Damage control surgery and packing in patients with blunt abdominal trauma

Abstract

AimBlunt abdominal traumas (BAT), which account for a large proportion of traumatic injuries, form a significant proportion of patients in emergency departments and are the leading cause of death in people under 45 years of age. In this study, we aimed to present the results of our patients who were admitted to our emergency department with BAT and underwent packing procedures during damage control laparotomy.MethodsThe patients aged ≥18 years who underwent emergency laparotomy for BAT and underwent packing with damage control surgery between 01.01.2021 and 31.12.2023 in our tertiary care hospital, a level 1 trauma center, were retrospectively analyzed in this study.ResultsOf the15 patients included in the study, 11 (73.3 %) were male. The mean age of the patients was 36.13 ± 1 4.16 years. Traffic accidents and occupational injuries were the most common causes of blunt trauma. The median duration of hospitalization was 14 (1-124) days, and mortality was observed in 3 patients (20%). In 13 patients (87.7%), both ultrasonography and computed tomography imaging were performed. Shock index, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS) values were calculated. The mean ISS was found to be 37.2 ± 9.4.ConclusionDamage control surgery, which is an essential approach for reducing mortality and morbidity rates in blunt abdominal trauma, remains crucial. The formation of multidisciplinary trauma teams with well-equipped trauma centers is necessary to achieve successful treatment outcomes in trauma patients.

Keywords

Introduction

Traumas are the seventh most common cause of death in the general population and among the leading causes of death in individuals under 45 years of age. As the third most frequently affected anatomical region, abdominal traumas constitute a significant proportion of emergency department admissions. Abdominal traumas are classified as penetrating or blunt according to etiology, with blunt abdominal traumas (BAT) accounting for the majority at 85%.¹
The spleen and liver are the most commonly injured organs in BAT, while intestines, mesentery, pancreas, and retroperitoneal structures may also be affected.² Abdominal injuries account for 15-20% of all trauma-related deaths. Compared to head and chest traumas, which are more fatal, mortality rates in abdominal traumas can be reduced with early intervention.³
The approach to trauma should be systematic and prioritized. Damage control surgery (DCS), defined in 1993, includes laparotomy, packing, and rapid wound closure to prevent bleeding and septic foci, aiming to restore physiological stability in trauma patients with hypothermia, acidosis, and coagulopathy — the so-called “death triad”.⁴
In this study, we aimed to present our perioperative results of packing procedures during damage control laparotomies in patients admitted to our emergency department with BAT who were not eligible for nonoperative treatment.

Materials and Methods

This retrospective cross-sectional study was conducted in a level one trauma center of a tertiary care training and research hospital. The study included patients aged 18 years and older who were diagnosed with blunt abdominal trauma in the emergency department between 01.01.2021 and 31.12.2023 and underwent packing with damage control surgery. Patients who were followed up without surgery for blunt abdominal trauma, patients who underwent surgery for trauma other than blunt abdominal trauma, patients who underwent packing in an operation other than trauma surgery, and patients who underwent surgery for blunt abdominal trauma but did not receive packing were excluded.
Demographic characteristics, vital parameters, cause of trauma, presence of additional injuries, laboratory and radiologic imaging, intraoperative findings, surgical intervention, duration of surgery, number of hospitalization days, mortality, and complications were retrospectively scanned through the hospital information management system and recorded on data forms. Shock Index (SI), Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS), and Glasgow Coma Scale (GCS) scores were calculated according to the data obtained from vital signs, radiological examinations, and consultation notes of other trauma branches.⁵ The extent of liver and spleen injury was reported using the “Injury Scoring Scale” recommended by the American Association of Trauma Surgery (AAST).⁶
All patients were resuscitated according to advanced trauma life support guidelines from the time of admission to the emergency department. Focused abdominal sonography for trauma (FAST) was performed by experienced emergency medicine specialists. All operations were performed by trauma surgery teams in the general surgery clinic. In cases with major liver injury, surgeons with hepatobiliary experience were also invited. Post-discharge follow-up of patients without mortality was carried out in the outpatient clinics of the emergency surgery unit.Surgical TechniqueInformed consent forms for surgical procedures were signed by patients and/or their relatives before surgery. Safe surgical procedures were followed. Patients who underwent emergency laparotomy for blunt abdominal trauma were studied through a midline incision above and below the umbilicus. After rapid exploration, the procedure was started with four-quadrant packing, then the area with intense bleeding was identified, and interventions were performed for the injured organ. Repairs or resections were performed in luminal organ injuries, but anastomosis was not carried out in the first session. Splenectomy was performed for high-grade spleen injuries. Primary suturing, hemostatic agents, and/or packing were applied according to the extent of liver injury. Interventions were managed according to patient stability and injuries to other organs. After packing, patients continued treatment in the ICU, and depacking surgery was planned within 24-48 hours.Ethical ApprovalThis study was approved by the Clinical Research Ethics Committee of Başakşehir Çam and Sakura City Hospital (Date: 04.09.2023, Decision No: 547).Statistical AnalysisAll data analyses were performed using SPSS version 25 (IBM, New York, USA). Since the sample size was smaller than 30 (n = 30), normality was examined by the Shapiro-Wilk test. Normally distributed data were expressed as mean ± SD. Non-normally distributed data were summarized with median, Q1 (25%), Q3 (75%), and min-max values. Nonparametric data were expressed as numbers (n) and percentages (%).

Results

In our study, the data of a total of 15 patients, including 11 (73.3%) males and 4 (26.7%) females, were analyzed. The mean age of the patients was 36.13 ± 14.16 years. Although traffic accidents were the most common cause of blunt trauma overall, blunt traumas in the form of impact and crushing due to occupational accidents ranked first among subtypes with a rate of 33.3% (Table 1).
Complete blood count, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and other laboratory test results measured at admission to the emergency department are presented in Table 2. Median hospitalization duration was 14 (1-124) days. Mortality was observed in 3 patients (20%). All patients were evaluated with FAST, and 13 patients (87.7%), excluding 2, were imaged with both FAST and computed tomography.
Shock index, ISS, RTS, TRISS, and GCS values of the patients, along with the organs injured, are presented in Table 3. Splenorrhaphy was successful in 4 patients (26.6%) with grade 2 lacerations, while splenectomy was performed in 3 patients with grade 4 injuries. One of the 14 patients (93.3%) with liver injury underwent non-anatomical right hepatectomy during depacking. In this patient and another with a large hematoma in segment 5, cholecystectomy was performed during depacking, and a catheter was placed in the cystic duct and removed from the abdomen.
Of the two patients with renal injury, one was followed conservatively, while the other underwent total nephrectomy in the first session. The findings of the exitus patients are given in Table 4. Two patients with intracranial hemorrhage also had a mortal outcome. Sphincterotomy and stenting were performed by ERCP in a patient with a pancreatic fistula and in another patient who underwent liver repair and developed a bile fistula through the drain.

Discussion

Our study includes the results of our practices in a three-year period in our hospital, a regional trauma center. In addition to being the largest trauma center in the region, our health facility is in a location with dense industrial facilities and a high population rate. In a study involving patients presenting with abdominal trauma, the majority of whom were BAT (70.8%), the mean age was 36 years, and the proportion of males was 79%.⁷ The majority of the patients in our study were also male, and the mean age (36 ± 14) was below 45 years, consistent with the literature. Traffic accidents rank first in the etiology of blunt abdominal injuries, followed by falls and battery cases, respectively.⁸ The most common cause of BAT in our study was traffic accidents, followed by occupational accidents and falls from height, respectively. Radiographic imaging is an important part of the clinical examination in BAT. Focused abdominal sonography (FAST) for trauma is preferred as the first screening method after the primary evaluation in trauma algorithms for thoracoabdominal injuries.⁹ However, due to various limitations caused by ultrasonography, computed tomography (CT) is considered the gold standard in trauma imaging evaluation. CT should only be performed under the supervision of the trauma team in patients who are hemodynamically stable or respond to fluid resuscitation.¹⁰ All patients in our study underwent bedside FAST assessment at the time of presentation to the emergency department. Two patients with unstable general conditions and diffuse intra-abdominal hemorrhagic fluid detected by FAST underwent emergency surgery without a CT scan. Since the most commonly injured organs in blunt abdominal trauma are the spleen and liver, it is crucial to perform complete blood count and liver function tests in laboratory tests. AST is initially higher than ALT due to rhabdomyolysis caused by blunt trauma. Newton et al. reported that ALT may be preferred as a screening tool for hepatic trauma.¹¹ Bilgic et al. suggested that patients with thresholds of ALT ≤76 U/L, AST <130 U/L had a low-grade liver injury and that these patients could be treated without surgery.¹² Similarly, high mean AST and ALT were associated with liver injury in our study. With the establishment of trauma centers in many large healthcare facilities in recent years, patients with hemodynamically stable or treatment-stabilized trauma can be managed with nonoperative management (NOM).¹³ In patients with abdominal trauma, systolic blood pressure (SBP) less than 90 mmHg at the first examination in the emergency department is an important finding indicating the severity of injury and hemodynamic instability. Harvin et al. found SBP <90 mmHg in 23% of 1,706 patients who underwent emergency laparotomy in their study of 74,048 patients in 12 trauma centers over a two-year period. In the same study, the rate of damage control laparotomy was reported as 38%.¹⁴ The Shock Index (SI), which is heart rate divided by SBP, may be a simple tool to identify patients with hemorrhagic shock. Four groups were defined as SI <0.6 (no shock), SI ≥0.6 to <1.0 (mild shock), SI ≥1.0 to <1.4 (moderate shock), and SI ≥1.4 (severe shock).¹⁵ In our study, the mean SBP of the patients was below 90 mmHg, the pulse rate was above 100/min, and the mean SI was 1.3, which was in the moderate shock category. As reported in various studies in the literature, the liver is one of the most common organ injuries secondary to trauma. Therefore, the treatment strategies to be applied in trauma-related liver injury should be thoroughly familiarized. According to the World Society of Emergency Surgery (WSES) liver trauma management guidelines, in laparotomy, in the absence of major bleeding, compression alone, electrocautery, bipolar devices, topical hemostatic agents, or simple suturing of the liver parenchyma may be sufficient to stop bleeding.¹⁰ However, in case of rapid deterioration of hemodynamics and high blood loss during surgery, perihepatic tamponade (packing) should be performed. Hemostasis is aimed to be achieved by compression between the tampons placed above and below the bleeding parenchyma.¹⁶ It is recommended to avoid hepatic resections in the treatment of unstable patients and during damage control procedures. Despite this, hepatic resection may be required in 2-4% of cases of major liver trauma.¹⁰ In the liver injuries in our study, mainly bipolar cauterization, primary suturing, and packing using hemostatic agents were performed, and hepatic resection during DCS was not used in any patient. During the depacking procedure, one patient underwent a right hepatectomy due to completely circulatory compromised liver segments. Trauma scoring systems are a common means to facilitate the assessment of injury severity and comparison of treatment outcomes. The most commonly used scoring systems include the Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS). The ISS score is the most common anatomical scoring system utilized for patients with multiple injuries. Duration of hospitalization is associated with morbidity and mortality.⁵ Bolorunduro et al. divided ISS into four groups as mild (<9), moderate (9-15), severe (16-25), and profound (>25).¹⁷ The mean ISS we calculated was 37.2 ± 9.4, and all patients were in the riskiest group. The most common injury accompanying abdominal trauma was thorax trauma with a rate of 53%. Due to its low sensitivity and specificity, ISS cannot distinguish between survivors and non-survivors. Instead, it has been suggested that RTS and TRISS can be used to predict the survival rates of trauma patients.¹⁸ In our study, the ISS was above 40 points in all three patients with mortality, while both RTS and TRISS values were significantly lower in two of them compared to the surviving patients. The timing of emergency laparotomy is one of the most important prognostic factors in patients with major trauma and hemodynamic instability. Although there is no strict time limit for emergency laparotomy, the American College of Surgeons Committee on Trauma (ACS-COT) recommends intervention within 120 minutes.¹⁹ Although DCS contributes to decreased mortality, it also carries complications such as sepsis, abscesses, biliary fistulas, abdominal compartment syndrome, gastrointestinal fistulas, and abdominal hernias.^20-21 Minor bile duct injuries often heal spontaneously within 14 days and do not require any intervention, but major bile duct injury or persistent bile leaks can be treated with ERCP and biliary stent drainage. Biliary complications rarely require surgical treatment except in cases of failure of conservative treatment or uncontrolled sepsis.²² In our study, we performed cholecystectomy and transcystic catheter placement through the cystic duct in a depacking procedure in two patients. Furthermore, one patient who underwent only liver repair needed stenting with ERCP due to a biliary fistula in the postoperative period. Similarly, a patient with pancreatic fistula required ERCP. As we applied packing to all patients in our study, no fascia closure was performed as a temporary abdominal closure method, and only skin closure was performed. No signs of abdominal compartment syndrome were observed in any of our patients. Although NOM has become a frequently used method in trauma centers in recent years, mortality is also observed in these patients. Even in high-volume trauma centers, the overall mortality rate in the treatment of trauma patients was reported to be 10%.²³ It was reported that in-hospital mortality was 10.9% in primary surgical treatment patients and 3.6% in NOM patients, while the mortality rate in primary surgery cases was 23.8% in patients with combined hepato-spleen injury.²⁴ In our study, no combined liver-spleen injury was observed in the patients with mortality. However, the presence of retroperitoneal bleeding or intracranial bleeding was noted in these patients. Talih et al. reported that ISS level, hypotension, and hemorrhagic shock on admission were significant risk factors for mortality in their study in which the mortality rate was found to be 47%.²⁵ Although DCS in trauma aims to reduce mortality, studies indicating that high complications were observed in survivors were also reported. Roberts et al. reported that there were significant differences between the indications for DCS in different trauma centers and that there were unnecessary referrals to this procedure. There is a growing number of studies examining admissions to DCS due to its high complicative consequences.²⁰ Lack of information about the causes of trauma and the patient can negatively impact surgical decision-making, leading to less effective clinical choices. Therefore, it is important to determine which patient should be treated with which treatment protocol. For this reason, the concept of teamwork emerges. In addition to being a major trauma center, the structure and dynamics of emergency trauma teams are determined by an in-house protocol. In fact, a division of labor within the team has been determined for emergencies that may cause a large number of trauma patients to apply, such as earthquakes, mass traffic accidents, and explosions. Having a trauma team contributes greatly to making joint treatment decisions for patients and taking the best decision.

Limitations

Our study had several limitations due to its retrospective and single-center design. Since we retrospectively scanned through the “packing” code in the surgical record system, we were able to screen only patients who underwent damage control surgery and packing. Therefore, we could not screen patients who were followed nonoperatively or underwent damage control surgery without packing. This led to the lack of a control group in our study. Although the number of patients in the study seems to be limited, we think that it is significant in terms of reflecting our packing results in our hospital, which has a level 1 trauma center.

Conclusion

Despite all the advances in the nonoperative management of patients with blunt abdominal trauma, damage-control laparotomies remain an effective procedure in the management of severe trauma in a group of patients with massive bleeding and coagulopathy. It is possible to achieve acceptable mortality and morbidity rates with trauma surgery teams experienced in damage control surgery. Furthermore, establishing well-equipped trauma centers and managing the process with a multidisciplinary approach are among the most crucial factors in increasing the success rates of trauma surgeries.

References

1. Shrestha A, Neupane HC, Tamrakar KK, Bhattarai A, Katwal G. Role of liver enzymes in patients with blunt abdominal trauma to diagnose liver injury. Int J Emerg Med. 2021;14(1):7. doi:10.1186/s12245-021-00332-1
   Article · PubMed · Google Scholar
2. Mehta N, Babu S, Venugopal K. An experience with blunt abdominal trauma: evaluation, management, and outcome. Clin Pract. 2014;4(2):599. doi:10.4081/cp.2014.599
   Article · PubMed · Google Scholar
3. Poletti PA, Mirvis SE, Shanmuganathan K, et al. Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography? J Trauma. 2004;57(5):1072-1081. doi:10.1097/01.ta.0000092680.73274.e1
   Article · PubMed · Google Scholar
4. Cirocchi R, Montedori A, Farinella E, Bonacini I, Tagliabue L, Abraha I. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2013;2013(3). doi:10.1002/14651858.cd007438.pub3
   Article · PubMed · Google Scholar
5. Javali RH, Krishnamoorthy, Patil A, Srinivasarangan M, Suraj, Sriharsha. Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score, and Trauma and Injury Severity Score for mortality prediction in elderly trauma patients. Indian J Crit Care Med. 2019;23(2):73-77. doi:10.5005/jp-journals-10071-23120
   Article · PubMed · Google Scholar
6. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207(5):646-655. doi:10.1016/j.jamcollsurg.2008.06.342
   Article · PubMed · Google Scholar
7. Gönültaş F, Kutlutürk K, Gok AFK, Barut B, Sahin TT, Yilmaz S. Analysis of risk factors of mortality in abdominal trauma. Ulus Travma Acil Cerrahi Derg. 2020;26(1):43-49.
   PubMed · Google Scholar
8. Kamabu K, La O Soria J, Tumwesigye D, et al. 24-hour mortality and its predictors among road traffic accident victims in a resource-limited setting: a multicenter cohort study. BMC Surg. 2023;23(1):97. doi:10.1186/s12893-023-02011-9
   Article · PubMed · Google Scholar
9. Smith ZA, Wood D. Emergency focused assessment with sonography in trauma and hemodynamic stability. Emerg Med J. 2014;31(4):273-277. doi:10.1136/emermed-2012-202268
   Article · PubMed · Google Scholar
10. Coccolini F, Coimbra R, Ordonez C, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg. 2020;15(1):24. doi:10.1186/s13017-020-00302-7
    Article · PubMed · Google Scholar
11. Newton MV, Subramanyam SG. Predicting and grading liver injury in the absence of computed tomographic imaging. J Family Med Prim Care. 2023;12(2):326-331. doi:10.4103/jfmpc.jfmpc_1532_22
    Article · PubMed · Google Scholar
12. Bilgic I, Gelecek S, Akgun AE, Ozmen MM. Predictive value of liver transaminases levels in abdominal trauma. Am J Emerg Med. 2014;32(7):705-708. doi:10.1016/j.ajem.2014.03.052
    Article · PubMed · Google Scholar
13. Cimbanassi S, Chiara O, Leppaniemi A, et al. Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: results from an International Consensus Conference. J Trauma Acute Care Surg. 2018;84(3):517-531. doi:10.1097/ta.0000000000001774
    Article · PubMed · Google Scholar
14. Harvin JA, Maxim T, Inaba K, et al. Mortality after emergent trauma laparotomy: a multicenter, retrospective study. J Trauma Acute Care Surg. 2017;83(3):464-468. doi:10.1097/ta.0000000000001619
    Article · PubMed · Google Scholar
15. Zarzaur BL, Croce MA, Fischer PE, Magnotti LJ, Fabian TC. New vitals after injury: shock index for the young and age x shock index for the old. J Surg Res. 2008;147(2):229-236. doi:10.1016/j.jss.2008.03.025
    Article · PubMed · Google Scholar
16. Paydar S, Mahmoodi M, Jamshidi M, et al. Perihepatic packing versus primary surgical repair in patients with blunt liver trauma: an 8-year experience. Bull Emerg Trauma. 2014;2(3):103-109.
    PubMed · Google Scholar
17. Bolorunduro OB, Villegas C, Oyetunji TA, et al. Validating the Injury Severity Score in different populations: Injury Severity Score predicts mortality better among Hispanics and females. J Surg Res. 2011;166(1):40-44. doi:10.1016/j.jss.2010.04.012
    Article · PubMed · Google Scholar
18. Indurkar SK, Ghormade PS, Akhade S, Sarma B. Use of the Trauma and Injury Severity Score as a predictor of patient outcome in cases of trauma presenting in the trauma and emergency department of a tertiary care institute. Cureus. 2023;15(6). doi:10.7759/cureus.40410
    Article · PubMed · Google Scholar
19. Bentin JM, Possfelt-Møller E, Svenningsen P, Rudolph SS, Sillesen M. A characterization of trauma laparotomies in a Scandinavian setting: an observational study. Scand J Trauma Resusc Emerg Med. 2022;30(1):43. doi:10.1186/s13049-022-01030-4
    Article · PubMed · Google Scholar
20. Roberts DJ, Stelfox HT, Moore LJ, Cotton BA, Holcomb JB, Harvin JA. Accuracy of published indications for predicting use of damage control during laparotomy for trauma. J Surg Res. 2020;248:45-55. doi:10.1016/j.jss.2019.11.010
    Article · PubMed · Google Scholar
21. Gungor F, Babayev A, Acar N, et al. Factors affecting the diagnosis, management, and clinical outcomes of liver traumas: clinical series and literature review. Surg Chron. 2021;26(2):171-176.
    PubMed · Google Scholar
22. Kanlerd A, Auksornchart K, Boonyasatid P. Nonoperative management for abdominal solid-organ injuries: a literature review. Chin J Traumatol. 2022;25(5):249-256. doi:10.1016/j.cjtee.2021.09.006
    Article · PubMed · Google Scholar
23. Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Cochrane Database Syst Rev. 2018;12(12). doi:10.1002/14651858.cd012669.pub2
    Article · PubMed · Google Scholar
24. Morell-Hofert D, Primavesi F, Fodor M, et al. Validation of the revised 2018 AAST-OIS classification and the CT severity index for prediction of operative management and survival in patients with blunt spleen and liver injuries. Eur Radiol. 2020;30(12):6570-6581. doi:10.1007/s00330-020-07061-8
    Article · PubMed · Google Scholar
25. Talih T, Gök M, Sözüer E, Akyıldız H. The presence of hemorrhagic shock on admission is the strongest predictor of mortality in trauma patients who require packing. Indian J Surg. 2021;83:58-63.
    PubMed · Google Scholar

Tables

Additional Information

Publisher’s Note
Bayrakol MP remains neutral with regard to jurisdictional and institutional claims.

Rights and Permissions