Exploratory laparotomy for proximal vascular control in combat-related injuries

Background: Combat casualties have endured an increase in traumatic lower extremity amputations secondary to improvised explosive devices. Often surgical control of the proximal vasculature is required. We evaluate the safety profile of exploratory laparotomy (EXLAP) for proximal control (PC) in combat-injured patients. Methods: Records of 845 combat casualties from June 2009 to December 2011 were reviewed. Patients undergoing EXLAP were divided by indication into PC and non-PC groups. Demographics, Injury Severity Score, mechanism of injury, transfusion requirements, EXLAP findings, reoperation rates, and abdominal-related complications were recorded. Results: 44 patients were identified as PC and 91 as non-PC. Age was similar (23.7 ± 4.1 vs. 24.0 ± 4.6, p = 0.7138), and all were male. Improvised explosive devices blast was the most common mechanism of injury. Injury Severity Score (25.8 ± 8.2 vs. 21.4 ± 9.1, p = 0.0075), lower extremity amputation (93.1% vs. 28.6%, p = 0.0001), and transfusion requirements were different. Days to fascial closure (1.8 ± 1.9 vs. 1.7 ± 2.8, p = 0.8308) and number of EXLAPs were similar (2.4 ± 1.3 vs. 2.1 ± 1.5, p = 0.2581). PC had higher complications (43.1% vs. 24.2%, p = 0.0292). Conclusion: PC demonstrated an increase in abdominal complications. The reason for this remains unclear. Alternative approaches of achieving proximal vascular control may avoid the morbidity associated with laparotomy, and predeployment training of such procedures should be considered for the general surgeon. Further studies are warranted to determine best practices for these patients.