Abstract
Background:
Emergency laparotomy is linked with high morbidity and mortality, with re-exploration and surgical site infection being major contributors to poor outcomes. Randomized evidence on strategies to minimize the performance of a relaparotomy and decrease postoperative complications is fragmented.
Objectives:
To synthesize randomized controlled trial evidence of interventions to reduce re-exploration and postoperative complications after emergency laparotomy.
Methods:
This systematic review and meta-analysis was performed in line with PRISMA 2020 guidelines. Randomized controlled trials including adults undergoing emergency laparotomy were included. Primary outcomes were relaparotomy and postoperative death. Secondary outcomes were surgical site infection (SSI), fascial dehiscence and incisional hernia. Risk ratios (RRs) with 95% confidence intervals (CIs) were used to conduct random-effects meta-analysis. Heterogeneity was tested using the I2 statistic.
Results:
Eleven randomized controlled trials involving 2,146 patients were included. In the case of severe peritonitis, the on-demand relaparotomy strategy reduced re-operations without an increase in mortality (RR for mortality 0.79, 95% CI 0.53-1.17). Three trials on SSI prevention showed a significant reduction in infection with subcutaneous suction drainage or negative pressure wound therapy (RR 0.35, 95% CI 0.21-0.58; I2 = 0%). Five trials involving interrupted or modified fascial closure compared to continuous closure had a non-significant trend on dehiscence (RR 0.48, 95% CI 0.16-1.42; I2 = 67%). STITCH trial showed less incisional hernia with small-bite surgical closure in a heterogeneous group of surgery (RR 0.63, 95% CI 0.42-0.94).
Conclusion:
Targeted wound management strategies have been found to significantly reduce surgical site infection after emergency laparotomy. Interrupted or altered closure methods may help decrease fascial dehiscence; however, the evidence remains inconsistent. An on-demand approach for relaparotomy reduces unnecessary re-operations without an increased mortality. Further high quality trials are required to standardize preventive strategies in emergency laparotomy