Efficacy of Early Exploratory Laparotomy versus Non-Operative Management in Blunt Abdominal Trauma Patients with Unstable Haemodynamics: A Systematic Review of Randomized Controlled Trial and Primary Studies

Abstract

Introduction. Blunt abdominal trauma accompanied by haemodynamic instability remains one of the most lethal presentations in acute care surgery. For four decades the doctrine has been categorical: the patient who does not respond to resuscitation belongs in the operating theatre. Yet the parallel maturation of whole-body computed tomography, transcatheter angioembolisation, damage-control resuscitation and the hybrid emergency room has begun to erode the absoluteness of that rule, and contemporary registry data now describe substantial numbers of hypotensive patients being managed without an immediate laparotomy. This review was undertaken to quantify, across the primary literature, what is gained and what is lost when early exploratory laparotomy is compared with non-operative management in this specific physiological subgroup.

Methods. The study strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines. Eligible designs were randomised controlled trials, prospective and retrospective cohort studies, case-control studies, cross-sectional studies and other observational designs enrolling adults with blunt abdominal trauma in whom haemodynamic status was explicitly reported. Systematic reviews and meta-analyses were excluded from the characteristics table and from the quantitative synthesis but were retained for the discussion. Two reviewers independently screened records, extracted data and appraised risk of bias using Cochrane RoB 2 for the randomised trial and ROBINS-I for non-randomised studies. Certainty of evidence was rated with GRADE. Because of substantial clinical and methodological heterogeneity, findings were synthesised narratively and displayed graphically; no pooled random-effects estimate was computed for mortality.

Results. Twenty primary studies met all criteria. Mortality after emergent trauma laparotomy in the whole population was 21%, rising to 46% in patients hypotensive on arrival, and survival fell in a stepwise, statistically significant fashion with the depth of hypotension (64%, 50% and 34% twenty-four-hour survival for admission systolic pressures above 80 mmHg, 61–80 mmHg and 60 mmHg or below respectively; p = 0.04). Every minute of delay between emergency department arrival and operating-room entry increased the adjusted odds of haemorrhagic death by 1.8% (adjusted odds ratio 1.018, 95% confidence interval 1.007–1.030). Against this, three large registry analyses restricted to hypotensive patients with high-grade splenic injury found no survival penalty for an angioembolisation-first strategy (entropy-balanced hazard ratio 1.02, 95% confidence interval 0.97–1.07), while splenic salvage was almost three times more likely than after open surgery (adjusted relative risk 2.84, 95% confidence interval 2.29–3.51; p < 0.001). Non-operative management, when applied to appropriately selected patients, succeeded in 89.9–100% of cases. Admission serum lactate discriminated the need for operation with an area under the receiver-operating-characteristic curve of 0.815 (95% confidence interval 0.721–0.910; p < 0.0001), and a four-variable admission model reached 0.904 (optimism-corrected 0.882). A positive focused assessment with sonography for trauma identified the need for therapeutic laparotomy in hypotensive patients with a sensitivity of only 62–85%, so a negative scan cannot exclude a surgical bleed.

Discussion. The evidence does not support replacing early laparotomy with non-operative management in the non-responder. It does, however, support a physiologically stratified pathway in which the transient responder — a group historically consigned to immediate laparotomy — may be offered angioembolisation when a rapid contrast study can be obtained without meaningful delay and when the bleeding source is a single solid organ. The pivotal determinant of survival is not the choice of technique but the interval to definitive haemorrhage control, and the pivotal determinant of safety is the availability of an immediate surgical rescue pathway. All comparative data derive from non-randomised designs vulnerable to indication bias, since the sickest patients are preferentially operated upon; the single randomised trial addressed prophylactic embolisation in patients who were not haemodynamically unstable.

Conclusion. Early exploratory laparotomy remains the standard of care for the blunt abdominal trauma patient who does not respond to resuscitation, and delay to operation is independently and significantly lethal. Angioembolisation-supported non-operative management is a defensible alternative in transient responders with isolated solid-organ injury treated in institutions with round-the-clock interventional radiology, hybrid capability and immediate surgical backup, where it delivers equivalent survival with markedly superior organ preservation. A pragmatic randomised trial in the transient-responder subgroup is the principal outstanding research need.