Objective: One of the primary goals of damage control surgery in the trauma patient is primary
closure of the abdomen. We hypothesized that extra-abdominal infections, such as those
complicating injuries to the thorax, diaphragm, long bones, or musculoskeletal system, would
decrease the likelihood of primary abdominal closure and increase hospital resource utilization
in patients requiring open abdominal management.
Methods: The trauma registry of the American College of Surgeons (TRACS) was reviewed
retrospectively from 1995–2002 for open abdomen technique and damage control surgery. The
outcome was primary fascial closure or delayed closure. Patients who died prior to closure
were excluded. We evaluated infectious complications, including ventilator-associated pneumonia
(VAP), blood stream infection (BSI), and surgical site infection (SSI). Other parameters
studied were multiple rib fractures, long bone fractures, chest injuries, diaphragm injuries,
empyema, and transfusion requirements. Hospital charges were obtained from the
hospital administrative database. Univariate, multivariate, and regression analyses were performed
to identify the effects of infectious complications on primary abdominal closure,
length of stay, total hospital charges, and disposition.
Results: Three hundred forty-four patients required the open abdomen technique: 67% received
damage control laparotomy and 33% decompression of abdominal compartment syndrome.
Two hundred seventy-six patients (80%) went on to abdominal closure of some form
and constituted the primary study group. Primary abdominal closure was achieved in 180
(65%) with a mean time to closure of 3.5 days. Ventilator-associated pneumonia, BSI, and SSI
were associated with lack of primary closure (p < 0.05). Increased blood transfusions also
were associated with failure of primary closure (p < 0.05). Ventilator-associated pneumonia
and BSI were associated with significantly greater lengths of stay in the intensive care unit
(ICU) (24.2 days vs. 12.6 days and 30.5 days vs. 17.9 days; both p < 0.0001) and significantly
greater total hospital charges ($232,080 vs. $142,893; $247,440 vs. $160,940; and $264,778 vs.
$170,447; all p < 0.001).
Conclusion: Inability to achieve primary abdominal closure was associated with infectious
complications (VAP, BSI, and SSI) and large transfusion requirements. Infectious complications
also significantly increased ICU utilization and hospital charges. Death was associated
with BSI, femur fractures, and large transfusion requirements, whereas infectious complications
did not have a significant impact on discharge disposition.
