Exploratory laparotomy for abdominal gunshot trauma in Palestine: Outcomes, predictors, and complications across a multicenter cohort

Background This study was conducted to determine the incidence and identify independent predictors of key postoperative events, including mortality, intensive care unit (ICU) admission, mechanical ventilation, reoperation, stoma formation, and postoperative infections among patients who underwent exploratory laparotomy for abdominal gunshot trauma in Palestine. Methods We conducted a multicenter retrospective cohort study across six major hospitals between January 2019 and December 2024. Medical records of patients undergoing exploratory laparotomy for abdominal bullet injuries were reviewed. Outcomes included mortality, ICU admission, mechanical ventilation, reoperation, stoma formation, and postoperative infection. Results Of 830 records screened, 96 male patients (median age 22 years [IQR 18.0–26.8]) met inclusion criteria. Isolated abdominal injury occurred in 47 (49%), while 49 (51%) had additional injuries. Small bowel (52.1%), large bowel (30.2%), and liver (22.9%) were the most frequently injured organs. ICU admission was required in 69 patients (71.9%), mechanical ventilation in 31 (32.3%), and reoperation in 19 (19.8%). Stoma formation occurred in 25 (26.0%), and postoperative infections in 15 (15.9%). Overall mortality was 8 (8.3%). Independent predictors of mortality included transfusion burden (aOR 1.40 per unit, p < 0.001) and intraoperative complications (aOR 57.4, p = 0.006). ICU admission was independently associated with multiple surgical indications (aOR 3.61, p = 0.025) and transfusion volume (aOR 1.24, p = 0.040). Mechanical ventilation correlated with injury complexity, transfusion requirements, and drain placement. Reoperation was predicted by mechanical ventilation and postoperative bleeding, while stoma formation was strongly linked to large bowel injury and planned second-look surgery. Stoma formation and prolonged hospitalization independently predicted postoperative infection. Conclusion Exploratory laparotomy for abdominal gunshot injuries in Palestine was associated with high rates of ICU admission, reoperation, stoma formation, infection, and mortality. Strengthening early resuscitation, standardized transfusion protocols, infection-prevention bundles, and postoperative rehabilitation may improve survival and reduce complications in resource-limited, conflict-affected settings.