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Sharrock AE, Barker T, Yuen HM, Rickard R, Tai N. Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis. Injury 2016; 47:296-306. [PMID: 26462958 DOI: 10.1016/j.injury.2015.09.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/11/2015] [Accepted: 09/12/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Damage control laparotomy for trauma (DCL) entails immediate control of haemorrhage and contamination, temporary abdominal closure (TAC), a period of physiological stabilisation, then definitive repair of injuries. Although immediate primary fascial closure is desired, fascial retraction and visceral oedema may dictate an alternate approach. Our objectives were to systematically identify and compare methods for restoration of fascial continuity when primary closure is not possible following DCL for trauma, to simplify these into a standardised map, and describe the ideal measures of process and outcome for future studies. METHODS Cochrane, OVID (Medline, AMED, Embase, HMIC) and PubMed databases were accessed using terms: (traum*, damage control, abbreviated laparotomy, component separation, fascial traction, mesh closure, planned ventral hernia (PVH), and topical negative pressure (TNP)). Randomised Controlled Trials, Case Series and Cohort Studies reporting TAC and early definitive closure methods in trauma patients undergoing DCL were included. Outcomes were mortality, days to fascial closure, hospital length of stay, abdominal complications and delayed ventral herniation. RESULTS 26 studies described and compared early definitive closure methods; delayed primary closure (DPC), component separation (CS) and mesh repair (MR), among patients with an open abdomen after DCL for trauma. A three phase map was developed to describe the temporal and sequential attributes of each technique. Significant heterogeneity in nomenclature, terminology, and reporting of outcomes was identified. Estimates for abdominal complications in DPC, MR and CS groups were 17%, 41% and 17% respectively, while estimates for mortality in DPC and MR groups were 6% and 0.5% (data heterogeneity and requirement of fixed and random effects models prevented significance assessment). Estimates for abdominal closure in the MR and DPC groups differed; 6.30 (95% CI=5.10-7.51), and 15.90 (95% CI=9.22-22.58) days respectively. Reporting poverty prevented subgroup estimate generation for ventral hernia and hospital length of stay. CONCLUSION Component separation or mesh repair may be valid alternatives to delayed primary closure following a trauma DCL. Comparisons were hampered by the lack of uniform reporting and bias. We propose a new system of standardised nomenclature and reporting for further investigation and management of the post-DCL open abdomen.
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Affiliation(s)
- A E Sharrock
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - T Barker
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - H M Yuen
- Department of Primary Care and Population Sciences, South Academic Block, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD
| | - R Rickard
- Department of Primary Care and Population Sciences, South Academic Block, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD
| | - N Tai
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Sharrock AE, Gokani VJ, Harries RL, Pearce L, Smith SR, Ali O, Chu H, Dubois A, Ferguson H, Humm G, Marsden M, Nepogodiev D, Venn M, Singh S, Swain C, Kirkby-Bott J. Defining our destiny: trainee working group consensus statement on the future of emergency surgery training in the United Kingdom. World J Emerg Surg 2015; 10:26. [PMID: 26161133 PMCID: PMC4496942 DOI: 10.1186/s13017-015-0019-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/22/2015] [Indexed: 11/16/2022] Open
Abstract
The United Kingdom National Health Service treats both elective and emergency patients and seeks to provide high quality care, free at the point of delivery. Equal numbers of emergency and elective general surgical procedures are performed, yet surgical training prioritisation and organisation of NHS institutions is predicated upon elective care. The increasing ratio of emergency general surgery consultant posts compared to traditional sub-specialities has yet to be addressed. How should the capability gap be bridged to equip motivated, skilled surgeons of the future to deliver a high standard of emergency surgical care? The aim was to address both training requirements for the acquisition of necessary emergency general surgery skills, and the formation of job plans for trainee and consultant posts to meet the current and future requirements of the NHS. Twenty nine trainees and a consultant emergency general surgeon convened as a Working Group at The Association of Surgeons in Training Conference, 2015, to generate a united consensus statement to the training requirement and delivery of emergency general surgery provision by future general surgeons. Unscheduled general surgical care provision, emergency general surgery, trauma competence, training to meet NHS requirements, consultant job planning and future training challenges arose as key themes. Recommendations have been made from these themes in light of published evidence. Careful workforce planning, education, training and fellowship opportunities will provide well-trained enthusiastic individuals to meet public and societal need.
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Affiliation(s)
- A E Sharrock
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK ; Department of Emergency Surgery, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD UK
| | - V J Gokani
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - R L Harries
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - L Pearce
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - S R Smith
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - O Ali
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - H Chu
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - A Dubois
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - H Ferguson
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - G Humm
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - M Marsden
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - D Nepogodiev
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - M Venn
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - S Singh
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - C Swain
- Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 - 43 Lincoln's Inn Fields, London, WC2A 3P3 UK
| | - J Kirkby-Bott
- Department of Emergency Surgery, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD UK
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Sharrock AE, Midwinter M. Damage control - trauma care in the first hour and beyond: a clinical review of relevant developments in the field of trauma care. Ann R Coll Surg Engl 2013; 95:177-83. [PMID: 23827287 DOI: 10.1308/003588413x13511609958253] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Trauma provision in the UK is a topic of interest. Regional trauma networks and centres are evolving and research is blossoming, but what bearing does all this have on the care that is delivered to the individual patient? This article aims to provide an overview of key research concepts in the field of trauma care, to guide the clinician in decision making in the management of major trauma. METHODS The Ovid MEDLINE(®), EMBASE™ and PubMed databases were used to search for relevant articles on haemorrhage control, damage control resuscitation and its exceptions, massive transfusion protocols, prevention and correction of coagulopathy, acidosis and hypothermia, and damage-control surgery. FINDINGS A wealth of research is available and a broad range has been reviewed to summarise significant developments in trauma care. Research has been categorised into disciplines and it is hoped that by considering each, a tailored management plan for the individual trauma patient will evolve, potentially improving patient outcome.
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Affiliation(s)
- A E Sharrock
- Vascular Surgery Department, Salisbury District Hospital, Odstock Road, Salisbury, Wiltshire, SP2 8BJ, UK.
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