Skip to main content
Download PDF
  • Research article
  • Open access
  • Published:

Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia

World Journal of Emergency Surgery volume 16, Article number: 53 (2021) Cite this article

Abstract

Background

It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy.

Methods

A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy.

Results

Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39–40.27], level-1 verification status (OR = 6.02; 95% CI 2.01–18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20–2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01–1.58) in the last year.

Conclusions

The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries.

Background

Damage control (DC) laparotomy was developed to quickly control exsanguinating hemorrhage and gross contamination in injured patients with severe physiologic derangements [1]. It was first adopted by American trauma centers in the 1970s–1990s and then increasingly used worldwide as it was felt to be associated with an increase in unexpected survival among the most critically injured patients [1,2,3,4]. However, systematic reviews of randomized and non-randomized studies have found insufficient evidence supporting that use of DC instead of definitive laparotomy improves mortality or other patient-important outcomes [5, 6]. Further, use of the procedure is resource-intensive and associated with increased morbidity when compared to definitive laparotomy [7,8,9,10,11,12,13].

The above suggests that there is likely insufficient evidence to support the high DC laparotomy utilization rates reported by some trauma centers [5]. Limited data exist suggests that there is substantial variation in the frequency of use of DC laparotomy across level-1 trauma centers [14,15,16,17]. In a post-hoc analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial, DC was used among 33–83% of patients requiring urgent laparotomy across 12 participating American level-1 trauma centers between 2012 and 2013 [17]. While there was no significant mortality difference between the participating trauma centers, the risk of complications was higher among those treated with DC laparotomy [5, 17]. This finding is supported by two other studies which reported that use of DC laparotomy among lower risk cohorts of injured patients is associated with increased risks of complications and longer hospital lengths of stay [5, 16, 18].

Reasons for variation in use of DC laparotomy between level-1 trauma centers in the United States are unknown. It is also unknown whether variation in use of DC laparotomy exists across trauma centers outside of the United States and how often the procedure is used across level-2 and -3 trauma centers (e.g., to stabilize a critically injured patient before transport to a level-1 centers). To address these knowledge gaps, a cross-sectional survey of trauma centers located in the United States, Canada, and Australasia (Australia and New Zealand) was conducted [19]. This survey had two objectives. First, it sought to determine if variation in use of DC laparotomy across trauma centers may be partially driven by surgeon uncertainty as to when the procedure was appropriately indicated. Results of this part of the study have been reported, which suggested that practicing surgeons have relatively consistent impressions of the appropriateness of using DC surgery in certain clinical scenarios [19]. Second, it sought to study variation in the frequency of use of DC laparotomy across level-1, -2, and -3 trauma centers in these regions and predictors of more frequent use of the procedure (the subject of the current study). The study hypothesis was that the reported frequency of use of DC laparotomy would be highly variable across trauma centers, including level-1 trauma centers, and that this variation would be predicted by trauma center and program characteristics, including differences in setting, institutional characteristics, and patient mix.

Methods

Design, ethics, and reporting

A self-administered, electronic, cross-sectional survey of trauma program medical directors or leaders located in 4 high-income countries with similar emergency medical services was conducted [19, 20]. Study methods have previously been described in detail [19]. The University of Calgary Conjoint Health Research Ethics Board approved the study. It is reported according to the Strengthening of Observational Studies in Epidemiology (STROBE) statement [21].

Setting and participants

The population of interest included level-1, -2, and -3 trauma centers that treat adult or adult and pediatric trauma patients in the United States, Canada, and Australasia. The sampling frame of American, Canadian, and Australian trauma centers was identified using lists of those verified by the American College of Surgeons in 2013 [22], that contributed data to the Canadian National Trauma Registry Comprehensive Data Set in 2010 to 2011 (with the exception of Quebec) [23], and that were part of the Australian Trauma Quality Improvement Program as of August 31, 2014 [24], respectively.

Questionnaire development and testing

The survey questionnaire was developed by modifying a previously developed questionnaire administered to trauma program directors or leaders in the above countries [25]. The modified questionnaire asked for information about respondents’ trauma center, including its geographic location, accreditation/verification, verification level, and academic status. It also asked for information about their trauma program, including the numbers and characteristics of injured patients assessed in the last calendar or fiscal year. Finally, it asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last calendar or fiscal year. This last question had the following ordinal response options: (1) at least once daily, (2) more than once weekly but less than once daily, (3) once weekly, (4) once every 2–3-weeks, (5) once monthly, (6) once every 2–3-months, (7) less than once every 3-months, (8) never, (9) other frequency, or (10) unsure. DC laparotomy was defined in the question stem as “abbreviated laparotomy with planned reoperation (e.g., packing of the liver followed by temporary abdominal closure with plans for reoperation to remove packs at a later time).” The questionnaire’s clarity, length, and completeness were assessed during semi-structured interviews with 5 surgeons or physicians. It was then pilot tested on 5 surgeons or physicians and 2 trauma program directors.

Questionnaire administration

All trauma centers in the sampling frame were purposively sampled by sending an e-mail to their trauma program director or leader in September, 2014 [26]. E-mails explained the study purpose and invited potential respondents to participate by accessing a link to a Web-based survey. Consent for study participation was inferred with questionnaire completion. To increase response rate, personalized questionnaires were administered that provided assurance of respondent confidentiality [27]. Potential respondents were also sent pre-notification and follow-up e-mails at approximately 1 week, 2–3 weeks, 4–5 weeks, and 5–6 weeks followed by a closing soon e-mail at approximately 7–9 weeks [27].

Statistical methods

Categorical survey responses were summarized using counts (percentages) and continuous survey responses using medians [with interquartile ranges (IQRs)]. Survey responses were summarized unstratified and stratified by country, reported frequency of use of DC laparotomy, and by volume and level of trauma center care. A high-volume trauma center was defined as per Nathens et al. as one that assessed > 650 major trauma [Injury Severity Scale (ISS) score > 15] patients in the last year [28]. Summary statistics were compared using Fisher’s exact and Kruskal–Wallis tests as appropriate.

Multivariable logistic regression with robust standard errors was used to identify independent predictors of a higher reported frequency of use of DC laparotomy across trauma centers. As there have been no studies to guide selection of evidence-informed predictors for inclusion in the model, all variables felt to be potentially predictive that lacked evidence of multicollinearity were included in the model. We also tested whether the volume of severely injured patients modified the relationship between reported frequency of use of DC laparotomy and level-1 verification status.

The degree of multicollinearity was estimated by calculating associations or correlations between variables and by using the Stata (Stata Corp. College Station, Texas, United States) command package “collin”. Model fit was tested using the Hosmer and Lemeshow’s goodness-of-fit test (non-significant p values indicate that the model fits the data). Finally, overall classification performance of the logistic regression model was assessed by generating a receiver operating characteristic (ROC) curve that plotted sensitivity against false-positive rate (1-specificity) across a range of diagnostic thresholds.

Statistical analyses were performed using Stata MP version 13.1.

Results

Response rate

Of the 366 potentially eligible trauma program directors or leaders that were sent the survey, 199 (51.8%) responded and provided data on the frequency of use of DC laparotomy in their center.

Characteristics of participating trauma centers

Of the 199 participating trauma centers, 156 (78.4%) were located in the United States, 26 (13.1%) in Canada, and 17 (8.5%) in Australasia. The 156 participating American trauma centers were located in 37 different states, with most in California (17.3%), Texas (9.6%), and Michigan (8.3%) (see the Figure in Additional File 1). The 26 participating Canadian trauma centers were located in 7 different provinces, with most in Alberta (26.9%), Ontario (26.9%), and British Columbia or Nova Scotia (15.4% each). Finally, of the 17 Australasian trauma centers, 13 (76.5%) were located in Australia and 4 (23.5%) in New Zealand.

Characteristics of the 199 participating trauma centers are outlined in Table 1. Ninety (45.9%) were verified or accredited to provide level-1 trauma care, 72 (36.7%) to provide level-2 care, and 26 (13.3%) to provide level-3 care. Trauma centers in the United States and Australasia assessed more adult (p = 0.007) and pediatric (p = 0.008) trauma patients than those in Canada. Trauma centers in the United States also assessed a higher percentage of patients with penetrating injuries than those in Canada or Australasia (p = 0.008). However, the number of severely injured (defined as an ISS score > 15) patients assessed was similar across trauma centers in the three regions.

Table 1 Characteristics of the trauma centers participating in the study
Full size table

Reported frequency of use of DC laparotomy by trauma centers

The reported frequency of use of DC laparotomy for trauma by the 199 participating trauma centers was highly variable (see the Figure in Additional file 2). Forty-four (22.1%) trauma centers reported using DC laparotomy less than once every 3 months. Ten (5.0%) reported never using it. Sixty (30.2%) reported using it once monthly or once every 2–3 months and 73 (36.7%) using it greater than once a month. Twelve (6.0%) trauma centers were unsure how often they used DC laparotomy.

DC laparotomy was reportedly used more frequently in level-1 than level-2 or -3 trauma centers (Fig. 1). High-volume level-1 trauma centers used DC laparotomy significantly more often than lower volume level-1 trauma centers (p = 0.02) (Fig. 2). In total, 24 (77.4%) high-volume and 34 (57.7%) lower volume level-1 trauma centers reported using DC laparotomy greater than once monthly. Further, 15 (48.4%) high-volume and 12 (20.3%) lower volume level-1 trauma centers reported using it at least once weekly. Two (6.4%) high-volume level-1 trauma centers reported never using DC laparotomy for trauma.

Fig. 1
figure 1

Reported frequency of use of damage control laparotomy for trauma by level-1, -2, and -3 trauma centers in the United States, Canada, and Australasia (Australia and New Zealand)

Full size image
Fig. 2
figure 2

Reported frequency of use of damage control laparotomy for trauma by high- and non-high-volume level-1 trauma centers in the United States, Canada, and Australasia (Australia and New Zealand)

Full size image

Predictors of increased reported frequency of use of DC laparotomy

Characteristics of the trauma centers that reported using DC laparotomy more instead of less frequently are compared in Table 2. Those centers that reported using it more frequently were significantly more likely to be high-volume, level-1, teaching centers located in urban settings. They were also more likely to participate in research and have a designated trauma service. Finally, they were more likely to have assessed a higher number of injured adult and pediatric patients (including those with an ISS > 15) and a higher percentage of patients with penetrating injuries in the last year.

Table 2 Characteristics of the participating trauma centers that reported using damage control laparotomy more instead of less frequently
Full size table

In a multivariable logistic regression model, there was no evidence that the volume of severely injured patients assessed in the last year modified the association between the reported frequency of use of DC laparotomy and level-1 verification status (p = 0.35). Variables describing teaching status and trauma center research activities were excluded from logistic regression models because there was evidence of multicollinearity between these variables and level-1 trauma center status. Significant adjusted predictors for more than once monthly reported use of DC laparotomy included country of origin (centers in the United States reported using DC laparotomy significantly more often than those in Canada), level-1 verification status, and the assessment of a higher number of severely injured patients and patients with penetrating injuries in the last year (Fig. 3). The Hosmer and Lemeshow test indicated that the model fit the data well (p = 0.62). The area under the ROC curve for the model was 0.88, indicating excellent performance for correctly classifying higher instead of lower reported use of DC laparotomy across trauma centers (see the Figure in Additional file 3).

Fig. 3
figure 3

Adjusted predictors of use of damage control laparotomy for trauma more than once a month by trauma centers in the United States, Canada, and Australasia (Australia and New Zealand)

Full size image

Discussion

In this large, international, cross-sectional survey of trauma program directors or leaders, the reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more often in level-1 than level-2 or -3 trauma centers in the United States, Canada, and Australasia. The frequency of use of DC laparotomy also varied significantly across level-1 trauma centers, especially between those that were high- versus lower volume (based on the number of severely injured patients assessed in the last year). Nearly half of high-volume, level-1 trauma centers reported using DC laparotomy at least once weekly. Trauma center and program characteristics that independently predicted higher reported use of DC laparotomy included country of origin (with centers in the United States reporting using DC laparotomy significantly more often than those in Canada), level-1 trauma verification status, and the assessment of a higher number of severely injured (ISS score > 15) patients and patients with penetrating injuries in the last year.

Studying variation in use of DC laparotomy is important because surgeons are at risk of confirmation bias when only those with whom they work reflect their practice [29]. However, to date, only one other study has examined variation in use of DC surgery between trauma centers [17]. In a post-hoc analysis of the PROPPR trial, DC laparotomy was reportedly used among a highly variable 33–83% of patients requiring urgent laparotomy across 12 American level-1 trauma centers between 2012 and 2013 [17]. In the current study, the trauma program directors who were surveyed also reported that the frequency of use of DC laparotomy varied widely across trauma centers, including level-1 trauma centers. Most level-1 trauma centers reported using DC laparotomy at least once a month, and nearly half of high-volume, level-1 trauma centers reported using it at least once weekly. However, 6% of high-volume, level-1 trauma centers reporting never using DC laparotomy during the past year. Reasons for variation in use of DC laparotomy between level-1 trauma centers may include differences in patient injury mechanisms, injury severity, and/or physiology; trauma center experience; trauma surgeon capabilities; and trauma provider education.

Trauma centers in the United States reported using DC laparotomy for trauma more often than those in Canada despite adjustment for level-1 verification status and the volume of severely injured patients and patients with penetrating injuries. This could be because of differences in institutional cultures regarding use of DC laparotomy between countries. It could also be because of unmeasured differences in patient mix between countries aside from injury mechanism or ISS scores (e.g., a higher percentage of patients with high-risk injury patterns, deranged physiology, or who receive significant volumes of resuscitation fluids) or beliefs regarding appropriate indications for use of the procedure [30]. Of the American, Canadian, and Australasian trauma centers included in this study, a nearly equal percentage reported using the procedure less than once every 3 months or never using it, using it once monthly or once every 2–3 months, or using it more than once monthly. Further, more than one-third of level-2 centers reported using DC laparotomy once monthly or more than once monthly and even some level-3 trauma centers reported using the procedure. We assume that many of these level-3 trauma centers may be using DC laparotomy to stabilize critically injured patients before transport to a higher level of trauma care [7].

In addition to country of origin, other independent predictors of an increased reported use of trauma DC laparotomy included level-1 trauma verification status and the assessment of a higher number of severely injured patients and patients with penetrating injuries in the last year. In the post-hoc analysis of the PROPPR study, the ISS score (OR per-1 point increase = 1.05; 95% CI 1.02–1.07) of the patients assessed at level-1 trauma centers also predicted an increased odds of use of DC laparotomy [17]. This is likely because high-energy blunt torso trauma often results in high ISS scores and also may produce some of the high-risk injury patterns considered by many surgeons to be appropriate indications for DC laparotomy (e.g., massive pelvic fracture-related hemorrhage or multiple injuries spanning across more than one body cavity that each require surgery) [19, 30, 31]. Further, while patients with penetrating injuries may have a lower ISS score, those with gunshot wounds (and especially shotgun wounds) more often present with certain injury patterns that have been suggested to be appropriate indications for DC laparotomy [30]. These may include a major abdominal vascular injury and multiple associated hollow organ injuries or an injured pancreaticoduodenal complex [19, 32].

The study findings should be considered in the context of its strengths and limitations. First, the opinions of trauma program directors could be argued to be only estimates of the frequency of use of DC laparotomy. Surveys are a practical strategy to capture practice variation across hundreds of level-1, -2, and -3 trauma centers in the United States, Canada, and Australasia. However, because of the limitations of using cross-sectional survey data, they should be confirmed by future observational studies. Second, although we used several techniques shown to increase response rates to surveys (and the response rate is above what has been reported by many surveys reported in the trauma or surgery literature), it is possible that respondents’ answers on the reported frequency of use of DC laparotomy differ systematically from those who did not respond to the survey [27]. Third, as the data used in this study are now over 5-years old, it is unclear whether our findings reflect current practice. However, based on evidence that adoption of new evidence-informed practices is slow in medicine (typically quoted to be 18 years), and evolving literature suggesting that deadoption of practices is likely even slower [33, 34], there may have been little change in use of DC laparotomy. This highlights the importance of conducting follow-up studies like ours to track practice patterns and ensure that practice is evidence-informed.

This study has important implications for future research, trauma surgery practice, and quality improvement efforts. First, a systematic review of 36 cohort studies found very little evidence to support that use of DC instead of definitive laparotomy in trauma patients was associated with an improvement in mortality or other patient-important outcomes [5]. However, use of the procedure is associated with an increased risk of morbidity, a longer length of intensive care unit and hospital stay, and possibly a reduced quality of life among survivors and an increase in healthcare utilization [7, 11,12,13, 35,36,37]. As equipoise now exists among some surgeons about the effectiveness of DC for improving mortality in many patients undergoing urgent laparotomy, there is a need for rigorously-designed randomized trials comparing it to definitive trauma laparotomy [38]. Second, although DC laparotomy is supported by insufficient evidence, nearly half of high-volume, level-1 trauma centers reported using it at least once weekly. One other study reported utilization rates exceeding 80% in some level-1 trauma centers (with most level-1 centers using it among 30% of those undergoing urgent laparotomy) [17]. Some authors have suggested that more comprehensive indications guiding patient selection for use of DC laparotomy may decrease its associated morbidity and costs [17]. However, our group previously compiled a comprehensive list of indications for the procedure that both experts and practicing trauma surgeons consistently agree appropriately indicate its use [7, 31, 32]. Further, a cohort study suggested that these comprehensive indications that highly predicted use of DC laparotomy in practice had an incidence of 2% or less [30]. Collectively, the above may indicate that DC laparotomy is presently overused in trauma centers. Reasons for this are largely unknown, but may include surgeons’ training, differences in patient mix between institutions, and/or institutional characteristics or culture [19, 29]. However, efforts to decrease use of DC laparotomy across trauma centers may be necessary until further evidence becomes available. The centers that may need to be targeted first include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries. Indeed, some data suggests that utilization rates of DC laparotomy can be safely reduced through quality improvement efforts such as audit-and-feedback without adversely influencing patient outcomes [14, 39, 40].

Conclusions

In this large, international, cross-sectional survey of trauma program directors or leaders, the reported frequency of use of DC laparotomy was highly variable across level-1, -2, and -3 trauma centers. The reported frequency of use of DC laparotomy also varied significantly across level-1 trauma centers, especially between those that were high- versus lower volume. The procedure was used most often in level-1 trauma centers in the United States that assessed a large percentage of patients with penetrating injuries. Nearly half of high-volume, level-1 trauma centers reported using DC laparotomy at least once a week. Those trauma centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage patients with penetrating injuries.

Availability of data and materials

Study data are available upon request from the principal author (D.J.R.).

Abbreviations

CI:

Confidence interval

DC:

Damage control

IQR:

Interquartile range

ISS:

Injury severity scale

OR:

Odds ratio

PROPPR:

Pragmatic, randomized optimal platelet and plasma ratios

ROC:

Receiver operating characteristic

STROBE:

Strengthening of observational studies in epidemiology

References

  1. Roberts DJ, Ball CG, Feliciano DV, Moore EE, Ivatury RR, Lucas CE, et al. History of the innovation of damage control for management of trauma patients: 1902–2016. Ann Surg. 2017;265(5):1034–44. https://doi.org/10.1097/sla.0000000000001803.

    Article  PubMed  Google Scholar 

  2. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983;197(5):532–5.

    Article  CAS  Google Scholar 

  3. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, et al. “Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375–82 (discussion 82-3).

    Article  CAS  Google Scholar 

  4. Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin N Am. 1997;77(4):761–77.

    Article  CAS  Google Scholar 

  5. Roberts DJ, Bobrovitz N, Zygun DA, Kirkpatrick AW, Ball CG, Faris PD, et al. Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review. World J Emerg Surg. 2021;16(1):10. https://doi.org/10.1186/s13017-021-00352-5.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Cirocchi R, Montedori A, Farinella E, Bonacini I, Tagliabue L, Abraha I. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2013;3:CD007438. https://doi.org/10.1002/14651858.CD007438.pub3.

    Article  Google Scholar 

  7. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, et al. Indications for use of damage control surgery and damage control interventions in civilian trauma patients: a scoping review. J Trauma Acute Care Surg. 2015;78(6):1187–96.

    Article  Google Scholar 

  8. Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF. Damage control: collective review. J Trauma. 2000;49(5):969–78.

    Article  CAS  Google Scholar 

  9. Chovanes J, Cannon JW, Nunez TC. The evolution of damage control surgery. Surg Clin N Am. 2012;92(4):859–75. https://doi.org/10.1016/j.suc.2012.04.002.

    Article  PubMed  Google Scholar 

  10. Brenner M, Bochicchio G, Bochicchio K, Ilahi O, Rodriguez E, Henry S, et al. Long-term impact of damage control laparotomy: a prospective study. Arch Surg. 2011;146(4):395–9. https://doi.org/10.1001/archsurg.2010.284.

    Article  PubMed  Google Scholar 

  11. Miller RS, Morris JA Jr, Diaz JJ Jr, Herring MB, May AK. Complications after 344 damage-control open celiotomies. J Trauma. 2005;59(6):1365–71 (discussion 71–4).

    Article  Google Scholar 

  12. Dubose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, Inaba K, et al. Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg. 2013;74(1):113–20. https://doi.org/10.1097/TA.0b013e31827891ce (discussion 1120–2).

    Article  PubMed  Google Scholar 

  13. Montalvo JA, Acosta JA, Rodriguez P, Alejandro K, Sarraga A. Surgical complications and causes of death in trauma patients that require temporary abdominal closure. Am Surg. 2005;71(3):219–24.

    Article  Google Scholar 

  14. Higa G, Friese R, O’Keeffe T, Wynne J, Bowlby P, Ziemba M, et al. Damage control laparotomy: a vital tool once overused. J Trauma. 2010;69(1):53–9. https://doi.org/10.1097/TA.0b013e3181e293b4.

    Article  PubMed  Google Scholar 

  15. Hatch QM, Osterhout LM, Podbielski J, Kozar RA, Wade CE, Holcomb JB, et al. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma. 2011;71(6):1503–11. https://doi.org/10.1097/TA.0b013e31823cd78d.

    Article  PubMed  Google Scholar 

  16. Martin MJ, Hatch Q, Cotton B, Holcomb J. The use of temporary abdominal closure in low-risk trauma patients: Helpful or harmful? J Trauma Acute Care Surg. 2012;72(3):601–6. https://doi.org/10.1097/TA.0b013e31824483b7 (discussion 6–8).

    Article  PubMed  Google Scholar 

  17. Watson JJ, Nielsen J, Hart K, Srikanth P, Yonge JD, Connelly CR, et al. Damage control laparotomy utilization rates are highly variable among level I trauma centers: pragmatic, randomized optimal platelet and plasma ratios findings. J Trauma Acute Care Surg. 2017;82(3):481–8. https://doi.org/10.1097/ta.0000000000001357.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Harvin JA, Wray CJ, Steward J, Lawless RA, McNutt MK, Love JD, et al. Control the damage: morbidity and mortality after emergent trauma laparotomy. Am J Surg. 2015. https://doi.org/10.1016/j.amjsurg.2015.10.014.

    Article  PubMed  Google Scholar 

  19. Roberts DJ, Zygun DA, Faris PD, Ball CG, Kirkpatrick AW, Stelfox HT. Opinions of practicing surgeons on the appropriateness of published indications for use of damage control surgery in trauma patients: an international cross-sectional survey. J Am Coll Surg. 2016;223(3):515–29. https://doi.org/10.1016/j.jamcollsurg.2016.06.002.

    Article  PubMed  Google Scholar 

  20. Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med. 1999;33(1):97–103.

    Article  CAS  Google Scholar 

  21. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9. https://doi.org/10.1016/j.jclinepi.2007.11.008.

    Article  Google Scholar 

  22. Surgeons ACo. Verified Trauma Centers. Chicago, IL, U.S.A.: American College of Surgeons; 2013 [cited 2013 August 29, 2013]; Available from: https://www.facs.org/search/trauma-centers?country=United%20States&distance=any.

  23. Information CIfH. National Trauma Registry Report 2013: Hospitalizations for Major Injury in Canada, 2010–2011 Data. Canadian Institutes for Health Information; 2013 [cited 2013 August 22, 2013]; Available from: https://secure.cihi.ca/free_products/NTR_Annual_Report_2013_EN.xls.

  24. Health A. Caring for the severely injured in Australia: inaugural report of the Australian trauma registry 2010 to 2012. Melbourne: Alfred Health; 2014.

    Google Scholar 

  25. Stelfox HT, Straus SE, Nathens A, Gruen RL, Hameed SM, Kirkpatrick A. Trauma center quality improvement programs in the United States, Canada, and Australasia. Ann Surg. 2012;256(1):163–9. https://doi.org/10.1097/SLA.0b013e318256c20b.

    Article  PubMed  Google Scholar 

  26. Burns KE, Duffett M, Kho ME, Meade MO, Adhikari NK, Sinuff T, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008;179(3):245–52. https://doi.org/10.1503/cmaj.080372.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Edwards PJ, Roberts I, Clarke MJ, Diguiseppi C, Wentz R, Kwan I, et al. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev. 2009;3:MR000008. https://doi.org/10.1002/14651858.MR000008.pub4.

    Article  Google Scholar 

  28. Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, et al. Relationship between trauma center volume and outcomes. JAMA. 2001;285(9):1164–71.

    Article  CAS  Google Scholar 

  29. Roberts DJ, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, James MT, et al. Challenges and potential solutions to the evaluation, monitoring, and regulation of surgical innovations. BMC Surg. 2019;19(1):119. https://doi.org/10.1186/s12893-019-0586-5.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Roberts DJ, Stelfox HT, Moore LJ, Cotton BA, Holcomb JB, Harvin JA. Accuracy of published indications for predicting use of damage control during laparotomy for trauma. J Surg Res. 2020;248:45–55.

    Article  Google Scholar 

  31. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, et al. Indications for use of damage control surgery in civilian trauma patients: a content analysis and expert appropriateness rating study. Ann Surg. 2016;263(5):1018–27. https://doi.org/10.1097/sla.0000000000001347.

    Article  PubMed  Google Scholar 

  32. Roberts DJ, Bobrovitz N, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, et al. Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: a content analysis and expert appropriateness rating study. J Trauma Acute Care Surg. 2015;79(4):568–79. https://doi.org/10.1097/ta.0000000000000821.

    Article  PubMed  Google Scholar 

  33. Niven DJ, Mrklas KJ, Holodinsky JK, Straus SE, Hemmelgarn BR, Jeffs LP, et al. Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med. 2015;13:255. https://doi.org/10.1186/s12916-015-0488-z.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Niven DJ, Rubenfeld GD, Kramer AA, Stelfox HT. Effect of published scientific evidence on glycemic control in adult intensive care units. JAMA Intern Med. 2015;175(5):801–9. https://doi.org/10.1001/jamainternmed.2015.0157.

    Article  PubMed  Google Scholar 

  35. Cheatham ML, Safcsak K, Llerena LE, Morrow CE Jr, Block EF. Long-term physical, mental, and functional consequences of abdominal decompression. J Trauma. 2004;56(2):237–41. https://doi.org/10.1097/01.ta.0000109858.55483.86 (discussion 41–2).

    Article  PubMed  Google Scholar 

  36. Cheatham ML, Safcsak K. Longterm impact of abdominal decompression: a prospective comparative analysis. J Am Coll Surg. 2008;207(4):573–9. https://doi.org/10.1016/j.jamcollsurg.2008.05.008.

    Article  PubMed  Google Scholar 

  37. Sutton E, Bochicchio GV, Bochicchio K, Rodriguez ED, Henry S, Joshi M, et al. Long term impact of damage control surgery: a preliminary prospective study. J Trauma. 2006;61(4):831–4. https://doi.org/10.1097/01.ta.0000239504.35149.c5 (discussion 5–6).

    Article  PubMed  Google Scholar 

  38. Harvin JA, Podbielski J, Vincent LE, Fox EE, Moore LJ, Cotton BA, et al. Damage control laparotomy trial: design, rationale and implementation of a randomized controlled trial. Trauma Surg Acute Care Open. 2017;2(1):e000083. https://doi.org/10.1136/tsaco-2017-000083.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Joseph B, Azim A, Zangbar B, Bauman Z, O’Keeffe T, Ibraheem K, et al. Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: analysis of 1,030 consecutive trauma laparotomies. J Trauma Acute Care Surg. 2017;82(2):328–33. https://doi.org/10.1097/ta.0000000000001273.

    Article  PubMed  Google Scholar 

  40. Harvin JA, Kao LS, Liang MK, Adams SD, McNutt MK, Love JD, et al. Decreasing the use of damage control laparotomy in trauma: a quality improvement project. J Am Coll Surg. 2017;225(2):200–9. https://doi.org/10.1016/j.jamcollsurg.2017.04.010.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

None.

Funding

This study was funded by an Alberta Innovates—Health Solutions Clinician Fellowship Award, a Knowledge Translation (KT) Canada Strategic Training in Health Research Fellowship, a KT Canada Student Research Stipend, and funding from the University of Calgary Clinician Investigator and Surgeon-Scientist Programs (all awarded to D.J.R.).

Author information

Authors and Affiliations

  1. Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Room A-280, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada

    Derek J. Roberts

  2. The Ottawa Hospital Trauma Program, The Ottawa Hospital, Ottawa, ON, Canada

    Derek J. Roberts

  3. School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada

    Derek J. Roberts

  4. Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada

    Derek J. Roberts

  5. The O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada

    Derek J. Roberts, Peter D. Faris, Chad G. Ball & Henry T. Stelfox

  6. Health Services Statistical and Analytic Methods, Data and Analytics (DIMR), Alberta Health Services, Foothills Medical Centre, Calgary, AB, Canada

    Peter D. Faris

  7. Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada

    Chad G. Ball & Andrew W. Kirkpatrick

  8. Department of Oncology, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada

    Chad G. Ball

  9. Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada

    Chad G. Ball & Andrew W. Kirkpatrick

  10. Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada

    Andrew W. Kirkpatrick & Henry T. Stelfox

  11. Department of Surgery, School of Medicine and the Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA

    Ernest E. Moore

  12. Department of Surgery and Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA

    David V. Feliciano

  13. Department of Surgery, Westchester Medical Center, Section of Trauma and Acute Care Surgery, New York Medical College, Valhalla, NY, USA

    Peter Rhee

  14. South Western Sydney Clinical School, UNSW, Sydney, NSW, Australia

    Scott D’Amours

  15. Acute Care Surgery Unit, Liverpool Hospital, Liverpool, NSW, Australia

    Scott D’Amours

  16. Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada

    Henry T. Stelfox

Authors
  1. Derek J. Roberts
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peter D. Faris
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Chad G. Ball
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andrew W. Kirkpatrick
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ernest E. Moore
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. David V. Feliciano
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Peter Rhee
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Scott D’Amours
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Henry T. Stelfox
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

DJR contributed to the study concept. All authors contributed to the study design. DJR obtained funding for the study, created the protocol, designed the survey instrument, administered the survey instrument and sent reminders, and drafted the manuscript. DJR also conducted the data analyses with input from PDF and HTS The manuscript was then critically revised after input from PDF, CGB, AWK, EEM, DVF, PR, SD, and HTS HTS contributed to study supervision. All authors read and approved the final manuscript..

Corresponding author

Correspondence to Derek J. Roberts.

Ethics declarations

Ethics approval and consent to participate

The University of Calgary Conjoint Health Research Ethics Board approved the study. Consent to participate in the study was implied with survey completion.

Consent for publication

Not applicable.

Competing interests

Dr. Kirkpatrick has consulted for Zoll, Innovative Trauma Care, CSL Behring, and SAM Medical Corporations, and is the principal investigator for a randomized controlled trial partially supported by Acelity Corporation. Dr. Moore receives research support from Haemonetics, Instrumentation Laboratory, Hemosonics, Diapharma, Humacyte, and Genetech. He is also the cofounder of ThromboTherapeutics. The other authors have no conflicts of interest to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1.

Location of the 156 participating American trauma centers.

Additional file 2.

Reported frequency of use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia (Australia and New Zealand).

Additional file 3.

Receiver operating characteristic curve for the multivariable logistic regression prediction model.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Roberts, D.J., Faris, P.D., Ball, C.G. et al. Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia. World J Emerg Surg 16, 53 (2021). https://doi.org/10.1186/s13017-021-00396-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13017-021-00396-7

Keywords

World Journal of Emergency Surgery

ISSN: 1749-7922