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Emergent laparotomies are associated with higher rates of morbidity and mortality. Recent studies suggest sarcopenia predicts worse outcomes in elective operations. The purpose of this study is to examine outcomes following urgent exploratory laparotomy in sarcopenic patients. This was a retrospective review of patients in a rural tertiary care facility between 2010 and 2014. Patients underwent a laparotomy within 72 h of admission and had an abdomen/pelvis CT scan were included. Primary outcomes were predictors of morbidity and mortality. Sarcopenia is the lowest quartile cross sectional area of the psoas muscles. Multivariate analysis of 967 patients found that sarcopenic patients had higher mortality, complication rate, were less likely to be discharged home, were more likely to undergo unplanned re-operation, and had a longer length of stay. Increasing abdominal wall fat has favorable outcomes in mortality, discharge destination, and complications. Sarcopenia is measured from CT scans, making it an accessible outcome predictor. In urgent laparotomies, sarcopenia was associated with higher morbidity, mortality, length of stay, and worse discharge destination. •Sarcopenia can easily be measured from CT scans.•It has been implemented in poor outcomes in elective surgery.•This study supports that sarcopenia is a predictor or poor outcomes in emergent cases.

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)Background and AimsWe present the anaesthetic management of a severely frail patient who underwent urgent exploratory midline laparotomy under bilateral erector spinae plane block (ESPB) and ‘Ketodex’ sedoanalgesia. ESPB can result in both visceral and somatic abdominal analgesia. Literature narrows ESPB to multimodal analgesia. However, some cases of ESPB as primary anaesthetic in abdominal surgery have been reported.MethodsA severely frail 87 yo women underwent inguinal hernioplasty with small bowel resection. At day 6, anastomosis dehiscence was suspected, and urgent exploratory midline laparotomy ensued. General anaesthesia was not considered ideal due to poor physical status and expected difficult ventilatory weaning. Neuraxial anaesthesia was not considered due to coagulopathy and thrombocytopenia. We proceeded with a bilateral ESPB injecting 30 mL of 0,5% Mepivacaine + 0,5% Ropivacaine deep to the erector spinae muscle in each side, at T9 level. We associated sedoanalgesia with bolus doses of a Ketamine and Dexmedetomidine mixture as needed, taking advantage of the opioid-free analgesia.ResultsNo anastomotic dehiscence was confirmed intraoperatively, and conversion to general anaesthesia was not needed. The patient maintained haemodynamic stability and spontaneous ventilation. Pain or discomfort was not reported during the procedure and no adverse events were recorded perioperatively.Abstract #36353 Figure 1Intraoperative picture showing the surgical approach after bilateral ESPB and the respiratory and hemodynamic profile (right)Abstract #36353 Figure 2Ultrasound-guided bilateral ESPB, demonstrating cranial-caudal local anesthetic (LA) spread in the ESP. Left side picture represents the ESPB performed on the left side. Right side picture represents the ESPB performed on the right sideConclusionsESPB is a feasible alternative anaesthetic technique for abdominal surgery in frail and severely ill patients, as demonstrated in this case. The synergic combination of dexmedetomidine and ketamine provides effective sedation and potentiates analgesia with a safe respiratory and hemodynamic profile.

BackgroundCombat 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.MethodsMilitary 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.ResultsAmong 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).ConclusionsOur 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.

Liver transplantation (LT) is the gold standard for end-stage liver disease (Prince Postgrad Med J 78:135–141, 2002). LT is a technically demanding operation. It needs experienced surgical team along with good anesthesia and critical care support (David et al. Gastroenterol Clin North Am 17:1–18, 1988). Survival after LT is approximately 90% at 1 year. Unlike other organs, 1 and 10-year survival for liver transplantation are the same (Jain and Reyes Ann Surg 232(4):490–500, 2000). Complications after LT are classified into technical, infective, and immunological (Moon and Lee Gut Liver 3(3):145–165, 2009). Re-exploratory laparotomy (REL) is one of the surgical complications of LT. Our study was aimed at analyzing the indications and impact of REL on the patient outcomes after living donor liver transplantation in our center. Retrospective analysis of all LTs done at our center by the same surgical team from January 1 2011 to June 30 2016 was included in the study. Pediatric transplants, combined liver kidney transplants, cadaveric transplants, planned REL, and re-transplantations were excluded from the study. Re-explored patients (REL) were classified as study group, and non-re-explored (NREL) patients were used as controls for statistical comparison. Twenty-five parameters (preoperative, intraoperative, and postoperative) between the two groups were studied. SPSS 22 statistical software was used for statistical analysis. The total number of LT during the study period was 1352. After exclusion, 1241 patients were in the study group. REL group had 111 patients. Out of 111 patients, 97 had one REL, 13 patients had two RELs, and 1 had three RELs. Hence, there were 126 RELs in 111 patients. NREL group had 1140 patients. REL rate in our series was 10.02%. On univariate analysis of 25 parameters analyzed between the two groups, age, graft weight, multiple bile ducts, and mortality were found to be statistically significant (P < 0.05). Preoperative total leucocyte count, model for end-stage liver disease, and warm ischemia time were statistically significant (P < 0.1). On subgroup analysis of REL, bleeding was the commonest indication followed by intraabdominal sepsis. Delayed non-function and small for size had high mortality rates. Multiple RELs were associated with higher mortality compared to single REL (P < 0.05). REL is associated with poor prognosis after adult living donor liver transplantation.

BackgroundExploratory laparotomy (EL) has been the definitive diagnostic and therapeutic modality for operative abdominal trauma in the US. Recently, many trauma centers have started using diagnostic laparoscopy (DL) in stable trauma patients in an effort to reduce the incidence of non-therapeutic laparotomy (NL). We aim to evaluate the incidence of NL in the trauma population in the US and compare the outcomes between DL and NL.MethodsUsing ICD-9 codes, the National Trauma Data Bank (2010–2015) was queried for patients undergoing any abdominal surgical intervention. Patients were divided into two groups: diagnostic laparoscopy (DL) and exploratory laparotomy (EL). Hemodynamically unstable patients on arrival and patients with abbreviated injury score (AIS) > 3 were excluded. Patients in EL group without any codes for gastrointestinal, diaphragmatic, hepatic, splenic, vascular, or urological procedures were considered to have undergone NL. After excluding patients who were converted to open from the DL group, multivariate regression models were used to analyze the outcomes of DL vs NL group with respect to mortality, length of stay, and complications.ResultsA total of 3197 patients underwent NL vs 1323 patients who underwent DL. Compared to DL group, the NL group were older (mean age: 35 vs. 31, P < 0.01). Rate of penetrating injury was 77% vs 86% for patients in NL vs DL. On multivariate analysis, NL was associated with increased mortality (OR 4.5, 95% CI 2.1–9.7), higher rate of complications (OR 2.2, 95% CI 1.4–3.3), and a longer hospital stay (OR 2.7, 95% CI 2.1–3.5). NL was also associated with higher rates of pneumonia, VTE, ARDS, and cardiac arrest.ConclusionWith increasing experience in minimally invasive surgery, DL should be a part of the armamentarium of trauma surgeons. This study supports that in well-selected trauma patients DL has favorable outcomes compared to NL. These findings warrant further investigation.Graphic abstract

BackgroundTrauma laparoscopy may provide a less invasive alternative to laparotomy by providing accurate diagnosis and minimally invasive management of selected trauma patients. The risk of missing injuries during the laparoscopic evaluation still refrains surgeons from using this approach. Our aim was to evaluate feasibility and safety of trauma laparoscopy in selected patients.MethodsWe performed a retrospective review of hemodynamically trauma patients who underwent laparoscopic management in a tertiary center in Brazil due to abdominal trauma. Patients were identified by searching through the institutional database. We collected demographic and clinical data, focusing on avoidance of exploratory laparotomy, and missed injury rate, morbidity, and length of stay. Categorical data were analyzed using Chi-square, while numerical comparisons were performed using Mann–Whitney and Kruskal–Wallis test.ResultsWe evaluated 165 cases, of which 9.7% needed conversion to an exploratory laparotomy. One-hundred and twenty-one patients (73%) had at least one intrabdominal injury. Two missed injuries to retroperitoneal organs were identified (1.2%), of which only one was clinically relevant. Three patients died (1.8%), one of which was due to complications from an intestinal injury after conversion. No deaths were related to the laparoscopic approach.ConclusionIn selected hemodynamically stable trauma patients, the laparoscopic approach is feasible and safe, and reduces the need for exploratory laparotomy and its associated complications.

BackgroundThe management of hemodynamically stable patients with anterior abdominal stab wounds (AASW) is debated. Mini-invasive techniques using laparoscopy and non-operative management (NOM) have reduced the rate of nontherapeutic laparotomies after AASW leading to unnecessary morbidity. The aim of this study was to determine with a systematic diagnostic laparoscopy of peritoneal penetration (PP), patients who do not require abdominal exploration in the management of stable patient with an AASW.MethodsAll patients with AASW were retrospectively recorded from 2006 to 2018. Criteria of inclusion were AASW patients who underwent a systematic diagnostic laparoscopy. Criteria of exclusion were patients with an evisceration, impaling, clinical peritonitis, and hemodynamic instability. If no PP was detected, laparoscopy was terminated. If defects of peritoneum were found, a laparotomy was performed looking for diagnosis and treatment of intra-abdominal injuries.ResultsOn 131 AASW patients, 35 underwent immediate emergency laparotomy, 96 underwent diagnostic laparoscopy, 47 were positive (PP) and had an intra-abdominal exploration by laparotomy, 32 (68.1%) had intra-abdominal injuries which required treatment. All patients with an intra-abdominal injury had a positive diagnostic laparoscopy. For the 49 patients with a negative laparoscopy, the mean hospital stay was 1.6 days with ambulatory care for some patients. No patient presented a delayed injury. Non-therapeutic laparotomy rate was 15.6%. For patients who did not have an intra-abdominal injury the morbidity rate was low (3%).ConclusionOur study shows that diagnostic laparoscopy was safe, with a low duration of hospitalization, a possible ambulatory care and had an excellent ability to screen the patients who did not need a abdominal exploration. This management can avoid many unnecessary laparotomies with an acceptable rate of negative laparotomy, without any delayed diagnosis of intra-abdominal injuries and with a low morbidity rate.

Objective: To compare post-operative outcome of mass closure technique versus Hughes repair in patients undergoing exploratory laparotomy. Study Design: Quasi experimental study. Place and Duration of Study: Department of Surgery, Combined Military Hospital, Multan Pakistan, from Dec 2022 to Jun 2024. Methodology: One hundred and fifty patients of age >20 years undergoing elective or emergency laparotomy were distributed in two groups on basis of repair technique used for laparotomy closure. Patients who underwent Hughes repair were placed in Group-S (study group) and standard mass closure patients were placed in Group-C (Control group). Procedural outcome in term of post-operative incisional hernia at six month was assessed and analyzed in both groups. Results: A Total 150 patients were included in final analysis with mean age of 47.23±9.86 years in Group-S (Hughes repair) and 47.82±9.44 years in Group-C (standard mass closure) (p=0.712). Post-operative complications were also noted and compared in both groups and Hughes repair group had lesser occurrence of post-op complications in comparison to standard mass closure group (p=0.142). At 6th month follow-up, incisional hernia was seen in 9(11.4%) and 17(23.9%) participants of Hughes repair and mass closure respectively (p=0.046). Odds ratio (OR) for the occurrence of incisional hernia at six months follow-up was <1 indicating less chances of incisional hernia (IHs) in Hughes repair as compared to standard mass closure method. Conclusion: Hughes repair is associated with a lower rate of incisional hernia as compared to standard mass closure in both emergency and elective exploratory laparotomy.

Emphysematous cystitis is a rare form of infection. Well known symptoms are: dysuria, urinary frequency and lower abdominal pain. We experienced a case of emphysematous cystitis presented with atypical peritoneal sign and computed tomography findings of massive intra-peritoneal fluid collection and abnormal gas appearance in pelvic space. Due to its presentation as acute abdomen, patient underwent exploratory laparotomy and the diagnosis of emphysematous cystitis was established. As far as we know, our case is the first report of emphysematous cystitis with intra-peritoneal fluid collection.

Peritoneal pseudocysts are benign, fluid-filled structures that arise from the accumulation of intra-abdominal fluid, which would typically be reabsorbed by the peritoneum. These pseudocysts form when peritoneal integrity is disrupted by adhesions, often secondary to trauma, surgery, or infection. While intraperitoneal pseudocysts are rare, they are most frequently associated with inflammatory processes, including ventriculoperitoneal shunt complications, catheter-related infections. Sclerosing peritonitis (SP), a rare but serious complication of long-term continuous ambulatory peritoneal dialysis, is characterized by marked thickening of the peritoneal membranes. Histologically, these membranes consist of dense fibrotic connective tissue infiltrated by mononuclear and polymorphonuclear cells. The pathogenesis of SP-associated pseudocysts is thought to involve low-grade infection or localized chronic inflammation. A 59-year-old male on peritoneal dialysis presented to the emergency department with chronic abdominal pain. Computed tomography imaging revealed a large peritoneal pseudocyst. During exploratory midline laparotomy, the pseudocyst was successfully evacuated, and the peritoneal dialysis catheter was removed.