The Impact of Prior Laparotomy and Intra-abdominal Adhesions on Bowel and Mesenteric Injury Following Blunt Abdominal Trauma

• Published in: World journal of surgery 2019-02, Vol.43 (2), p.457-465
• Main Authors: Loftus, Tyler J., Morrow, Megan L., Lottenberg, Lawrence, Rosenthal, Martin D., Croft, Chasen A., Smith, R. Stephen, Moore, Frederick A., Brakenridge, Scott C., Borrego, Robert, Efron, Philip A., Mohr, Alicia M.
• Format: Article
• Language: English
• Subjects: Abdomen; Abdominal Injuries - complications; Abdominal Injuries - surgery; Abdominal Surgery; Adult; Cardiac Surgery; Computed tomography; Deceleration; Diagnostic systems; Exploration; Female; General Surgery; Health risks; Humans; Injuries; Injury Severity Score; Intestine; Intestines - injuries; Intestines - surgery; Laparotomy - adverse effects; Male; Medicine; Medicine & Public Health; Mesentery - injuries; Mesentery - surgery; Middle Aged; Original Scientific Report; Patients; Peritoneum; Radiography; Regression analysis; Retroperitoneum; Retrospective Studies; Risk Factors; Shear Strength; Surgery; Tethering; Thoracic Surgery; Tissue Adhesions - complications; Transition points; Trauma; Ultrasound; Vascular Surgery; Wounds, Nonpenetrating - complications; Wounds, Nonpenetrating - surgery
• ISSN: 0364-2313; 1432-2323
• DOI: 10.1007/s00268-018-4792-6

Background Early recognition of bowel and mesenteric injury following blunt abdominal trauma remains difficult. We hypothesized that patients with intra-abdominal adhesions from prior laparotomy would be subjected to visceral sheering deceleration forces and increased risk for bowel and mesenteric injury following blunt abdominal trauma. Methods We performed a multicenter retrospective cohort analysis of 267 consecutive adult trauma patients who underwent operative exploration following moderate-critical (abdominal injury score 2–5) blunt abdominal trauma, comparing patients with prior laparotomy ( n  = 31) to patients with no prior laparotomy ( n  = 236). Multivariable regression was performed to identify predictors of bowel or mesenteric injury. Results There were no significant differences between groups for injury severity scores or findings on abdominal ultrasound, diagnostic peritoneal aspirate/lavage, pelvic radiography, or preoperative CT scan. The prior laparotomy cohort had greater incidence of full thickness bowel injury (26 vs. 9%, p  = 0.010) and mesenteric injury (61 vs. 31%, p  = 0.001). The proportion of bowel and mesenteric injuries occurring at the ligament of Treitz or ileocecal region was greater in the no prior laparotomy group (52 vs. 25%, p  = 0.003). Prior laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI 1.6–16.8) along with prior abdominal inflammation and free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74–0.88). Conclusions Patients with a prior laparotomy are at increased risk for bowel and mesenteric injury following blunt abdominal trauma. The distribution of bowel and mesenteric injuries among patients with no prior laparotomy favors embryologic transition points tethering free intraperitoneal structures to the retroperitoneum.