The cost of damage control laparotomy: hernia incidence after laparotomy in the war-injured patient

Jillian Piaggione, BS¹, Amy Vertrees, MD². ¹Uniformed Services University of the Health Sciences, ²Walter Reed National Military Medical Center

Objectives: The hernia incidence after trauma laparotomy in the war-injured patient is not known. This study sought to determine the hernia incidence as well as factors that contributed to hernia occurrence.

Methods: Retrospective review of records for patients returning to Walter Reed Army Medical Center (WRAMC) from the conflicts in Iraq and Afghanistan from January 2003 through November 2009.

Results: From January 2003 through November 2009, 510 patients returned to WRAMC after undergoing laparotomy in the combat zone. Patients were mostly male (n=500, 98%) with average age 27+/-7 years. Mechanism of injury included secondary blast (n=325, 64%), gunshot (n=139, 27%), and blunt or crush (n=46, 9%) injuries. The overall incidence of hernia was 6% (n=33). Single laparotomy (n=273, 54%) resulted in hernia in 3% (n=9). Unanticipated laparotomy in those patients occurred in 6% (n=16), with hernia incidence of 6% (n=1). Patients returning to WRAMC after damage control laparotomy (DCL), but with their fascia closed (n=237, 46%) had a hernia incidence of 7% (n=9). Patients returning with persistent open abdomen (n=110, 46%) were either closed after admission (n=30, 27%), underwent serial abdominal closure with prosthetic mesh (n=66, 60%), failed fascial closure with planned ventral hernia (n=12, 11%), or died (n=2, 2%). Those who were closed after admission had a hernia incidence of 13% (n=4). Those who underwent serial abdominal closure had a hernia incidence of 17% (n=11). Hernia was diagnosed an average of 2 years after injury with an average follow up approaching 4 years.

Conclusion: Hernia incidence was increased after damage control laparotomy and after unexpected laparotomy. Follow up for hernia incidence after trauma should be at least 2 years.