Surgical Apgar Score as a Predictor of 30-Day Postoperative Complications Following Emergency Laparotomy: A Prospective Observational Study

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Background: Emergency laparotomy carries high morbidity and mortality, and simple tools for postoperative risk stratification are needed, particularly in resource-limited settings. The Surgical Apgar Score (SAS) is a 10-point score calculated from three routinely recorded intraoperative variables: estimated blood loss, lowest mean arterial pressure and lowest heart rate. Objective: To evaluate the Surgical Apgar Score as a predictor of 30-day postoperative complications and mortality following emergency laparotomy. Methods: This prospective observational study included 107 adult patients who underwent emergency laparotomy at Government Medical College, Orai, Jalaun, Uttar Pradesh, from August 2025 to July 2026. The SAS was calculated at the end of surgery, and patients were grouped as high risk (0–4), medium risk (5–6) or low risk (7–10). Complications within 30 days were graded by the Clavien-Dindo classification. Outcomes were compared across the risk groups, and predictive accuracy was assessed by receiver operating characteristic (ROC) curve analysis. Results: Thirty-four patients (31.8%) were high risk, 43 (40.2%) medium risk and 30 (28.0%) low risk. Overall, 62 patients (57.9%) developed a complication, 38 (35.5%) had a major complication (Clavien-Dindo grade ≥ III) and 9 (8.4%) died. From the high-risk to the low-risk group, rates fell for any complication (94.1%, 53.5% and 23.3%), major complications (70.6%, 27.9% and 6.7%) (both p < 0.001) and 30-day mortality (17.6%, 7.0% and 0%; p = 0.030). The area under the ROC curve was 0.806 for any complication, 0.796 for major complications and 0.741 for mortality. SAS ≤ 4 was the optimal cut-off, with a sensitivity of 63.2% and specificity of 85.5% for major complications and a negative predictive value of 95.9% for mortality. Conclusion: The Surgical Apgar Score is a simple, objective and cost-free predictor of 30-day complications and mortality after emergency laparotomy. Patients with a score of 4 or less should be considered for closer postoperative monitoring and high-dependency care.