Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD, 20814, USA.
Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.
Surg Endosc. 2024 Oct;38(10):5778-5784. doi: 10.1007/s00464-024-11102-4. Epub 2024 Aug 14.
Combat casualties are frequently injured in austere settings where modern imaging modalities are unavailable. Exploratory laparotomies are often performed in these settings when there is suspicion for intra-abdominal injury. Prior studies of combat casualties reported non-therapeutic laparotomy (NTL) rates as high as 32%. Given improvements in combat casualty care over time, we evaluated NTLs performed during later years of the wars in Iraq and Afghanistan.
Military personnel with combat-related injuries (6/1/2009-12/31/2014) who underwent exploratory laparotomy based on concern for abdominal injury (i.e. not performed for proximal vascular control or fecal diversion) and were evacuated to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals were assessed. An NTL was defined as a negative laparotomy without substantial intra-abdominal injuries requiring repair. Characteristics, indications for laparotomy, operative findings, and outcomes were examined.
Among 244 patients who underwent laparotomies, 41 (16.8%) had NTLs and 203 (83.2%) had therapeutic laparotomies (i.e. positive findings). Patients with NTLs had more computed tomography scans concerning for injury (48.8% vs 27.1%; p = 0.006), less penetrating injury mechanisms (43.9% vs 71.9%; p < 0.001), and lower Injury Severity Scores (26 vs 33; p = 0.003) compared to patients with therapeutic laparotomies. Patients with NTLs were also less likely to be admitted to the intensive care unit (70.7 vs 89.2% for patients with therapeutic laparotomies; p = 0.007). No patients with NTLs developed abdominal surgical site infections (SSI) compared to 16.7% of patients with therapeutic laparotomies (p = 0.002). There was no significant difference in mortality between the groups (p = 0.198).
Our proportion of NTLs was lower than reported from earlier years during the wars in Iraq and Afghanistan. No infectious complications from NTLs (i.e. abdominal SSIs) were identified. Nevertheless, surgeons should continue to have a low threshold for exploratory laparotomy in military patients in austere settings with concern for intra-abdominal injury.
在现代成像方式无法使用的恶劣环境中，战斗伤员经常受伤。当怀疑有腹腔内损伤时，这些环境中通常会进行剖腹探查术。先前对战斗伤员的研究报告称，非治疗性剖腹术（NTL）的比例高达 32%。鉴于战斗伤员救治水平的提高，我们评估了伊拉克和阿富汗战争后期进行的 NTL。
根据对腹部损伤的关注（即不是为了近端血管控制或粪便分流而进行的手术），对 2009 年 6 月 1 日至 2014 年 12 月 31 日期间因战斗相关受伤而接受剖腹探查术的军事人员进行评估，并将他们运送到兰施图尔地区医疗中心（德国），然后转移到参与的美国军事医院。定义 NTL 为无实质性腹腔内损伤需要修复的阴性剖腹术。检查了特征、剖腹术的指征、手术发现和结果。
在 244 例接受剖腹术的患者中，41 例（16.8%）行 NTL，203 例（83.2%）行治疗性剖腹术（即阳性发现）。行 NTL 的患者接受了更多的 CT 扫描以确定损伤（48.8%比 27.1%；p=0.006），更少的穿透性损伤机制（43.9%比 71.9%；p<0.001），以及较低的损伤严重程度评分（26 比 33；p=0.003）。与治疗性剖腹术患者相比，行 NTL 的患者也较少入住重症监护病房（70.7%比 89.2%；p=0.007）。与治疗性剖腹术患者（16.7%）相比，行 NTL 的患者无一例发生腹部手术部位感染（SSI）（p=0.002）。两组间死亡率无显著差异（p=0.198）。
我们的 NTL 比例低于伊拉克和阿富汗战争早期的报告。未发现 NTL 引起的感染性并发症（即腹部 SSI）。尽管如此，在对怀疑有腹腔内损伤的军事伤员在恶劣环境中进行剖腹探查时，外科医生仍应继续保持较低的剖腹术阈值。
