ISSN: 2320-5407 Int. J. Adv. Res.

10(10), 279-286

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/15489
DOI URL: http://dx.doi.org/10.21474/IJAR01/15489

RESEARCH ARTICLE
UTILITY OF SURGICAL APGAR SCORE TO PREDICTPOSTOPERATIVE MORBIDITY AND
MORTALITY IN LAPAROTOMY PATIENTS - A PROSPECTIVE STUDY”

Dr. Akshaya Parthiban, Dr. Ali Reza Shojai, Dr. Pooja Agarwal, Dr. Mohit Vardey and Dr. Mahima Agarwal
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background:This Ten-point Surgical Apgar Score also known as the
Received: 10 August 2022 SAS score predicts postoperative mortality and morbidity in patients
Final Accepted: 14 September 2022 undergoing laparotomy.
Published: October 2022 Method:50 patients undergoing laparotomy surgery were enrolled. 42
of these were emergency surgeries forintestinal
obstruction,perforationperitonitis, subacute intestinal
obstruction,penetrating injury,blunt injury to abdomen, ovarian cyst
rest.8 cases were elective surgeries. The Surgical Apgar Score (SAS)
was calculated intra-operatively based on estimated blood loss, lowest
mean arterial pressure and lowest heart rate. Post-operative
complications and mortality were recorded.
Results:In our study 10 out of 12 patients in the high-risk group
developed complications. In other words, 83.34%developed
complications.7 out of18 patients belonging to the medium-risk group
developed complications which is 38.8%.Only 5 out of 20 patients in
the low-risk group suffered from complications. 75% of the patients in
the low-risk groups did not have any major complications following the
surgery. This was statistically significant with a p-value of 0.04.
Conclusions:In our situation, laparotomy is still considerably high
related with morbidity and mortality. The Surgical Apgar Score is
excellent at classifying the postoperative risk of major complication
following laparotomyusing straightforward and highly varying
intraoperative measurements. The SAS score alarms the surgeon and
empowers him to take proactive action19.

Copy Right, IJAR, 2022,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
One of the most frequently performed surgeries in general surgery is exploratory laparotomy.All surgical fields can
utilize this 10-point Surgical Apgar Score, widely known as the SAS score, to determine postoperative mortality and
morbidity1.

Exploratory Laparotomy is one of the most common surgeries in general surgerypractice. This Ten-point Surgical
Apgar Score also known as the SAS score predictspostoperative mortality and morbidity and can be used in all
specialties of surgery1.

The Three important variables that were derived and formulated into the Surgical Apgar Score are the lowest heart
rate, the lowest mean arterial pressure, andestimated blood loss during the surgery1.

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Corresponding Author:- Dr. Akshaya Parthiban
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The SAS score provides an easy, quick, and objective means of estimating andcommunicating the patient outcome
following surgery, using data that are routinelyavailable even in low-resource settings. The score can be very useful
in choosingpatients at the higher- and lower-than-average likelihood of severe complications ost-surgery and may
help guide interventions to avoid poor outcomes2.

The parameters of the score highlight the patient's overall condition

The Surgical Apgar Score was developed using three crucial factors: the lowest heart rate, the lowest mean arterial
pressure, and the anticipated blood loss during the procedure1. The SAS score uses data that are frequently
accessible even in low-resource situations to give a simple, rapid, and objective way of evaluating and
communicating the patient outcome following surgery. The score can be highly effective in selecting patients who
are more and less likely than average to experience serious complications after surgery and may be useful in
directing treatments to minimize undesirable outcomes2. The factors that make up the score reflect the patient's
underlying health.

Aim
The study aims to demonstrate the Surgical Apgar Score's applicability in post-operative risk categorization for
morbidity and death within the first 30 days following laparotomy at tertiary hospitals.

Objectives Of The Study:-

1. To evaluate the percentage of laparotomy patients who experience significant symptoms 30 days after surgery.
2. To measure the 30-day postoperative mortality of laparotomy patients.
3. To establish a link between the Surgical Apgar Score and the occurrence of significant complications and
mortality within 30 days of surgery.

Patients And Methods:-

The institutional ethics committee granted its clearance to a prospective, cross-sectional study and was conducted in
a tertiary care facility.

Criteria For Inclusion:

1. Every patient who is older than 18 was scheduled for a mid-line laparotomy.
2. Senior resident rank and above operate.

Criteria For Exclusion:

1. Patients undertaking major surgeries on other parts of their bodies immediately or within 30 days of the
laparotomy under study.
2. patients with tumors that have spread and were unresectable.
3. Patient in chemotherapy /immunocompromised state

Patients undergoing laparoscopic and mini-laparotomies. Every patient undergoing an emergency or elective
laparotomy. Before engaging a person in the study, formal & informed consent will be sought from the patient. With
the assistance of the PAC sheet, the proforma page is filled up within 24 hours of the actual surgery date. Three
color-coded groups of patients were created, and every group was monitored up till the 30th postoperative day.

All patients who were discharged before thirty days had scheduled follow-up appointments at the outpatient clinic.

Results:-
After obtaining the necessary patient consent, Fifty patients who satisfied the inclusion criteria participated in the
study. These 50 patients were accessible to track the results.

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14

12

10

0
18-27 28-37 38-47 48-57 58-67 68-77

Fig 1:- Age Distribution.

The study population have 36 male and rest 14 female,which is 72 % predominantly to male and the remaining 28 %
female

SEX DISTRIBUTION

NO OF PATIENTS

0 5 10 15 20 25 30 35 40

MALE FEMALE

Fig 2:- Sex.

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Fig 3:- Setting Of Laparotomy.

NO.OF PATIENT

EMERGENCY ELECTIVE

Risk group Presence or Absence of complication Total

Absent Present
High risk 2 10 12
Medium risk 11 7 18
Low risk 15 5 20
Total 50
In the study population, there were 42 emergency cases and 8 elective cases.

FIG 4a: Indications for laparotomy

FIG 4b:- Indications for laparotomy.

DIAGNOSIS NOS PERCENTAGE
BLUNT INJURY TO ABDOMEN 2 4
INTESTINAL OBSTRUCTION 21 42
PERFORATION PERITONITIS 19 38
PENETRATING INJURY 3 6
SUBACUTE INTESTINAL OBSTRUCTION 4 8
OVARIAN CYST 1 2

COMPLICATIONS FREQUENCY PERCENT

No complications 28 56%
Anastomotic leakage 2 4%
Renal dysfunction 4 8%
Death 3 6%
Deep wound infection 4 8%
Respiratory infection 3 6%
Wound dehiscence 6 12%
TOTAL 50 100%

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Percentage

8%0%
4%
6%

43%

39%

BLUNT INJURY TO ABDOMEN INTESTINAL OBSTRUCTION

PERFORATION PERITONITIS PENETRATING INJURY
SUBACUTE INTESTINAL OBSTRUCTION OVARIAN CYST

Fig 5a:-Complications.

No complications Anastamotic leakage

12% 0%
Renal dysfunction Death
6%

8% Deep wound infection Respiratory infection

6% 56%
Wound dehiscence

8%
4%

FREQUENCY
Fig 5b:-Complications.

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According to SAS Score

NO OF PATIENT
RED YELLOW GREEN

0%

RED
GREEN 36%
40%

YELLOW
24%

Chart Title

GREEN 5
20

YELLOW 7
18

RED 10
12

0 5 10 15 20 25

COMPLICATIONS TOTAL NO OF PATIENT

Fig 6:- Correlation Of Complication With Sas Score.

The high-risk group in our study experienced complications in 10 out of 12 participants. Alternatively put, 83.34%
of the patients in the high-risk groups experienced problems. 38.8%, or 7 out of 18, of the patients in the medium-
risk group, suffered problems. In the low-risk group, only 5 patients out of 20 experienced problems. Only 15% of
patients in the low-risk groups experienced serious postoperative problems, compared to 75% of patients overall.
Statistical significance was achieved here with a p-value of 0.04.

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Discussion:-
An ideal surgical risk rating system would be straightforward, minimally complex in terms of calculations, data, and
factors, reasonably accurate, objective, affordable, and applicable to both elective and emergency surgeries as well
as all specialties. The SAS is an easy method to anticipate postoperative problems. Using just three variables, this
straightforward grading system may accurately predict catastrophic postoperative effects 2.

In our study group, the median of these age groups was 39.5 years. The mean of the study group was 41.44 and the
standard deviation was 16.50.This runs counter to research on SAS conducted in Western nations when it was
discovered that patients undergoing laparotomies were generally substantially older. The study by Regenbogen et al.
in 2009 found that the mean age was 64.2 years. Gawande et al study's indicated that the average age of the patient
population was 63.6 years old.

The mean age was determined to be 64.2 years in the 2009 study by Regenbogen et al. According to studies by
Gawande et al, the average age of the sample group was 63.6.

This study's 72% male preponderance is comparable to Mwangi et al.'s 67% male preponderance. The most frequent
causes of laparotomy in our study were intestinal obstruction (42%), perforation peritonitis (38%), penetrating injury
to the abdomen (6%), blunt abdominal injury (4%), and ovarian cyst (2%), whereas the most frequent causes in the
study by Mwangi et al. in 2007 were peritonitis, intestinal obstruction, and appendicitis.

In our current study, mortality accounts for 6% of the total in the following 30 days post-surgery. This is found to be
reasonably high when compared to studies by Mwangi et al. and Gawande et al. Additionally, it is comparable to Yii
and Ng10.4.8% of people died within 30 days, according to Mwangi et al. The 30-day mortality rate discovered by
Yii and Ng was 6.1%10. Patients who underwent gastrectomy and a colectomy in the 2010 trial by Regenbogen and
colleagues saw a mortality rate of 5.2%3. According to a 2007 study by Gawande et al., 4% of patients underwent
colectomy.
Present study Mwangi study Yii&Ng(%) Regenbogen Gawande(%)
(%)
Mortality rate 6 4.8 6.1 5.2 4

The primary yardstick for the efficiency and ability of the surgeon and his team is the surgical mortality of the
patients they are operating on. Surgical mortality is used as a substitute metric to assess their effectiveness. In our
study, elderly participants had issues far more frequently. The fact that patients in our study who were older than 40
had a lower average Surgical Apgar Score serves to highlight it. This is in line with the findings of Regenbogen et
al. (2009) and Gawande et al. (2007) 3,7, which reported that older patients had a higher incidence of postoperative
problems.

In a Developing country like India, where there are few resources available, the SAS score would guide us to plan
and manage the restricted resources for the post-operative care, monitoring, and follow-up of deserving high-risk
patients.

The surgical Apgar Score also be implemented in surgical audits as an outcome of studies correlating surgical
performance, intraoperative anesthesia, and the score. The SAS can be used to optimize performance if it is serially
analyzed within a unit. However, more study is also essential in this domain across other surgical subspecialties.

Conclusion:-
In our situation, laparotomy is still considerably related to morbidity and mortality. The Surgical Apgar Score is
excellent at classifying the postoperative risk of major complications following laparotomy despite using
straightforward and highly varying intraoperative measurements. The SAS score alarms the surgeon and empowers
him to take proactive action19.

Limitations
To determine the worth of the score, this study needs to be conducted on a larger scale over a longer span of time
with a larger population.

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Minor inaccuracies resulted from the inability to measure the precise amount of blood lost throughout the procedure.

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