Supplement 22:
Should We Use Decompressive Laparotomy for IAH or ACS?
Decompressive laparotomy historically constituted the standard method to treat severe
IAH/ACS and to prophylaxis against their development in high risk situations (e.g., following
damage control laparotomy for significant intra-peritoneal injury) [[1, 2]]. It frequently has
significant physiologic effects among those with ACS, with immediate decreases in IAP and
frequent improvements in organ function previously being noted [[3, 4]]. However,
decompressive laparotomy is associated with multiple complications and overall reported patient
mortality is considerable (up to 50%) even after decompression [[4]].
Evidence Summary
We found no systematic reviews or RCTs comparing decompressive laparotomy to
strategies not using decompressive laparotomy in critically ill adults. The best available data is
therefore derived from before-and-after case series [[3, 5-19]]. Although most of these studies
were retrospective, in three data were collected prospectively [[10, 14, 17]]. The IAP at which
decompressive laparotomy was performed in these studies ranged from a mean of 21 and 49
mmHg among adults, with lower levels being used in pediatric patients. In most studies IAP
decreased significantly after decompressive laparotomy, especially when baseline IAP was
higher. Other reported beneficial effects on organ function included decreased vasopressor
requirements [[6]], increased PaO2/FIO2 ratio and oxygenation indices [[6]], decreased lactate
levels [[6]] and Sequential Organ Failure Assessment (SOFA) scores [[3]], and increased static
compliance [[20]].
Recommendation
The WSACS RECOMMENDS the use of decompressive laparotomy to reduce IAP
in cases of overt ACS compared to strategies that do not use decompressive laparotomy in
critically ill adults with ACS in critical care units (Management Recommendation 5;
GRADE 1D).
Rationale:
These studies were limited by risk of bias and inconsistency in the effect of
decompressive laparotomy on IAP. Moreover, no study was able to examine the effect of
decompressive laparotomy on patient-important outcomes such as mortality. While the overall
quality of evidence describing the effect of decompressive laparotomy on outcomes was very
low (D), decompressive laparotomy is frequently associated with a profound reversal of
abnormal patient physiology.
A Summary of Studies Table is available online at
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