Bedside Exploratory Laparotomy: Factors Associated With Mortality and Clinical Implications in Critically - Ill Patients

BACKGROUND: Bedside exploratory laparotomy is a heroic intervention for unstable patients who cannot be transported to the operating room. Given a previously documented high mortality rate, some argue against the procedure on assumption of non-beneficence. This study aims to evaluate procedural mortality rate and identify physiologic factors associated with death after bedside exploration. METHODS: A single-center, retrospective review of consecutive patients who underwent bedside exploratory laparotomy between 2019 and 2024 was conducted. Patients were stratified into cohorts based on a composite outcome of in-hospital or 30-day survival, and an analysis was conducted to identify factors associated with mortality. RESULTS: A total of 51 patients underwent bedside exploratory laparotomy, with a mortality rate of 82.4% (42/51) within 30 days or during index hospitalization. The median postoperative time to death was 18.1 hours. Mortality rates were 73.9% in SICU, 90.0% in MICU, and 88.2% in CTICU. Survivors were younger than non-survivors (46.5 vs. 60.8 years; p = 0.025) and had lower Charlson Comorbidity Index scores (2 vs. 4; p = 0.0011). Preoperative lactate was lower (4.12 vs. 10.16 mmol/L; p = 0.0012) and pH higher (7.30 vs. 7.20; p = 0.042) in survivors. Significant intraoperative findings were more frequent in non-survivors (95% vs. 33%; p < 0.001). CONCLUSION: Bedside exploratory laparotomy is a last-resort intervention with exceedingly high mortality. We observed older patients with significant acidosis or identifiable intraoperative findings have worse prognoses. Preoperative goals-of-care discussions should be prioritized in elderly patients before proceeding with bedside exploration to ensure ethical delivery of surgical care.