Predictors of Failed Primary Abdominal Closure in the Trauma Patient with an Open Abdomen

Background: We sought to characterize risk factors for failed closure after damage-control laparotomy and to examine the impact of two broad categories of open abdomen-management technique on rates of fascial approximation. Methods: We retrospectively reviewed (January 2006-December 2008) all trauma patients with an open abdomen after damage-control laparotomy. Patients with definitive abdominal closure before discharge were classified as successful closure (SC) and those discharged with a planned ventral hernia were classified as failed closure (FC). Univariate stepwise logistical analyses were conducted to identify covariates related to resuscitation volumes and injury severity that were associated with FC. Surgical techniques were dichotomized as fascial based or vacuum based and compared with chi square. Results: Sixty-two subjects met final eligibility (SC 44, FC 18). SC and FC were similar, with the exception of, respectively, initial base excess (-8.0 +/- 4.2 vs -11.4 +/- 4.9; P = 0.009), injury severity score (ISS; 29.0 +/- 15.2 vs 20.6 +/- 12.1; P = 0.04), and frequency of penetrating injury (47.7% vs 77.8%; P = 0.03). Stepwise regression showed significant associations between failed closure and increasing Penetrating Abdominal Trauma Index (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.01-1.11), worsening base excess on arrival (OR 0.79, 95% CI 0.66-0.93), and lower ISS (OR 0.94, 95% CI 0.89-1.00). Fascial-based versus vacuum-based management techniques had no effect on closure rates. Conclusions: Volume of blood transfused, crystalloid given, and open abdomen management technique were not related to closure rates; however, worsened base excess on arrival, penetrating trauma, higher Penetrating Abdominal Trauma Index, and a lower ISS were associated with FC. The latter was true despite an association also being found between FC and lower ISS scores, reflecting the propensity of ISS to underestimate injury burden after penetrating injury.