Sustaining better care for patients undergoing emergency laparotomy.

Emergency laparotomy is associated with high mortality. Implementation of an evidence-based care bundle has been shown to improve patient outcomes. A quality improvement project to implement a six-component care bundle was undertaken between July 2015 and May 2018. As part of this project, we worked with 27 hospitals in the Emergency Laparotomy Collaborative. Previous pilot implementation of the same bundle in our hospital between December 2012 and July 2013 had shown marked improvement, maintained until April 2014, but then deterioration. Understanding the reasons for this deterioration informed our work to re-implement the bundle and sustain improvement. A cohort of 930 consecutive patients requiring emergency laparotomy between October 2014 and April 2019 were included. Baseline data were collected between October 2014 and June 2015, and the bundle was re-implemented in July 2015. Thirty-day mortality decreased from 11% in the baseline group to 7.3% after bundle implementation. Hospital length of stay decreased from 19.5 to 17.9 days. Full bundle compliance improved from < 60% to > 80% for all patients, with improvement in application of all individual bundle components. This study provides further evidence that outcomes for high-risk surgical patients can be improved with an evidence-based care bundle, but attention must be paid to maintaining bundle compliance. Issues around sustaining improvement must be considered from project initiation.

Minimally Invasive Surgery Rate as a Quality Metric for Endometrial Cancer.

STUDY OBJECTIVE: To determine the frequency with which Commission on Cancer-accredited hospitals met a metric of ≥80% minimally invasively performed hysterectomies for endometrial cancer and to compare the clinical outcomes of hospitals meeting this metric with those that did not. DESIGN: Retrospective cohort study. SETTING: Hospitals caring for ≥20 endometrial cancer patients per year recorded in the National Cancer Database in 2015 were included. PATIENTS: Women who had undergone hysterectomy for endometrial cancer and had an epithelial histology, a Charlson comorbidity score of 0, and stage I to III disease. INTERVENTION: Patient characteristics, patterns of care, and outcomes were compared between hospitals performing ≥80% minimally invasive hysterectomies and hospitals not meeting this metric. MEASUREMENTS AND MAIN RESULTS: The hospitals (n = 510) treated 20 670 women with endometrial cancer. In 283 (55%) hospitals ≥80% of hysterectomies were minimally invasively performed (high-minimally invasive surgery [MIS] hospitals, overall MIS rate 89%). In the 227 hospitals that did not meet this metric, 61% of hysterectomies for endometrial cancer were performed using a minimally invasive approach. In high-MIS hospitals, patients were more likely to be white (87% vs 82%, p<.001), privately insured (53% vs 49%, p <.001), and have stage I disease (84% vs 82%, p = .002) and an endometrioid histology (79% vs 76%, p <.001). Surgery was more often performed robotically (80% vs 71%), and conversion to laparotomy was less likely (1.5% vs 3.2%, adjusted odds ratio [aOR], 0.47; 95% confidence interval [CI], 0.39-0.57) (both p <.001). Patients treated at high-MIS hospitals were more likely to have undergone lymph node assessment at the time of surgery (76% vs 69%; aOR, 1.43; 95% CI, 1.35-1.53) and been discharged on the same or next day (74% vs 57%; aOR, 2.27; 95% CI, 2.13-2.42) and were less likely to have an unplanned 30-day readmission (1.8% vs 2.9%; aOR, 0.64; 95% CI, 0.53-0.77). CONCLUSION: An MIS rate of ≥80% for endometrial cancer is feasible on a national scale and is associated with other hospital-level measurements of high-quality care.

Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center.

BACKGROUND: Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center. METHOD: The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011-2013) and trauma center (TC) (2014-2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality. RESULT: Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80 min, p = 0.022), time from admission to operation (125 vs. 112 min, p = 0.010), time from admission to first treatment (119 vs. 99 min, p = 0.004), and time from admission to first transfusion (70 vs. 52 min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24 h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period. CONCLUSION: After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.

Effect of decompressive laparotomy on organ function in patients with abdominal compartment syndrome: a systematic review and meta-analysis.

BACKGROUND: Decompressive laparotomy has been advised as potential treatment for abdominal compartment syndrome (ACS) when medical management fails; yet, the effect on parameters of organ function differs markedly in the published literature. In this study, we sought to investigate the effect of decompressive laparotomy on intra-abdominal pressure and organ function in critically ill adult and pediatric patients with ACS, specifically focusing on hemodynamic, respiratory, and kidney function and outcome. METHODS: A systematic review and meta-analysis of the literature was performed. Articles reporting data on intra-abdominal pressure (IAP), hemodynamic (mean arterial pressures [MAP], central venous pressure [CVP], cardiac index [CI], heart rate [HR], systemic vascular resistance index [SVRI] and/or pulmonary capillary wedge pressure [PCWP]), respiratory (positive end-expiratory pressure [PEEP], peak inspiratory pressure [PIP] and/or ratio of partial pressure arterial oxygen and fraction of inspired oxygen [P/F ratio]), and/or urinary output (UO) following decompressive laparotomy were analyzed. RESULTS: A total of 15 articles were included; 3 included children only (aged 18 years or younger). Of the 286 patients who were included, 49.7% had primary ACS. The baseline mean IAP in adults decreased with an average of 18.2 ± 6.5 mmHg following decompression, from 31.7 ± 6.4 mmHg to 13.5 ± 3.0 mmHg. There was a decrease in HR (12.2 ± 9.5 beats/min; p = 0.04), CVP (4.6 ± 2.3 mmHg; p = 0.022), PCWP (5.8 ± 2.3 mmHg; p = 0.029), and PIP (10.1 ± 3.9 cmH2O; p < 0.001) and a mean increase in P/F ratio (70.4 ± 49.4; p < 0.001) and UO (95.3 ± 105.3 ml/h; p < 0.001). In children, there was a significant increase in MAP (20.0 ± 2.3 mmHg; p = 0.006), P/F ratio (238.2; p < 0.001), and UO (2.88 ± 0.64 ml/kg/h; p < 0.001) and a decrease in CVP (7 mmHg; p = 0.016) and PIP (9.9 cmH2O; p = 0.002). The overall mortality rate was 49.7% in adults and 60.8% in children following decompressive laparotomy. CONCLUSIONS: Decompressive laparotomy resulted in a significantly lower IAP and had beneficial effects on hemodynamic, respiratory, and renal parameters. Mortality after decompressive laparotomy remains high in both adults and children.

Pathways to professionalism? Quality improvement, care pathways, and the interplay of standardisation and clinical autonomy.

Care pathways are a prominent feature of efforts to improve healthcare quality, outcomes and accountability, but sociological studies of pathways often find professional resistance to standardisation. This qualitative study examined the adoption and adaptation of a novel pathway as part of a randomised controlled trial in an unusually complex, non-linear field - emergency general surgery - by teams of surgeons and physicians in six theoretically sampled sites in the UK. We find near-universal receptivity to the concept of a pathway as a means of improving peri-operative processes and outcomes, but concern about the impact on appropriate professional judgement. However, this concern translated not into resistance and implementation failure, but into a nuancing of the pathways-as-realised in each site, and their use as a means of enhancing professional decision-making and inter-professional collaboration. We discuss our findings in the context of recent literature on the interplay between managerialism and professionalism in healthcare, and highlight practical and theoretical implications.

[Prevention of the wound infection: little changes, huge results]. / Resultados de la modificación de la actitud ante la asepsia en cirugía neonatal: pequeños cambios, grandes resultados.

INTRODUCTION: Neonatal surgical wound infection occurs in almost 50% of neonatal procedures. It increases the rates of morbimortality in neonatal units. There is no guidelines about prevention of wound infection in neonatal surgery. We present our results after changing our behaviour in neonatal surgery. MATERIALS AND METHODS: Comparative study between 2 groups. In order to decrease wound infection at the end of the procedure gloves, covertures and surgical instruments were changed and saline and antiseptic solutions were used during laparotomy closing. Group P included procedures with these recommendations and Group NP without them. Age, weight, surgery, infection, length of stay, and mortality were analized between groups through a logistic regression model. RESULTS: Group P included 55 procedures in 32 patients, median weight 1,300 g (1,000-2,100), 19 median days of life (6-40), 5 postoperative wound problems (9%). Group NP included 26 procedures in 14 neonates, median weight 1,700 g (700-2,500), 20 median days of life (3-33), 14 wound problems (53.8%). We decrease the wound problems in our patients in 44.8% (p < 0.0001). Additionally, the protection provided by our recommendations was maintained after adjustment by weight, age and type of pathology (0.07) p= 0.000. CONCLUSIONS: Simple changes in during the procedures in neonatal surgery can reduce the appearance of wound infection and morbidity.

OBJETIVOS: La infección de herida quirúrgica neonatal tiene una incidencia de hasta el 50% y produce un aumento de morbimortalidad. No existen recomendaciones preventivas consensuadas en la literatura. Presentamos los resultados tras la implantación de un protocolo creado en nuestro Servicio para cierre de laparotomía en cirugía neonatal contaminada y sucia. MATERIAL Y METODOS: Estudio ambispectivo de las laparotomías neonatales realizadas durante 32 meses comparando los resultados con un grupo de pacientes intervenidos durante un período previo similar. El protocolo incluye cambio de guantes, de campo y material quirúrgico, lavado por planos con antiséptico y sutura antibacteriana en el cierre. Se analizan edad, peso, tipo de intervención, infección, estancia hospitalaria y mortalidad y se compara con un grupo similar de pacientes intervenidos de forma previa a la creación del protocolo (NP) y se analiza la influencia del protocolo en la aparición de infección mediante regresión logística. RESULTADOS: El grupo P incluye 55 laparotomías en 32 neonatos con mediana de peso 1.300 g (1.000-2.100), mediana de edad 19 días (6-40) con 3 infecciones de herida (2 cultivos positivos) y 2 dehiscencias leves (9%). El grupo NP incluyó 26 intervenciones en 14 neonatos, mediana de peso 1.700 g (700-2.500), mediana de edad 20 días (3-33), 14 infecciones (53,8%), 8 cultivos positivos y 2 muertes. Se redujo un 44,8% la aparición de infección (p < 0,0001) y el efecto protector del protocolo se mantuvo después del ajuste por peso, edad y tipo de patología (0,07) p= 0,000. CONCLUSIONES: La sencilla modificación de la asepsia y técnica de cierre ha contribuido a disminuir considerablemente la tasa de infección y morbimortalidad en nuestros pacientes y consideramos que es necesario hacer conciencia de ello.

Evaluation of the performance of the ACS NSQIP surgical risk calculator in gynecologic oncology patients undergoing laparotomy.

OBJECTIVE: The objective of this study was to evaluate the ability of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) surgical risk calculator to predict complications in gynecologic oncology patients undergoing laparotomy. METHODS: A chart review of patients who underwent laparotomy on the gynecologic oncology service at a single academic hospital from January 2009 to December 2013 was performed. Preoperative variables were abstracted and NSQIP surgical risk scores were calculated. The risk of any complication, serious complication, death, urinary tract infection, venous thromboembolism, cardiac event, renal complication, pneumonia and surgical site infection were correlated with actual patient outcomes using logistic regression. The c-statistic and Brier score were used to calculate the prediction capability of the risk calculator. RESULTS: Of the 1094 patients reviewed, the majority were <65years old (70.9%), independent (95.2%), ASA class 1-2 (67.3%), and overweight or obese (76.1%). Higher calculated risk scores were associated with an increased risk of the actual complication occurring for all events (p<0.05). The calculator performed best for predicting death (c-statistic=0.851, Brier=0.008), renal failure (c-statistic=0.752, Brier=0.015) and cardiac complications (c-statistic=0.708, Brier=0.011). The calculator did not accurately predict most complications. CONCLUSIONS: The NSQIP surgical risk calculator adequately predicts specific serious complications, such as postoperative death and cardiac complications. However, the overall performance of the calculator was worse for gynecologic oncology patients than reported in general surgery patients. A tailored prediction model may be needed for this patient population.

Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (ELPQuIC) bundle.

Implementation of a quality improvement bundle for peri-operative management of emergency laparotomy (ELPQuIC) improved mortality in a previous study. We used data from one site that participated in that study to examine whether it was associated with the cost of care. We collected data from 396 patients: 144 before, 144 during and 108 after implementation of the bundle. We estimated costs incurred using previously published methodology based on the time the patient spent in hospital, in the operating theatre and in critical care. Duration of stay in hospital and critical care did not differ between time periods, p = 0.14 and p = 0.28, respectively. The costs per patient and per survivor did not differ between the time periods, p = 0.87 and p = 0.17, respectively. Costs were similar for patients aged < 80 years vs. ≥ 80 years. Implementation of a quality improvement bundle for emergency laparotomy has the capacity to save lives without increasing hospital costs.

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy.

BACKGROUND: Emergency laparotomies in the U.K., U.S.A. and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. METHODS: The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. RESULTS: Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6.47 in the baseline interval (299 patients included) to 12.44 after implementation (427 patients included) (P < 0.001). The overall case mix-adjusted risk of death decreased from 15.6 to 9.6 per cent (risk ratio 0.614, 95 per cent c.i. 0.451 to 0.836; P = 0.002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0.197 and 0.223 before and after implementation respectively; P = 0.395). CONCLUSION: Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

Safety and efficacy of the minilaparotomy for myomectomy: a systematic review and meta-analysis of randomized and non-randomized controlled trials.

Myomectomy is the most frequent reproductive surgery to preserve, improve fertility, or both. The present study was designed to assess the safety and efficacy of minilaparotomy for myomectomy through a systematic review of randomized and non-randomized controlled trials with a meta-analysis. All available studies comparing minilaparotomy myomectomy with laparotomy, other minimally invasive surgeries, or both, were included. Available surgical and reproductive data were extrapolated, and a qualitative and quantitative analysis was carried out. Fourteen studies were included in the final analysis for an overall sample of 2151 patients. A total of 1139 patients were treated with minilaparotomy, whereas 239 and 773 patients were treated, respectively, with the laparotomy or laparoscopy. Only two studies comparing minilaparotomy with laparoscopy assessed the reproductive outcomes, and their data synthesis did not demonstrate significant difference between the two surgical techniques. Specific surgical end-points differed significantly between minilaparotomy and laparotomy or laparoscopy, even if those differences were not clinically relevant. In conclusion, current data do not permit a definite conclusion to be drawn. Further studies are needed to clarify the risk-benefit ratio of the minilaparotomy compared with the other minimally invasive surgical procedures for myomectomy to provide clinical recommendations with strong scientific evidence.

Conversion from robotic surgery to laparotomy: a case-control study evaluating risk factors for conversion.

OBJECTIVES: To determine risk factors associated with conversion to laparotomy for women undergoing robotic gynecologic surgery. METHODS: The medical records of 459 consecutive robotic surgery cases performed between December 2006 and October 2011 by 8 different surgeons at a single institution were retrospectively reviewed. Cases converted to laparotomy were compared to those completed robotically. Descriptive statistics were used to summarize the demographic and clinical characteristics. RESULTS: Forty of 459 (8.7%, 95% CI 6.3%-11.7%) patients had conversion to open surgery. Reason for conversion included poor visualization due to adhesions (13), inability to tolerate Trendelenburg (7), enlarged uterus (7), extensive peritoneal disease (5), bowel injury (2), ureteral injury (1), vascular injury (1), bladder injury (1), technical difficulty with the robot (2), and inability to access abdominal cavity (1). 5% of cases were converted prior to docking the robot. On univariate analysis, preoperative diagnosis (p=0.012), non-White race (p=0.004), history of asthma (p=0.027), ASA score (p=0.032), bowel injury (p=0.012), greater BMI (p<0.001), need for blood transfusion (p<0.001), and expected blood loss (p<0.001) were associated with conversion. On multivariate analysis, non-White race (OR 2.88, 95% CI 1.39-5.96, p=0.004), bowel injury (OR 35.40, 95% CI 3.00-417.28, p=0.005), and increasing BMI (OR 1.06, 95% CI 1.03-1.09, p<0.001) were significantly associated with increased risk for conversion. Prior surgery was not associated with conversion to open surgery (p=0.347). CONCLUSION: Conversion to laparotomy was required for 8.7% of patients undergoing robotic surgery for a gynecologic indication. Increasing BMI and non-white race were identified as the two preoperative risk factors associated with conversion.

Could clinical scores guide the surgical treatment of necrotizing enterocolitis?

PURPOSE: Test the diagnostic reliability of the score for neonatal acute physiology-perinatal extension-II (SNAPPE-II) and the metabolic derangement acuity score (MDAS) as predictors of surgery in patients with necrotizing enterocolitis (NEC). METHODS: The SNAPPE-II and the MDAS were applied to 99 patients with NEC. Both the scores were calculated at the moment of diagnosis (T(0)) and when surgical assessment was required (T(1)). The main outcome was the need of surgical revision. Comparison between models was made through their receiver operator characteristics (ROC) curves. RESULTS: Thirty-five patients required surgical treatment (group A) and 64 responded to medical therapy (group B). Median SNAPPE-II was 22 versus 5 for group A (U test 621, p = 0.002) at T(0); and 22 versus 10 for group A (U test 487, p = 0.01) at T(1). Measuring the value of the SNAPPE-II as a predictor of surgery, the ROC curve was 0.69 (CI 95%, 0.57-0.80) at T(0) and 0.67 (CI 95%, 0.55-0.80) at T(1). Median MDAS were 2 for both groups A and B at T(0) (U test 890.5, p = 0.113) and 2 versus 1.5 for group A at T(1) (U test 570, p = 0.043). The ROC curve for MDAS was 0.59 (CI 95%, 0.47-0.71) at T(0) and 0.64 (CI 95%, 0.52-0.77) at T(1). CONCLUSIONS: The diagnostic performance of the SNAPPE-II offers mild results in the moment of the diagnosis of NEC, and at T(1). The MDAS is non significant at T(0) and obtains moderate results at T(1). These results do not encourage using the SNAPPE-II and the MDAS as definite tools to decide for surgical treatment of the patients affected by NEC.

Standardized video-assisted retroperitoneal minilaparotomy surgery for 615 living donor nephrectomies.

To increase the rate of living kidney donation, the long-term safety of nephrectomy must be demonstrated to potential donors. We analyzed long-term donor outcomes and evaluated the standardization of surgical technique. We evaluated 615 donors who underwent Video-assisted minilaparotomy living donor nephrectomy (VLDN) at Yonsei Severance Hospital between 2003 and 2009. Perioperative data and predictors of outcomes were prospectively analyzed. The mean operative time and mean warm ischemia time were 192.7 and 2.2 min, respectively. Mean estimated blood loss was 195.3 ml. The mean post-transplant serum creatinine levels and Modification of Diet in Renal Disease study equation for estimating glomerular filtration rate were 1.1 mg/dl and 68 ml/min/1.73 m(2) , respectively at 5 years after VLDN. The intra-operative and postoperative complication rate were 3.1% and 6.3%, respectively. Delayed renal function, 5-year graft survival, and complication rates of recipients were 1.1%, 98.4%, and 0.4%, respectively. Predictors of operative time were medical history, vessel anomaly, and surgeon experience (>50 cases). The single predictor of intra-operative complications was vessel anomaly. Standardized VLDN is feasible and safe. Our data on long-term outcomes can assist in demonstrating the long-term safety of donor nephrectomy to potential donors. To compare VLDN to other types of donor nephrectomy, a prospective multicenter study must be performed.

Impact of improved combat casualty care on combat wounded undergoing exploratory laparotomy and massive transfusion.

BACKGROUND: Studies have shown decreased mortality after improvements in combat casualty care, including increased fresh frozen plasma (FFP):red blood cell (RBC) ratios. The objective was to evaluate the evolution and impact of improved combat casualty care at different time periods of combat operations. METHODS: A retrospective review was performed at one combat support hospital in Iraq of patients requiring both massive transfusion (≥ 10 units RBC in 24 hours) and exploratory laparotomy. Patients were divided into two cohorts based on year wounded: C1 between December 2003 and June 2004, and C2 between September 2007 and May 2008. Admission data, amount of blood products and fluid transfused, and 48 hour mortality were compared. Statistical significance was set at p < 0.05. RESULTS: There was decreased mortality in C2 (47% vs. 20%). Patients arrived warmer with higher hemoglobin. They were transfused more RBC and FFP in the emergency department (5 units ± 3 units vs. 2 units ± 2 units; 3 units ± 2 units vs. 0 units ± 1 units, respectively) and received less crystalloid in operating room (3.3 L ± 2.2 L vs. 8.5 L ± 4.9 L). The FFP:RBC ratio was also closer to 1:1 in C2 (0.775 ± 0.32 vs. 0.511 ± 0.21). CONCLUSIONS: The combination of improved prehospital care, trauma systems approach, performance improvement projects, and improved transfusion or resuscitation practices have led to a 50% decrease in mortality for this critically injured population. We are now transfusing blood products in a ratio more consistent with 1 FFP to 1 RBC. Simultaneously, crystalloid use has decreased by 61%, all of which is consistent with hemostatic resuscitation principles.

Assault induced stab injuries: epidemiology and actual treatment strategy.

OBJECTIVES: To investigate and analyse epidemiology, demographics and patterns of presentation of assault induced stab injuries in a main Belgian trauma centre. To evaluate surgical management, complications and postoperative follow-up of the stab wound victims. METHODS: One hundred and seventy assaulted patients, hospitalised because of stab injuries from January 2000 to June 2007 are studied retrospectively. RESULTS: Ninety-five percent of the assaults occurred on men and the mean age of the patients was 31.1 +/- 9.7 years. Ethnic minorities represent 77% of the patients hospitalised for assaults and 26.5% of all patients proved to be under toxic influence, predominantly from alcohol (21.8%). A decline of admissions of patients with stab injuries during the period 2002-2004 is recorded. However, the incidence doubled in the next two-year period. A weekend peak and circadian rhythm is apparent with more than 20% of the patients admitted between 4 and 6 am. The trunk is most frequently stabbed (54.5%) resulting in a laparotomy rate of 51%. One third of the patients who underwent thoraco-abdominal surgery revealed diaphragmatic injuries. Seventy-five percent of the patients left the hospital in a good condition while 2.4% had neuromuscular lesions. Two patients had serious vascular complications during follow-up. During the study period, no mortality was recorded. CONCLUSIONS: Stab wounds were recorded mainly in young and middle-aged men from ethnic minorities, whereas almost 27% were under the influence of drugs. A conservative approach was generally used resulting in a low laparotomy and thoracotomy rate without affecting mortality. Neuromuscular lesions are important long-term complications of stab injuries.

[Intra-operative complications and causes of conversion during aortofemoral reconstruction through mini-laparotomy].

Results of 269 reconstructive operations on infrarenal aorta (among them 30 - for aneurysms) applied using mini-laparotomy (abdominal midsection 5-10 cm) were analyzed. Complexities during the operation occurred in 12,6% of patients; among them complications were observed in 4.8%. In 7.1% of cases it resulted in conversion of access. With accumulation of experience frequency of complications decreased from 6.1 to 3.8% (p=0,616) and frequency of conversions - from 12.2 to 3.2% (p=0.017). Comparison with group of 162 patients operated using standard laparotomy showed that despite rather more frequent complexities with infrarenal aorta reconstruction from mini-access (12.6% against 9.4%, p=0.505) amount of complications didn't differ significantly (4.8% and 5.6% respectively, p=0.930). Authors consider abdominal aorta reconstruction from mini-access to be a safe operation.

[Relaparotomy and laparostomy in treatment of early postoperative complications].

The cause-and-effect analysis of early (within 3 weeks after the initial surgery) relaparotomy was made, using the experience of 5286 laparotomized patients, of whom 82 (1,55%) had relaparotomy. The main reason of intraabdominal complications was the initial generalized peritonitis in emergency patients (85,4%). In comparison with data of 30 years prescription, the portion of postoperative peritonitis and bleeding had increased, though the number of eventrations and postoperative ileus, on the contrary, decreased. The introduction of laparoscopy eliminated the necessity of diagnostic relaparotomies. The mortality rate after the repeated surgery had decreased from 38,0% to 30,5%.