Anaesthesia 2020, 75 (Suppl. 1), e75–e82 doi:10.1111/anae.

14821

Review Article

A review of surgical and peri-operative factors to consider

in emergency laparotomy care
H. Boyd-Carson,1 T. Gana,2 S. Lockwood,3 D. Murray4 and G. M. Tierney5

1 National Emergency Laparotomy Audit (NELA) Surgical Research Fellow, Department of Surgery, Division of Medical
Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
2 Surgical Registrar, Bradford Royal Infirmary, Yorkshire and Humber Deanery, Leeds, UK
3 Consultant Surgeon and NELA Surgical Lead, Bradford Royal Infirmary, Bradford, UK
4 Consultant Anaesthetist and NELA Chair, James Cook University Hospital, Middlesbrough, UK
5 Consultant Surgeon and Association of Surgeons of Great Britain and Ireland (ASGBI) Director of Emergency Surgery,
Royal Derby Hospital, Derby, UK

Summary
Patients undergoing emergency laparotomy are a heterogeneous group with regard to comorbidity, pre-
operative physiological state and surgical pathology. There are many factors to consider in the peri-operative
period for these patients. Surgical duration should be as short as possible for adequate completion of the
procedure. This is of particular importance in the elderly and comorbid population. To date, there are limited
data addressing the role of damage control surgery in emergency general surgery. Dual consultant-led care in
all stages of emergency laparotomy care is increasing, with increased presence out of hours and also for high-
risk patients. The role of the stoma care team should be actively encouraged in all patients who may require a
stoma. Due to the emergent and unpredictable nature of surgical emergencies, healthcare teams may need to
employ novel strategies to ensure early input from the stoma care team. It is important for all members of the
medical teams to ensure that patients have given consent for both anaesthesia and surgery before emergency
laparotomy. Small studies suggest that patients and their families are not aware of the high risk of morbidity and
mortality following emergency laparotomy before operative intervention. Elderly patients should have early
involvement from geriatric specialists and careful attention paid to assessment of frailty due to its association
with mortality and morbidity. Additionally, the use of enhanced recovery programmes in emergency general
surgery has been shown to have some impact in reducing length of stay in emergency surgical patients.
However, the emergent nature of this surgery has been shown to be a detrimental factor in full implementation
of enhanced recovery programmes. The use of a national database to collect data on patients undergoing
emergency laparotomy and their processes of care has led to reduced mortality and length of stay in the UK.
However, internationally, fewer data are available to draw conclusions.

.................................................................................................................................................................
Correspondence to: H. Boyd-Carson
Email: hannah.boyd-carson@nhs.net
Accepted: 1 August 2019
Keywords: emergency laparotomy; peri-operative; multidisciplinary

Introduction demonstrate that this group of patients is heterogeneous.

Approximately 30,000 patients have an emergency There is an increasing number of older patients, often
laparotomy in England and Wales every year [1–4]. Data comorbid or frail, and postoperative mortality rates remain
from the National Emergency Laparotomy Audit (NELA) high. Patients requiring emergency laparotomy are some of

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Anaesthesia 2020, 75 (Suppl. 1), e75–e82 Boyd-Carson et al. | Peri-operative factors for emergency laparotomy care
the sickest in the hospital and around 50% are deemed to
require surgical intervention within 6 h from the time of
admission [4]. Although urgent access to surgery is a
priority, there is often a window of opportunity to improve
a patient’s condition which can lead to improved
postoperative outcomes [5].
A recent comprehensive review highlighted strategies
for pre- and peri-operative optimisation of patients having
emergency laparotomy [6]. Suggestions included: timely
antibiotics; appropriate fluid and electrolyte replacement;
medication management; addressing nutrition early; and
glycaemic control if diabetic. This review also highlighted
the benefits of streamlining admission and diagnostic care
pathways, with early identification of high-risk patients and
consultant-led care [6]. This approach is echoed by the
Emergency Laparotomy Collaborative bundle who
reported a reduction in the risk of death in patients
undergoing emergency laparotomy after bundle
implementation [7]. This review aims to discuss additional
peri-operative factors that are important for all members of
the emergency team providing care for these patients.
Duration of operation
With increase in operative time, patients are exposed to
numerous factors which adversely affect outcomes:
hypothermia; periods of hypotension and organ
hypoperfusion, with subsequent fluid and electrolyte
imbalance; prolonged tissue handling; and increased
blood loss [8–12].
It has been demonstrated that surgical duration
greater than 130 min is independently associated with
postoperative morbidity [13, 14]. There is an association
between increasing operative duration and postoperative
surgical site infections [15]. These findings are supported by
a recent systematic review and meta-analysis that revealed a
robust association between prolonged operation time and
postoperative complications across all surgical specialities
but, most significantly, within the general surgical sub-
group [16].
Although the impact of operative duration on
postoperative morbidity has been extensively examined,
the association with mortality is less clear. A cohort study
from Spain demonstrated an association between
increasing ASA physical status and 30-day postoperative
mortality in patients who had prolonged operation times
[17]. Patients from all surgical specialities were included but,
notably, those undergoing emergency surgery were not
included. Furthermore, in those > 80 y, increased odds of
death of 17% were reported for every 30 min increase in
operative time [18]. In this paper, the authors had controlled
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for urgency of the operation, ASA physical status and the
presence of pre-operative hypertension. Although not
directly applicable to the emergency laparotomy
population, these results do highlight that the elderly and
those patients with more comorbidity pre-operatively are
the most likely to be affected by prolonged surgical times.
National Emergency Laparotomy Audit data demonstrate
that the emergency laparotomy population in England and
Wales are older and have increased comorbidity [1–4],
therefore, it is not unreasonable to suggest they would
benefit from reducing the surgical duration and having
more experienced clinical input.
Utilising published evidence regarding trauma surgery
[19] to minimise the duration of surgery in the acutely unwell
patient having emergency laparotomy has led to the
development of the concept of ‘damage control surgery’ in
the general surgical non-traumatic population. This involves
an abbreviated source control laparotomy, followed by
admission to the ICU for physiological correction, then a
delayed but planned return to theatre for definitive surgical
management [20–22]. The aim of damage control surgery is
to prevent the triad of acidosis, hypothermia and
coagulopathy [23]. A systematic review in 2014 addressed
the concept of damage control surgery in emergency
general surgery [23]. It noted that the literature regarding
this topic consists largely of retrospective case series with
clear discrepancies in definitions of what comprises
damage control surgery, and limited details on the
physiological state of the patients. Despite this, the authors
suggested that damage control surgery principles may be
applicable when treating patients with intra-abdominal
bleeding [23]. However, in the remaining emergency
laparotomy patient cohort, a damage control surgery
approach may not be appropriate. The review highlighted
that correct patient selection is vital and that damage
control surgery, if overused, could lead to additional
morbidity and mortality due to multiple operations, open
abdomen management and prolonged ICU stay [23, 24].
There are no randomised, controlled trials regarding the
use of damage control surgery in the non-traumatic
emergency laparotomy population. However, the
importance of source control either surgically or
radiologically is well established.
Specialist input
A key quality standard of care measured within NELA is
whether a consultant surgeon and anaesthetist are present
in the theatre for patients having emergency laparotomy
who have a predicted postoperative mortality of 5% or
higher [1–4]. Over the last 4 years of the audit, there has
© 2020 Association of Anaesthetists
Boyd-Carson et al. | Peri-operative factors for emergency laparotomy care
been an increase in both consultants’ presence in theatre;
from 75% in the first year of audit, to 83% in the fourth year
[1, 4]. Consultant surgeons, specifically, were present for
92% of all cases in the most recent audit, whereas
anaesthetic consultants were present in 88% of all cases.
Ninety-five percent of patients had input from a consultant
surgeon and 86% from a consultant anaesthetist before
surgery. However, intensive care input in the pre-operative
period is still lacking; only 15% of the high-risk patients
received a documented review before operative
intervention [4]. There is no literature internationally
regarding the roles and presence of consultants in patients
requiring an emergency laparotomy.
Role of the stoma care team
Defunctioning stoma via midline laparotomy and
procedures that could lead to the formation of either
colostomy or ileostomy are frequently performed during
emergency laparotomy [1–4]. The role of the stoma care
team is two-fold: assessment and marking of the location of
the proposed stoma; and education and counselling of the
patient and family [25]. Complications associated with
stoma formation include necrosis, stenosis, retraction
prolapse, parastomal infection or hernia, skin problems,
bleeding or fistulation [26]. The positive role of the stoma
care team is well documented in the elective setting. Large
case series have suggested that therapist input can prevent
early complications when compared with those who
received no input pre-operatively [25, 27]. Institutes that
describe introducing dedicated formal pre-operative stoma
care education sessions report significantly lower
peristomal complications [28]. This is also well known to
have a positive impact on a patient’s quality of life after
stoma formation [29–31].
Emergency laparotomies take place 24 h a day.
Patients are much less likely to have involvement from the
stoma care team if they have their stoma as part of an
emergency operation [27, 32]. Not surprisingly,
nationwide cohort study highlighted that patients who have
their stoma formed in the emergency setting are more likely
to develop stoma-related complications [33]. This is likely to
be due to both patient and surgical factors. Clearly there is a
benefit from involvement of the stoma care team for these
patients and novel strategies may be required to overcome
logistical barriers in patients undergoing emergency
laparotomy.
Consent
Following the recent UK Supreme Court ruling in
Montgomery vs. Lancashire Health Board [34], the ‘Bolam
© 2020 Association of Anaesthetists
Anaesthesia 2020, 75 (Suppl. 1), e75–e82
Test’, which judges a doctor’s action against a reasonable
body of medical opinion, is no longer applicable to issues
surrounding consent [35]. Therefore, a doctor taking any
form of consent must ensure that they take “reasonable care
to ensure that the patient is aware of any material risks
involved in any recommended treatment and of any
reasonable alternative or variant treatments”. A material risk
is further defined “as a risk to which a reasonable person in
the patient’s position would be likely to attach significance
or a risk that a doctor knows – or should reasonably know –
would probably be deemed of significance by this particular
patient” [35]. Obtaining informed consent is more than
having a patient sign a consent form, and should ensure the
patient has an understanding of the risks, benefits and
alternatives of the procedure in the context of their own life
and limitations. Using these definitions, it is clear that the
increased risk of death, social support postoperatively and
the need for re-operation or stoma formation are some of
the issues that need to be discussed during consent for
emergency laparotomy. In the majority of cases, a hand-
written consent form comprises the only written information
and evidence of this process [36] and, therefore, it is
imperative that discussions and risks are also clearly
documented in the medical notes. The use of the NELA risk
score [37] should be used when discussing operative
intervention. This is a validated risk tool formulated using
the emergency laparotomy patient cohort in this country
[37]. Documentation of discussion of this with patient and
family should be in the consent form and clinical notes
whenever possible.
A single-centre review of consent forms for emergency
laparotomy found that only 21% had death included as a
documented risk [38]. The study did not give a summary of
what grade of surgeon had completed the consent forms;
however, they did comment that the majority of forms were
completed by speciality registrars (or equivalent) or
consultants. Additionally this retrospective study was
a completed before the implementation of NELA; currently,
75% of patients have their risk assessed and documented
pre-operatively [4]. No further results regarding consent for
emergency procedures by either surgeons or anaesthetists
are available within the published literature. Of those doctors
regularly taking consent, including both consultants and
trainees, 45% were not familiar with concept of material risk
[39]. In addition, previous studies have demonstrated that it
is usually junior doctors who are responsible for obtaining
consent before surgical procedures [40, 41]. We suggest that
it is the responsibility of the most senior operating surgeon
to ensure a patient has given appropriate informed consent
and that it is fully documented.
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Anaesthesia 2020, 75 (Suppl. 1), e75–e82 Boyd-Carson et al. | Peri-operative factors for emergency laparotomy care
Elderly
Nearly 50% of patients undergoing emergency laparotomy
are aged > 70 y [4]. It is well recognised that this group of
patients has a higher postoperative mortality [1–4] and are
more likely to have comorbidity, be on polypharmacy and
be frail. There are, therefore, several things to consider in
the peri-operative period. In particular, the role of the
multidisciplinary team in the assessment and implications of
frailty, assessment of capacity and the decision making
process around high-risk emergency surgery is important.
High-level evidence from elective surgery demonstrates
that a multidisciplinary approach to assessment and care of
older patients improves postoperative outcomes [42–44].
A similar approach has been adopted with improved
outcomes for patients presenting with neck of femur
fractures [45, 46]. Despite this strong evidence base,
comprehensive geriatric assessment and input is still
lacking in the emergency laparotomy population. In the
most recent NELA report, 23% of those aged > 70 were
assessed by a geriatrician postoperatively [4]. Only a small
number of individual hospitals have developed and
published strategies and pathways specifically for the
elderly population having emergency general surgery [47].
To date, these observational studies have included small
numbers of patients with no risk adjustment for other
contributory factors known to affect mortality. Input from
geriatricians appears prone to influence by local
organisational factors [48] and workforce. A randomised,
controlled trial is planned to investigate the role of a pre-
operative rehabilitation bundle in the elderly having
abdominal surgery [49] but, again, this is targeted in the
elective non-emergency setting. However, it is not
unreasonable to suggest that multidisciplinary involvement
in the care of older people having emergency laparotomy
should be balanced against avoiding delay.
Frailty, particularly, is emerging as a significant factor
affecting outcomes. It should be noted that not all frail
patients are old and, therefore, frailty should be deemed as
a risk factor independent of age. Frailty is thought to be
present in 10–20% for all those aged > 65 [50, 51] and rises
to 40% in patients aged > 80 [50]. Frailty has become of
increasing interest as a formal assessment can add
additional prognostic insight, previously solely provided by
organ-based risk scoring systems [52]. Frailty has been
defined in numerous ways, as a combination of age-related
progressive decline in multiple physiological reserves that
can result in reduced resilience, loss of capacity and
increased vulnerability to external stressors [53]. There
are currently multiple assessment tools available.
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Understandably, frailty is associated with postoperative
complications, prolonged hospital stay, increased re-
admission rates and short- and long-term mortality [54–57].
International guidelines have suggested that assessment of
frailty is critical in the pre-operative setting [58]. Within the
UK, a large multicentre observational study looking at the
correlation between the Rockwood scoring scale and
mortality, specifically in the elderly emergency laparotomy
cohort, demonstrated that a fifth of these patients are frail
and 90-day mortality was independently associated with
this finding [59].
From a surgical and anaesthetic perspective, the
importance of frailty and its assessment provides an
opportunity for open and honest discussion with patients
and families. Although it may not be possible to have a
lengthy discussion, this knowledge can, at least, allow
informed consent. Additionally, if we can identify earlier
those patients who are frail then they can benefit from the
input of geriatricians and a multidisciplinary team in the
postoperative period.
Patient selection
The NELA collects data on patients who have undergone
emergency laparotomy and hence does not have a clear
picture of patients who have not undergone emergency
laparotomy, those who are ‘turned down’ for an operation
due to comorbidity or because they are unlikely to benefit
from surgery. It is difficult to decide not to operate on any
patient, but particular in an emergency situation when
timing is key. Careful consideration needs to be taken in
assessing the patient’s pre-morbid status, past medical
history and, most importantly, their wishes. We currently do
not have a good understanding of the discharge destination
of these patients and the level of dependence with which
they are left. The American College of Surgeons National
Surgical Quality Improvement Program Database has been
used to identify what factors are the most strongly
associated with 30-day mortality [60]. Using multivariant
model formulation, it suggests that white blood cell count
< 4500/mm3 or > 20,000/mm3; septic shock; ASA status 4
at the time of surgery; 70 years or older; and a dependent
functional status were the strongest predicators. They also
report, unsurprisingly, that, in those > 90 y with an ASA
status 5, with the above factors, probability of death was
> 90% [60]. It suggests that mesenteric vascular
insufficiency, pancreatitis and neoplasm were associated
with a higher risk of mortality compared with gastro-
intestinal perforation. Although it is important to take these
factors into account when assessing a patient, we would not
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advocate basing clinical decisions wholly on risk scoring
scales regardless that these have been formulated using the
emergency laparotomy population exclusively. To date, we
have no strong information around those who did not have
emergency laparotomy. Examining this cohort, patients
who did not undergo laparotomy could provide further
information and insight into the predictive factors that may
contribute to mortality and aid decision making in the
emergency setting. A major UK study of this patient group is
planned (Moug S, personal communication. 2019).
Enhanced recovery programmes
Enhanced recovery after surgery (ERAS) is a multifaceted
approach to the pre-, intra- and postoperative
management of patients undergoing surgery, aimed at
reducing stress and returning patients to
physiological baseline (Table 1) [61]. It is well established
in elective surgery and has been proven to be effective in
reducing postoperative complications, length of hospital
stay and costs [62–64]. Emergency surgery is a significant
component of gastro-intestinal surgery and its subset of
patients should also be able to benefit from the positive
outcomes of ERAS. This patient group is exposed to more
physiological stressors, including prolonged
hypoxia, tissue damage, haemorrhage, hypothermia, pain,
than those in the elective setting. It is reasonable to
question if ERAS is feasible in the emergency setting,
however, there are few well-designed studies on this
subject. Retrospective cohort studies [65–69]
compared outcomes between patients receiving
modified ERAS protocol and those receiving traditional
postoperative care after emergency general surgery.
Some of the outcomes highlighted in the ERAS groups
include a reduction in length of hospital stay, time to
return of gastro-intestinal function and postoperative
complications, without increased risk of re-admission, re-
operation or mortality within 30 days. In most of the
studies it is worth noting that complex and severe
underlying conditions like bowel perforation, unresectable
and recurrent colonic cancers were excluded. A
prospective cohort study compared clinical outcomes
between emergency and elective colonic resections in
patients on an ERAS protocol [70]. Although emergency
operations were associated with a significantly longer
length of stay, there was no difference in postoperative
complications or re-admissions within 30 days between
groups. This suggests that ERAS can safely be applied in
the emergency setting. Emergency surgery is time
sensitive and components such as pre-operative
counselling and stoma education are unlikely to be as
their detailed, as previously mentioned. In those who do
receive counselling, it is unclear what they understand or
retain. Similarly, in bowel obstruction or perforation, pre-
operative fasting is unavoidable and carbohydrate loading
is not an option, but peri-operative carbohydrate/glucose
preservation should be optimised in both diabetic and
non-diabetic patients [71]. Epidural or spinal anaesthetic
options may also not be possible in patients who are
fasting, unstable, anticoagulated or have sepsis. The literature
suggests that, even in patients, where not all aspects of
ERAS were applied, some essential principles of ERAS
confer some of the benefits demonstrated in the elective
setting, without a significant difference in mortality and re-
have admission rate. There is certainly a need for more well-
a designed studies.
Emergency laparotomy care
internationally
The UK-based NELA is the first prospectively maintained
database solely focused on patients that have undergone

Table 1 Components of enhanced recovery after surgery (ERAS) [63].

Pre-operative Intra-operative Postoperative
Pre-admission counselling Short-acting anaesthetic agents Mid-thoracic epidural analgesia
Fluid and carbohydrate loading Mid-thoracic epidural No nasogastric tubes
No prolonged fasting No drains Prevention of nausea and vomiting
None/selective bowel preparation Avoidance of salt and water overload Avoidance of salt and water overload
Antibiotics prophylaxis Maintenance of normothermia Early removal of catheter
Thromboprophylaxis Early oral nutrition
No premedication Non-opioid oral analgesia/NSAIDs
Early mobilisation
Stimulation of gut motility
Audit of compliance and outcomes
NSAID, non-steroidal anti-inflammatory drug.

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Anaesthesia 2020, 75 (Suppl. 1), e75–e82 Boyd-Carson et al. | Peri-operative factors for emergency laparotomy care
emergency laparotomies. Since its introduction in 2013,
there have been reductions in both mortality and length of
stay [1–4]. These improvements followed the introduction
and promotion of the nine key standards of care which are
now seen as basic requirements for patients who require an
emergency laparotomy within hospitals in the UK. In the
USA, although no emergency laparotomy-specific database
exists, the National Surgical Quality Improvement Program
database is a nationally-validated risk-adjusted, outcomes-
based program to measure and improve quality of surgical
care [72]. Many studies have used these data to report on
emergency laparotomy outcomes and it has been found
that 30-day mortality was 14%, with higher mortality rates in
the elderly and those with pre-existing medical conditions
[60]. A similar national registry database study from
Denmark reported 30-day mortality of 18%, again with
higher mortality in comorbid patients [73]. Although these
studies give us information on the patients and outcomes,
we do not have a clear picture of what care pathways these
patients are receiving internationally. Currently, the Royal
Australasian College of Surgeons and the Australia and
New Zealand College of Anaesthetists are in the process of
running a 60-hospital pilot of an emergency laparotomy
audit. Internationally, it is evident that while we have clear
facts regarding the incidence of emergency laparotomy and
the outcome figures, less is known about the care processes
these patients encounter. Perhaps more countries should
adopt the NELA approach to data collection to facilitate
both quality assurance and improvement?
Acknowledgements
No external funding or competing interest declared.
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