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Damage-control laparotomy in nontrauma patients: review of indications and outcomes.

BACKGROUND The principle of damage-control laparotomy (DCL) in trauma is well established. The DCL concept can be applied in emergency general surgery when an abbreviated laparotomy is performed at the initial stage. Subsequent definitive management and abdominal closure are achieved when the patient is stabilized. In this study, we report our experience with DCL in acute general surgical nontrauma patients. METHODS A retrospective review was performed of all nontrauma patients who underwent DCL at Auckland City Hospital from January 2008 to December 2010. Data including indications and outcome were collected and analyzed. RESULTS Forty-two nontrauma patients underwent DCL in the 3-year period. The median age was 66 years. There were 22 males and 20 females. The most common primary indications for DCL were bowel ischemia (13 patients), bleeding (13 patients), and peritonitis (10 patients). Majority of patients had an American Society of Anesthesiologists score of 3 or 4. Overall, 24 patients (57%) underwent closure of the fascia within 7 days, 7 patients were closed after more than 7 days, and 11 patients could not undergo primary closure at all. The main complications after DCL were sepsis (14 patients) and intra-abdominal collections (10 patients). There were significantly fewer postoperative complications in patients undergoing early closure. The medium length of stay in intensive care as well as in hospital was significantly less in the early closure group. However, postoperative respiratory failure was more common in those with early closure (5 vs. 0). The mortality rate overall was 19%, with no significant difference regarding timing of abdominal closure. CONCLUSION The DCL principle is often applied to the critically ill surgical patients in the nontrauma setting. This group of critical surgical patients has a high morbidity and mortality. However, early abdominal closure should be performed where possible to prevent complications. It is unclear whether patients with early closure were going to have a better outcome regardless, and prospective studies are needed to address. LEVEL OF EVIDENCE Therapeutic/care management, level V.

Comparison of appendicectomy outcomes: acute surgical versus traditional pathway

The acute surgical unit (ASU) is an evolving novel concept introduced to address the challenge of maintaining key performance indicators (KPIs) in the face of an increasing acute workload.

Acute Surgical Unit at Auckland City Hospital: a descriptive analysis

Lack of timely assessment and access to acute operating rooms is a worldwide problem and also exists in New Zealand hospitals. To address these issues, an Acute Surgical Unit (ASU) was set up at Auckland City Hospital (ACH) in January 2009. This service has evolved and been modified to address the specific needs of acute surgical patients of ACH. Despite initial challenges inherent to setting up a new service, the Unit has been in steady operation and enhanced its performance over time. This paper is a descriptive analysis of the design of the ACH ASU and discusses some of the indications for streamlining acute surgical services at a large tertiary metropolitan hospital in New Zealand. Performance of the ASU has shown benefits for acute patients and the Hospital. The acute surgical rotation has also been beneficial for surgical training.

Diagnosis of blunt traumatic ruptured diaphragm: is it still a difficult problem?

Background:  Blunt traumatic rupture of the diaphragm (BTRD) is uncommon. The diagnosis can be easily overlooked, and radiological findings misinterpreted. In a 15‐year experience at the two major trauma hospitals in Brisbane reported in 1991, 85 patients with BTRD were treated, and the diagnosis not always made expeditiously. With the introduction of mandatory Early Management of Severe Trauma course training in the 90s and newer diagnostic tools, it might be expected that BTRD would be a less problematic diagnosis. The aim of this study was to review the incidence, diagnosis and outcome of BTRD at Auckland City Hospital over the last 10 years.

Crossbow injury in a developed country

Crossbow injuries are not common in developed countries such as Australia and New Zealand. Despite this, there have been a number of crossbow injuries in New Zealand mainly related to hunting exercises. When such incidents occur, it is important for the surgeons involved in the emergency care of the patient to have some background in the management of these injuries. A 24-year-oldmanpresented to the emergency department (ED) with a crossbow bolt penetrating his left supraclavicular fossa. A broad head arrow was accidentally fired with a high powered crossbow during a hunting exercise and travelled approximately 30 m before striking the jaw (resulting in a superficial laceration) and the left supraclavicular fossa (Fig. 1a). Theaccident occurred in a rugged terrain resulting in 4-h delay in transfer to ED. Vital signs on arrival were: pulse 88 beats/min, systolic blood pressure 140mmHg (after 1 l of normal saline), oxygen saturation 100% (trauma mask) and respiratory rate 32 breaths/min. Chest X-ray (CXR) showeda left haemothoraxwith the arrow traversing through the left supraclavicular fossa into the thoracic cavity (Fig. 1b). Insertionofan intercostal chestdrain immediatelydrained600 mlof bloodwith resolution of the haemothorax on repeat CXR. Therewas minimal chest drain output with no air leak and the patient remained haemodynamically stable. He was then transferred for a computerised tomography (CT) scan. The shaft of the bolt had to be carefully shortened in order for the patient to fit into the scanner. The CT scan (Fig. 2) showed that the bolt lodged posterior to the left carotid sheath, trackingmedially across the left first intercostal space, directing downwards and posterior across the vertebral processes with its tip at the right erector spinae muscle. There was no obvious vital vascular injury or residual pneumothorax. In the operating theatre, an incision was made in the back where the tip of the bolt was expected to be located based on the CT scan and approximation by gentle manipulation of the bolt (Fig. 3). After the identification of the tip, the bolt was carefully advanced forward

Ageing acute surgical population: the Auckland experience

This study provides data supporting the supposition that more elderly patients are requiring surgical care and illustrates the risks associated with acute surgical illness in elderly patients.

Major Retroperitoneal Vascular Trauma

Retroperitoneal hematoma from trauma often represents a life-threatening injury. As the retroperitoneum is an area that is difficult to access by physical examination, management depends on the grade and severity of the damaged structures. The division into three retroperitoneal zones as suggested by Selivanov facilitates decision making. Most vascular injuries can be managed by surgical control; however, venous injuries are sometimes difficult to assess completely and damage control approach should be considered. This same principle should be used in retroperitoneal hematoma from pelvic fractures, in combination with the start of a massive transfusion protocol. Stabilization of the pelvic fracture with external devices or fixators and surgical or endovascular (angioembolization) control of the hemorrhage are the keystones of the treatment.