"Second-look" laparotomy: warranted, or contributor to excessive open abdomens?

Abstract

Introduction: The overuse of temporary abdominal closure and second look (SL) laparotomy in emergency general surgery (EGS) cases has been questioned in the recent literature. In an effort to hopefully decrease the number of open abdomen (OA) patients, we hypothesize that reviewing our cases, many of these SL patients could be managed with single-stage operative therapy and thus decrease the number of OA patients.

Methods: This is a retrospective review of prospectively collected data from Jun 2013-Jun 2014, evaluating EGS patients managed with an OA who required bowel resection in either index or SL laparotomy. Demographics, clinical variables, complications and mortality were collected. Fisher's exact t test was used for statistical analysis.

Results: During this time frame, 96 patients were managed with OA and 59 patients required a bowel resection. 55 (57%) of those required one bowel resection at the index operation with 4 (4.2%) only requiring one bowel resection at the second operation. In the patients requiring bowel resections, 18 (30%) required a resection at SL. At SL laparotomy, resection was required for questionably viable bowel at the index operation 60% (11), whereas 39% (7) had normal appearing bowel. Indications for resection at SL laparotomy included evolution of existing ischemia, new onset ischemia, staple line revision, and "other". 23 patients (39%) were hemodynamically unstable, contributing to the need for temporary abdominal closure. In the multivariate analysis, preoperative shock was the only predictor of need for further resection. Complications and mortality were similar in both groups.

Conclusion: Almost one-fifth of the patients undergoing SL laparotomy for open abdomen required bowel resections, with 6.8% of those having normal appearing bowel at index operation, therefore in select EGS patients, SL laparotomy is a reasonable strategy.

Keywords: And mesenteric ischemia; Bowel ischemia; Bowel resection; Relook laparotomy; Second look.