Direct peritoneal resuscitation accelerates primary abdominal wall closure after damage control surgery

Abstract

Background: Damage control surgery is a staged approach to the trauma patient in extremis that improves survival, but leads to open abdominal wounds that are difficult to manage. We evaluated whether directed peritoneal resuscitation (DPR) when used as a resuscitation strategy in severely injured trauma patients with hemorrhagic shock requiring damage control surgery would affect the amount of and timing of resuscitation and/or show benefits in time to abdominal closure and reduction of intra-abdominal complications.

Study design: A retrospective case-matched study of patients undergoing damage control surgery for hemorrhagic shock secondary to trauma between January 2005 and December 2008 was performed. Twenty patients undergoing standardized wound closure and adjunctive DPR were identified and matched to 40 controls by Injury Severity Score, age, gender, and mechanism of injury. A single early death was excluded because of inability to control ongoing hemorrhage.

Results: There were no differences in age, gender, or mechanism of injury between the groups. Injury Severity Score (35.07 +/- 17.1 versus DPR 34.95 +/- 16.95; p = 0.82) and packed red blood cell administration in 24 hours (23.8 +/- 14.35 U versus DPR 26.9 +/- 14.1 U; p = 0.43) were similar between the groups. Presenting pH was similar between the study group and the DPR group (7.24 +/- 0.13 d versus DPR 7.26 +/- 0.11; p = 0.8). Time to definitive abdominal closure was significantly less in the DPR group compared with controls (DPR: 4.35 +/- 1.6 d versus 7.05 +/- 3.31; p < 0.003). DPR also allowed for a higher rate of primary fascial closure, lower intra-abdominal complication rate, and lower rate of ventral hernia formation at 6 months. Adjunctive DPR afforded a definitive wound closure advantage compared with Wittmann patch closure techniques (DPR 4.35 +/- 1.6 versus Wittmann patch 6.375 +/- 1.3; p = 0.004).

Conclusions: The addition of adjunctive DPR to the damage control strategy shortens the interval to definitive fascial closure without affecting overall resuscitation volumes. As a result, this mitigates intra-abdominal complications associated with open abdomen and damage control surgery and affords better patient outcomes.

Figure 1

Demonstrating the significant differences between the control group and the directed peritoneal resuscitation (DPR) group. *indicates statistical significance.

Figure 2

Odds ratio of significant variable between control and directed peritoneal resuscitation (DPR) group showing a decrease rate of hernia formation, increased primary fascial closure rate, and lower number of intra-abdominal complications.

Figure 3

Liver enzymes levels in the control versus directed peritoneal resuscitation (DPR) groups showing a trend toward improvement in the DPR group compared with worsened aspartate transaminase (AST)/alanine transaminase (ALT) levels at 24 hours in the control group. IU, international units.