Indications and Outcome of Laparostomy
Condition: Laparotomy
Study type: Observational

Summary: 
      Brief study Introduction/background Laparostomy is defined is a surgical procedure in which
      abdominal cavity is opened and left opened deliberately because of difficult primary closure
      or when primary closure is avoided due to severe intraabdominal sepsis, trauma and risk of
      abdominal compartment syndrome.

      Patients and methods Retrospective Proforma based study conducted from 1st May 2014-31st May
      2018. All patients admitted through emergency diagnosed clinically with peritonitis,
      intraabdominal sepsis and abdominal trauma managed with laparotomy and laparostomy were
      included in the study. On laparotomy primary cause was identified and controlled with damaged
      control surgery to save the lives and abdomen was left open with temporary abdominal wall
      cover of urine bag stitched all around either with skin or external oblique aponeurosis
      temporarily for second relook laparotomy after 24-48 hours. On second relook of abdomen
      haemostasis secured and abdomen was washed with normal saline, any missed pathology
      identified and controlled and abdomen was closed in some patient when there was no need to
      recheck the abdomen while in other patients abdominal content were covered again temporarily
      with urine bag. All patients were managed by the team of surgery and ICU. Finally abdomen was
      closed by deep tension suture DTS or direct layered closure of abdominal wall.
    

Detailed description: 
      Detail study Introduction Laparostomy is a surgical procedure in which abdominal cavity is
      opened and left opened deliberately called open abdomen, an open abdomen is based on the
      principle of incision and drainage of an abscess and leaving the wound open for free
      drainage, washouts and multiple dressings1.

      Usually abdomen is closed primarily in all abdominal surgeries but some time it is difficult
      to close the abdomen primarily to avoid intraabdominal hypertension because the risk of
      abdominal compartment syndrome and to manage severe intraabdominal sepsis2. Trauma required
      damage control surgery 3, and other complex abdominal pathologies, injuries due to explosive
      devices4, laparostomy and finally staged abdominal closure or DTS deep tension sutures are
      used to close the abdomen5. Multiple techniques are used to close the abdomen temporarily
      after laparotomy to have a second relook laparotomy6. Laparostomy is a complex procedure and
      it is difficult to identify which is the best technique for temporary abdominal closure,
      primary fascial closure, mesh, plastic sheet, bagota bag, urine bag, vacuum assisted closure
      are commonly used methods to cover the abdominal content to prevent the risk of injury
      evisceration and direct exposure to the atmosphere7.

      Our objective is to identify the indications and outcome of laparostomy in emergency
      laparotomy and prevent the abdominal compartment syndrome, in critically ill patients due to
      fecal peritonitis, intraabdominal sepsis and trauma.

      Patients and methods Retrospective Proforma based study conducted from 1st May 2014-31st May
      2018 at Dow International Hospital Ojha Campus Dow University of Health Sciences Karachi
      Pakistan.

      Inclusion Criteria: all critically ill patients admitted through emergency, diagnosed with
      peritonitis, intraabdominal sepsis and trauma managed with damaged control surgery initially
      along with laparostomy in which the abdomen was left open with temporary abdominal cover to
      have a relook laparotomy were included in the study Exclusion Criteria: Patients diagnosed
      clinically with peritonitis and trauma but managed by primary abdominal wall closure were
      excluded from the study.

      Initially all Patients were optimized and resuscitated and all necessary investigations were
      send in emergency eg blood grouping and cross matching, blood complete picture, serum
      electrolyte ,blood urea & creatinine screening for hepatitis. Antibiotic cover, fluid and
      electrolyte support was given to all patients. FFP arranged according to the requirement.
      Imaging performed where necessary in stable patients.

      On laparotomy primary cause was identified and managed with damaged control surgery along
      with abdominal washout and abdomen was covered with a urine bag open from the center to make
      a sheet then sutured all around with the skin or external oblique aponeurosis. All patients
      were managed in the ICU initially for a second relook laparotomy.

      Second relook laparotomy was performed after 24-48 hours abdomen was washed with normal
      saline haemostasis secured and any missed primary pathology was identified and controlled.
      Abdomen was closed in few patient where no need to recheck the abdomen, while in remaining
      patients abdominal content were covered again with urine bag who require multiple washouts
      and dressing. All patients managed by the team of ICU, anesthesia, surgeon, and physician
      from critical care medicine. Morbidity and mortality happen recorded during the period of
      hospital stay Patient discharged after complete recovery with the final closure of abdominal
      wall either with deep tension suture DTS figure 4 or direct layered closure of abdominal
      wall. Data was collected and recorded on a pre designed research Proforma made for this
      study. SPSS version 20 was used to analyze the data.
    

Intervention name(s): Reopen the abdomen to check missed pathology or abdominal washouts
Intervention type(s): Procedure
Intervention description(s): Re opening of the abdomen once the patient is stabilized after 24-48 hours to check the missed injury after damaged control surgery in trauma and to control the sepsis in fecal peritonitis due to abdominal tuberculosis or typhoid perforation
Observational model: Case-Only
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        ll Emergency surgery and intensive care admission who require exploratory laparotomy
      
Keywords: Laparotomy; Laparostomy; Open abdomen (OA); Temporary abdominal closure (TAC); Relook laparotomy