Urgent relaparotomy: the high-risk, no-choice operation

Abstract

Two thousand six hundred fifty-seven primary laparotomies were performed during a 50-month period; 192 (7%) of these were relaparotomies within 21 days for complications of primary laparotomy. The overall mortality rate was 36% (69/192). Relaparotomy for dehiscence (0/15) or obstruction (5%-1/21) carried little risk and for abscess a moderate risk (13%-6/47). Relaparotomy for gastrointestinal or intraperitoneal hemorrhage entailed higher risks at 44% (4/9) and 27% (6/22), respectively. Age was a significant determinant of mortality, being 16% (13/82) for less than 50 years of age but 50% (56/110) for greater than 50 years (p less than 0.001). The major determinant at all age groups was sepsis, varying from 50% (4/8) for patients less than 50 years to 89% (34/38) for patients greater than 50 years (p less than 0.01). Differentiation was made between localized intra-abdominal infection (IAS-1) and nonlocalized/systemic infection (IAS-2): the mortality rate for 47 patients with IAS-1 was 13% and for IAS-2 83% (p less than 0.001). Urgent relaparotomy is necessary and may be performed safely for incisional dehiscence, obstruction, or IAS-1, with low mortality and high patient salvage rates. Directed relaparotomy for IAS-2 carries a high mortality rate but is the only means of patient salvage. Nondirected relaparotomy for multiple system and organ failure alone without supportive clinical or radiologic findings was futile, with a 13% (2/15) rate of positive exploration (p less than 0.001) and no patient salvage.