blood supply or >5 injuries 
5 
Stomach 
2 
single wall 
1 
through-and-through 
2 
minor debridement 
3 
wedge resection 
4 
>35% resection 
5 
Ureter 
2 
contusion 
1 

 
17
laceration 
2 
minor debridement 
3 
segmental resection 
4 
reconstruction 
5 
Bladder 
1 
single wall 
1 
through-and-through 
2 
debridement 
3 
wedge resection 
4 
reconstruction 
5 
Bone 
1 
periosteum 
1 
cortex 
2 
through-and-through 
3 
intra-articular 
4 
major bone loss 
5 
Minor vascular 
1 
nonbleeding small hematoma 
1 
nonbleeding large hematoma 
2 
suturing 
3 
ligation of isolated vessels 
4 
ligation of named vessels 
5 
where: 
• 
The percent injury to an organ wall probably indicates the portion of the entire 
circumference involved. 
organ score = (risk factor) × (injury estimate) 
penetrating abdominal trauma index (PATI) = SUM (all injured organs) 
 
Interpretation 
• 
minimum PATI: 0 
• 
maximum PATI: 200 
Risk of postoperative complications 
• 
The risk of postoperative complications is low if the PATI is ≤ 25. 
• 
The rate of postoperative complications increases sharply if the PATI >25. 

 
18
Appendix 2: Clavien-Dindo’s Classification of Surgical 
Complications11 12 
Grades  
Definition  
Grade I: 
Any deviation from the normal postoperative course 
without the need for pharmacological treatment or 
surgical, endoscopic and radiological interventions.  
Allowed therapeutic regimens are: drugs as 
antiemetic’s, antipyretics, analgesic’s, diuretics and 
electrolytes and physiotherapy. This grade also includes 
wound infections opened at the bedside.  
Grade II: 
Requiring pharmacological treatment with drugs other 
than such allowed for grade I complications. 
Blood transfusions and total parenteral nutrition are 
also included.  
Grade III: 
Requiring surgical, endoscopic or radiological 
intervention  
Grade III-a:  
intervention not under general anaesthesia  
Grade III-b: 
intervention under general anaesthesia  
Grade IV: 
Life-threatening complication (including CNS 
complications) ‡ requiring IC/ICU-management  
Grade IV-a: 
single organ dysfunction (including dialysis)  
Grade IV-b: 
multi organ dysfunction  
Grade V: 
Death of a patient  
Suffix 'd': 
If the patients suffers from a complication at the time of 
discharge, the suffix “d” (for ‘disability’) is added to 
the respective grade of complication. This label 
indicates the need for a follow-up to fully evaluate the 
complication.  
  
‡ brain haemorrhage, ischemic stroke, subarachnoidal bleeding, but excluding transient ischemic attacks (TIA); 
IC: Intermediate care; ICU: Intensive care unit. 
  
 
 
 

 
19
Appendix 3: Surgical Site Infection defined by WHO13 
 
• 
Superficial incisional, affecting the skin and subcutaneous tissue. These 
infections may be indicated by localized signs such as redness, pain, heat or 
swelling at the site of the incision or by the drainage of pus. 
• 
Deep incisional, affecting the fascial and muscle layers. These infections may be 
indicated by the presence of pus or an abscess, fever with tenderness of the 
wound, or a separation of the edges of the incision exposing the deeper tissues. 
• 
Organ or space infection, which involves any part of the anatomy other than the 
incision that is opened or manipulated during the surgical procedure, for example 
joint or peritoneum. These infections may be indicated by the drainage of pus or 
the formation of an abscess detected by histopathological or radiological 
examination or during re-operation. Organ infection is not included within the 
scope of this guideline. 
 
 

 
20
Appendix 4: Case Report From 
 
 
  
 
 
 
 
 
 
Exploratory laparotomy following penetrating 
abdominal injuries: a cohort study from a referral 
hospital in Erbil, Kurdistan region in Iraq 
 
 
 
 
 
 
 
 
Case Report Form 
 
1 November 2017 
 
FINAL version 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Patient Data 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. Time of admission 
/ 
/   
 
:   
 
  
 
 
day 
month 
year 
 
hours minutes 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
2. Age 
  
  
in years 
  
 
 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
3. Sex 
  
 
  
 
  
 
 
 
 
 
Male 
 
Female 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
4. Ethnicity 
  
 
  
 
  
 
  
 
 
 
Arabic 
Kurdish 
Other 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
If other, specify 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
5. Civilian/Combatant 
  
 
  
 
  
 
 
 
 
 
Civilian 
Combatant 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
If combatant 
  
 
  
 
  
 
 
 
 
 
Iraqi 
 
Peshmerga 
IS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
Unknown 
Other 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
If other, specify 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
 
day 
month 
year 
 
 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Injury Data 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
6. Time of injury 
:   
 
/ 
/   
 
  
 
 
hours minutes 
 
day 
month 
year 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
7. Geographical location where injury occurred 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
Unknown 
Other 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
If other, specify location where injury occurred  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
 
day 
month 
year 
 
 
 
Mark location with X 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Injury Data continued 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
Patient no 
  
    
  
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
8. War-related injury 
  
 
  
 
  
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
9. Cause of injury  
  
 
  
 
  
 
 
 
(If several causes number in 
Bullet 
 
Shell 
 
Mine 
 
 
 
same order as question 
 
 
 
 
 
 
 
 
20 and 21) 
  
 
  
 
  
 
 
 
 
IED 
 
Unknown 
Other 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
If other, specify 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
10. Mechanism of injury 
  
 
  
 
  
 
 
 
(If several number in 
Gunshot 
Stab 
 
Blast 
 
 
 
same order as question 
 
 
 
 
 
 
 
 
20 and 21) 
  
 
  
 
  
 
 
 
 
Crush 
 
Fragment 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
  
 
 
 
 
Burn 
 
Other 
 
Traffic accident 
 
 
 
  
 
 
 
 
 
  
  
    
  
  
  
  
 
If other, specify 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
  
  
    
  
  
  
  
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
 
Investigators signature 
  
    
  
/ 
/   
 
 
 
  
 
day 
month 
year 
 
 
 
  
 
 
 
 
 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Prehospital Care Data 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
11. Care prior to admission to EH   
 
  
 
  
 
 
 
(If several number in chronological order) 
First aid 
Medical 
None given 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
Unknown 
Surgery 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
If surgery, specify procedure done 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
/ 
/   
of procedure  
 
 
 
day 
month 
year 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
12. Provider of care prior to EH 
  
 
  
 
  
 
 
 
(If several number in chronological order) 
MSF 
 
Aspen  
ICRC 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
Unknown 
Samaritan Purse 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
None 
 
Department of Health 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
Other, specify 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 
 
 
 
 
 
 
 
 
 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Prehospital Care Data cont. 
 
 
 
 
 
 
 
 
  
 
 
 
 
Patient no 
  
  
    
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
13. Mode of transport to EH 
  
 
  
 
 
 
 
 
(If several number in chronological order) 
Military 
Private car 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
  
 
  
 
 
 
 
Motorcycle Ambulance Unknown 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
    
  
  
 
Other, specify 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
14. Medical history 
  
 
  
 
  
 
  
 
 
Healthy 
Unknown 
Prior surgery 
Prior medical 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
    
  
  
  
 
If prior surgery specify procedure(s) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
    
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
    
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
    
  
  
  
 
If prior medical condition(s) specify 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
    
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
    
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
    
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Clinical Data at OPD 
 
 
  
 
 
 
 
 
 
 
  
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
  
 
 
 
 
15. Body temperature 
  
  
in Celsius.  
 
  
 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
16. Heart rate 
  
  
in beats/min 
 
  
 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
17. Blood pressure  
  
/ 
  
in mmHg 
  
 
 
 
Systole 
Diastole 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
18. Pregnant 
  
 
  
 
  
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
19. Pregnancy status based on 
  
 
  
 
  
 
  
 
 
Lab 
 
Question 
Status 
 
Unknown 
 
 
 
 
 
 
 
 
 
20. Site and extent of abdominal wound  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If >2 injuries 
 
 
use remarks 
 
 
 
 
Mark each wound by number 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. 
  
  
  
  
  
  
  
 
Brief description of size and depth 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2. 
  
  
  
  
  
  
  
 
Brief description of size and depth 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Clinical Data at OPD cont.  
 
  
 
 
 
 
 
 
  
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
21. Other injuries 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If >3 injuries 
 
 
use remarks 
Mark each wound by number 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. 
  
  
  
  
  
  
  
Brief description of size and depth 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2. 
  
  
  
  
  
  
  
Brief description of size and depth 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3. 
  
  
  
  
  
  
  
Brief description of size and depth 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
day 
month 
year 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
 
Preoperative Data 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
22. Preoperative haemoglobin 
  
g/dL 
 
  
 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
23. Preoperative transfusions  
  
 
 
  
 
 
 
 
 
None given 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Units of whole blood 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Units of packed red blood cells 
 
 
 
 
 
 
 
 
 
 
 
 
  
Units of Platelets 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Units of Plasma 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
24. Use of preoperative radiology   
 
 
  
 
 
 
 
 
No 
 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Computed Tomography (CT) 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
If CT was used, specify findings 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Conventional radiology (X-ray) 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
If X-ray was used, specify findings 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 
 
 
 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Operative Data 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
25. Time and date of procedure 
:   
 
/ 
/   
 
  
 
 
hours minutes 
 
day 
month 
year 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
26. Duration of procedure 
: 
  
 
  
 
 
 
 
 
 
hours minutes 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
27. Antibiotics prophylaxis 
  
 
  
 
  
 
 
 
 
 
No 
 
Yes 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
If yes, specify type, dose and duration 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
28. Procedure done 
 
 
 
If lack of space use remarks 
 
 
(If several procedures are relevant. Mark most relevant with S.) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary haemostasis (damage control) 
  
 
  
 
  
 
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
Removal of foreign bodies 
  
 
  
 
  
 
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
Raphi of bowel 
  
 
  
 
  
 
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
If raphi, specify site(s) and count(s) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Small intestinal resection with anastomosis 
  
 
  
 
  
 
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
If anastomosis, specify site(s) and technique(s) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
  
 
 
 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Operative Data cont. 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
Procedure done cont. 
 
 
 
 
 
 
 
 
Colon resection with anastomosis 
  
 
  
 
  
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
If anastomosis, specify site(s) and technique(s) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stoma/Bowel deviation 
  
 
  
 
  
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
If stoma(s), specify site(s) and technique(s) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vascular repair 
  
 
  
 
  
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
If vascular repair(s), specify location(s) and technique(s) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Splenectomy 
  
 
  
 
  
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
  
 
 
 
 
 
 
 
Other 
  
 
  
 
  
 
 
 
 
Yes 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
If other(s), specify location(s) and procedure(s) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
29. Perioperative complication 
  
 
  
 
  
  
 
 
 
Yes 
 
No 
 
Unknown 
 
 
  
  
  
  
  
  
  
  
 
If yes, specify type 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
 
 
Postoperative Data 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
30. Postoperative antibiotic prophylaxis 
  
 
  
 
  
 
 
 
(without treating a defined infection) 
No 
 
Unknown 
Yes 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
If yes, specify type, doses and duration 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
31. Postoperative infection 
  
 
  
 
 
Appendix 3 for 
 
(If several is possible mark all with 
No  
 
Unknown 
 
definition 
 
with appropriate postop. day.) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Affecting the skin and subcutaneous tissue 
/ 
/   
Date of diagnosis 
 
 
 
day 
month 
year 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Affecting the fascial and muscle layers 
/ 
/   
Date of diagnosis 
 
 
 
 
 
 
 
 
 
 
 
Affecting abdominal cavity 
/ 
/   
Date of diagnosis 
 
 
 
 
 
 
 
 
 
 
 
Sepsis  
/ 
/   
Date of diagnosis 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
Measures taken (for ex. intensive care, iv antibiotics, dialysis) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
Unspecified infection  
/ 
/   
Date fo diagnosis 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
Explain and measures taken 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Postoperative Data cont. 
 
 
 
 
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
32. Other postoperative complication 
  
 
  
 
 
Appendix 2 
 
 
 
No 
 
Unknown 
 
for definiton 
 
 
 
 
 
 
 
 
 
 
 
 
Yes 
/ 
/   
Date of diagnosis 
 
 
 
 
day 
month 
year 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
Type and measures taken 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
33. Need of postoperative intensive care 
  
 
  
 
/ 
/   
Date 
 
No 
 
Unknown 
Yes 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
If yes, specify reason(s) for intensive care 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discharged from Intensive Care Unit 
/ 
/   
Date 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
34. Postoperative transfusions  
  
 
 
  
 
 
 
 
 
 
None given 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Units of whole blood 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Units of packed red blood cells 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Units of Platelets 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
Units of Plasma 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
35. Use of postoperative radiology 
  
 
  
 
  
 
  
 
 
 
No 
 
Unknown 
CT 
 
X-ray 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
If use of radiology, specify findings 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
 
day 
month 
year 
 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
 
 
 
 
 
Postoperative Data cont. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
36. Further surgery done 
  
 
  
 
/ 
/   
Date 
 
No 
 
Unknown 
1.Yes 
 
 
 
 
 
 
 
 
 
 
 
 
1. 
  
  
  
  
  
  
  
 
If yes, specify procedure done 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
/ 
/   
Date 
 
 
 
 
 
2.Yes 
 
 
 
 
 
 
 
 
 
 
 
 
2. 
  
  
  
  
  
  
  
 
If yes, specify procedure done 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
/ 
/   
Date 
 
 
 
 
 
3.Yes 
 
 
 
 
 
 
 
 
 
 
 
 
3. 
  
  
  
  
  
  
  
 
If yes, specify procedure done 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
 
Postoperative Data cont. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
37. Discharge 
  
 
  
 
 
 
 
 
 
No 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
Date of discharge 
/ 
/   
 
 
  
 
 
day 
month 
year 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discharged Status 
  
 
 
 
 
 
 
 
 
Hospital care complete 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
Left Against Medical Advice 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
Transferred for further care 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
Transferred to where 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
Type of care planned 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 
 
 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
 
Postoperative Data cont. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
38. Follow-up scheduled 
  
 
  
 
  
 
 
 
 
No 
 
Yes 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
When and reason for follow-up 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
39. Re-admission 
  
 
  
 
  
 
 
 
 
No 
 
Yes 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
Date of re-admission 
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
  
 
Reason for re-admission 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
40. Deceased during hospital stay 
  
 
  
 
  
 
 
 
 
No 
 
Yes 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
 
 
  
 
 
 
Cause of death 
 
 
 
 
Unknown 
 
 
 
 
 
 
 
 
 
 
 
Date of death 
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
day 
month 
year 
 
 
 
 
 
 
 
 
 

Exploratory laparotomy following penetrating abdominal injuries: a cohort study from a referral hospital in 
Erbil, Kurdistan region in Iraq 
Case Report From (CRF), version 171101, protocol: _________________________ 
Validated by and date: ________________________ 
 
Postoperative Data cont. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient no 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
41. Remarks 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Investigators signature 
  
  
  
  
/ 
/   
 
 
 
 
 
 
day 
month 
year