Negative Trauma Laparotomy Patterns in GOAL-Trauma

Key Takeaways

• In this global trauma laparotomy cohort, 7.2% of operations were negative, meaning no intra-abdominal injury was identified at the index operation.
• Penetrating injury remained independently associated with higher odds of a negative trauma laparotomy after adjustment.
• Cases with a surgical registrar/resident as the recorded surgeon grade had higher adjusted odds of negative laparotomy than cases with a consultant/attending.
• Among patients who underwent negative laparotomy, 7.8% died in hospital within 30 days, 16.4% required postoperative organ support, and 9.7% of survivors with recorded ACDiT scores had severe complications.

Time-pressured evaluation of possible abdominal injury forces trauma teams to balance two competing risks: missing a life-threatening lesion and performing an exploration that proves unnecessary. A negative trauma laparotomy can resolve immediate diagnostic uncertainty, yet it still exposes patients to postoperative morbidity and critical care use even when no abdominal injury is found. Investigators therefore examined how often this scenario occurred across trauma systems and which patient and system factors accompanied it.

Investigators conducted a secondary analysis of the Global Outcomes After Laparotomy for Trauma (GOAL-Trauma) study, a prospective international multicentre observational cohort of 1769 trauma laparotomy patients at 187 centres in 51 countries from April to December 2024, reported in the GOAL-Trauma sub-analysis of negative trauma laparotomy patterns. Negative laparotomy was defined as no intra-abdominal injuries identified during the index operation, whereas non-therapeutic laparotomy referred to injuries found that did not require operative treatment. A directed acyclic graph (DAG)-informed multivariable logistic regression with complete-case restriction examined patient-level factors along with Human Development Index (HDI) tertile and a hospital resource availability score.

Negative laparotomy occurred in 128 of 1769 patients (7.2%). In the complete-case model of 1765 patients, negative trauma laparotomy predictors were penetrating mechanism (OR 2.37, 95% CI 1.53-3.69, p<0.001) and surgical registrar/resident grade relative to consultant/attending (OR 2.91, 95% CI 1.90-4.47, p<0.001). Pre-operative computed tomography (CT) trended toward higher odds without a significant association, and neither HDI tertile nor hospital resource availability was associated. Among patients with negative laparotomy, 7.8% died in hospital within 30 days and 16.4% required postoperative organ support, with severe complications also reported among survivors.

Negative laparotomy status was self-reported by collaborators, and later deaths after a negative operation left open the possibility of missed indexed pathology in some cases. Many participating hospitals were tertiary urban centres, and the dataset lacked granular detail on pre-operative decision-making, exact complication types, and post-discharge functional outcomes. This was a worldwide cohort spanning six continents, including sites in the United States and Canada, so the findings describe global practice patterns rather than any single trauma system. Within those constraints, the observed pattern tied negative laparotomy more closely to injury mechanism and surgeon experience than to national development level or measured hospital resource availability, while the secondary observational design leaves room for selection bias, unmeasured confounding, and type 2 error.

The authors concluded that negative trauma laparotomy occurred in roughly one in fourteen cases in this global cohort, and that the adjusted signal centered on penetrating trauma and less senior operating surgeons rather than Human Development Index tertile or hospital resource score. They also proposed negative laparotomy rate as a trauma-system benchmark for further exploration, not as an established performance metric.

Clinician Questions

How did the GOAL-Trauma analysis define a negative trauma laparotomy versus a non-therapeutic laparotomy?

In the GOAL-Trauma analysis, negative trauma laparotomy meant no intra-abdominal injuries were identified during the index operation, whereas non-therapeutic laparotomy meant intra-abdominal injuries were found but did not require operative intervention. That distinction matters because negative laparotomy was defined as a case in which 'no intra-abdominal injuries were identified during the index operation,' not simply an injury that required no repair.

Which factors in the global trauma cohort were not independently associated with negative laparotomy risk?

Human Development Index tertile and hospital resource availability were not independently associated with negative laparotomy risk in the adjusted model, and pre-operative CT showed only a nonsignificant trend toward higher odds. The analysis therefore did not support a clear system-level gradient in negative laparotomy rates across the measured development and resource categories.

What limits how far the negative trauma laparotomy findings can be applied across trauma systems?

The authors noted that negative laparotomy status was self-reported, that some later deaths after a negative operation left open the possibility of missed indexed pathology, and that many participating hospitals were tertiary urban centres. They also reported that the dataset lacked detailed pre-operative decision-making variables, exact complication-type data, and post-discharge functional outcomes, which narrows how fully the findings can be generalized across trauma systems.