Choosing the surgical approach for repeat abdominal surgery: a decision-making algorithm

Introduction. MPostoperative intra-abdominal complications (POIACs) remain one of the most challenging problems in modern abdominal surgery, associated with high morbidity, significant mortality, and substantial socio-economic burden. To date, there are no systematized, clinically validated algorithms in the global literature for selecting the surgical approach in the management of POIACs. Existing recommendations are primarily descriptive, based on expert opinion, and do not provide quantitative decision-making criteria.

The purpose of this study To develop a clinical algorithm for selecting the surgical approach (laparoscopic or open) in reoperations for patients with postoperative intra-abdominal complications (POIACs).

Materials and methods. The study included 253 patients with POIACs requiring reintervention. Infectious complications (peritonitis) were diagnosed in 141 (55,7 %) patients, and non-infectious complications in 112 (44,3 %). An assessment was performed of demographic parameters, physical status (ASA), prognostic scores (SAPS II, SOFA, APACHE II), specialized peritonitis indices (Mannheim Peritonitis Index – MPI, Peritonitis Strategy Scale – PSS, WSES SSS scale), and laboratory markers (procalcitonin – PCT, C-reactive protein, lactate). Independent predictors for selecting an open approach and their threshold values were determined using logistic regression and ROC analysis.

Research results and discussion. Independent predictors for choosing laparotomy were age ≥60 years, ASA ≥IV, SAPS II ≥28 (AUC 0,820), SOFA ≥4 (AUC 0,781), APACHE II ≥17 (AUC 0,776). In patients with peritonitis, additional significant criteria were MPI ≥21 (AUC 0,813), PSS ≥4 (AUC 0.841), and WSES SSS ≥6 (AUC 0.833). The combined criterion "PCT ≥7 ng/mL and lactate ≥2 mmol/L" had 85 % specificity for predicting an open approach. In patients with non-infectious complications, a body mass index ≥30,6 kg/m² (AUC 0,747) was a significant predictor. Based on the obtained data, a three-level risk stratification algorithm ("green", "yellow", and "red" zones) was developed to guide intervention strategy. The use of a laparoscopic approach in accordance with the algorithm reduced 90-day mortality in infectious complications from 15,1 % to 1,1 % (p<0.001), shortened hospitalization duration by 17–29 %, and reduced ICU length of stay by 2–5 times. In 48.7% of cases with infectious complications and 63,5 % with non-infectious complications, laparoscopic management was successfully performed after primary laparotomy (a "minimally invasive step").

Conclusion. The proposed algorithm, based on the integration of objective prognostic criteria, allows for standardization of surgical approach selection in reoperations, minimization of subjectivity, and significant improvement in treatment outcomes for patients with POIACs.

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