Nontherapeutic laparotomy in combat casualties

Abstract

Background: The selective nonoperative management of ballistic abdominal injury remains contentious, particularly in the military setting. The exigencies of military practice have traditionally favored a more liberal approach to abdominal exploration. The driver for selective nonoperative management is the avoidance of morbidity incurred by nontherapeutic intervention. However, the incidence and complications of nontherapeutic laparotomy (NTL) in the military setting are not known.

Methods: All UK military patients undergoing a laparotomy following battlefield trauma were identified from the UK Joint Theatre Trauma Registry. Procedures were classed as therapeutic laparotomy (TL) or NTL. Demographics, admission physiology, injury pattern, and mortality were compared, and complications in the NTL group were determined by Joint Theatre Trauma Registry and case record review.

Results: Between March 2003 and March 2011, 130 (7.2%) of 1,813 combat wounded UK service personnel underwent a laparotomy. A total of 103 (79.2%) were considered TL, and 27 (20.8%) were NTL. There was no difference in demographic distribution or mechanism of injury. Patients undergoing TL were more likely to be hypotensive (systolic blood pressure, <90 mm Hg; p = 0.015) and have a reduced consciousness level (Glasgow Coma Scale [GCS] score ≤ 8; p = 0.006). There was a greater abdominal injury burden in the TL group (p < 0.001). There was no difference in severe extra-abdominal injury (Abbreviated Injury Scale [AIS] score ≥ 3), overall Injury Severity Score (ISS) and New ISS (NISS) scores, or mortality. Of the 27 patients who underwent NTL, 7 (25.9%) developed complications.

Conclusion: During the past decade, trauma laparotomy has become a relatively uncommon procedure. The NTL rate is also relatively low. This finding could be explained by the fact that selective nonoperative management is used more widely in the military setting than previously thought or that very few military injuries are amenable to nonoperative management. NTL is associated with a significant risk of complications and should therefore be minimized but not at the expense of missing a life-threatening intra-abdominal injury.

Level of evidence: Therapeutic study, level IV.