Is Time of the Essence: A Retrospective Analysis of Operating Room Procedure Length for First Phase Damage Control Trauma Surgery

Abstract

Background:The concept of Damage Control Surgery (DCS) consists of a truncated surgical intervention with main focus on hemorrhage and contamination control. Traditionally,DCS involves limiting operating room (OR) time for patients with multiple life-threatening injuries and coagulopathy who are reaching physiologic exhaustion. However, in the modern era of hemostatic resuscitation, there is a paucity of evidence to support a survival benefit with shorter OR times. The objective of this study was to determine the practice habits of trauma surgeons in the modern era of DCS and to determine if operation length affects mortality in trauma patients with abdominal injuries. Methods:An 8-year retrospective review of consecutive adult patients with DCSfor penetrating abdominal trauma at a Level I trauma center was conducted. Patient demographics, injury severity score (ISS), and penetrating abdominal trauma index (PATI) scores were obtained. Average operating room times for initial DCS were determined. Patient outcomes were analyzed with a t-test for univariate analysis and a Cox proportional hazard ratio modeling was used to predict factors for survival.  Results:A total of 193 patients were included in the study.  The overall patient mortality was 14.0% (n=27/193). Median OR time was 157 minutes (range, 59-573 min). Patients were stratified into short OR group (SHORT, n=95) and long OR group (LORT, n=98) based on the median operative time. Only one patient had an initial DCL less than 60 minutes.  The SHORT group received more blood transfusions (52.6% vs. 35.7%, p=0.02) in the ICU. Average operative room time was almost twice as long in the LORT group (214.6+6.2 vs. 121.4+2.6 minutes, p<0.0001). The average hospital length of stay (22.8+2.3 vs. 31.0+3.5 days, p=0.05) and ICU length of stay (10.6+1.2 vs. 12.6+1.4 days, p=0.28) were both lower in the LORT group compared to the SHORT group. The SHORT group had 22 patients with unplanned return to the OR compared to 3 in the LORT group (p<0.0001). On multivariate analysis, OR time was not an independent risk factor for mortality (OR 1.0, 95% CI 0.98-1.0, p=0.48). Conclusions: Modern damage control practices should focus on early and effective surgical hemorrhage control in combination with effective intra-op hemostatic resuscitation efforts and not on how time limitations. These findings suggest that OR time restrictions in the era of effective hemostatic resuscitation in combination with DCS does not impact mortality.