Abstract
- Damage Control (DC) initially referred to surgical techniques used in the operating room. This concept has now been expanded to include damage control resuscitation, which includes permissive hypotension, early empiric blood component therapy, and the prevention and treatment of hypothermia and acidosis.
- DC techniques can be applied to most anatomical areas and structures, including the neck, chest, abdomen, vessels, and fractures.
- DC surgery is an abbreviated procedure with the goal of rapidly controlling bleeding and contamination so that the initial procedure can be terminated, decreasing surgical stress and allowing a focus on resuscitation. This should be considered in patients with progressive physiologic exhaustion, who are at risk of irreversible shock and death. After physiologic resuscitation, the patient is returned to the operating room for definitive reconstruction and eventual definitive closure of the involved cavity.
- The standard indications for DC include:
- Patients in “extremis,” with coagulopathy, hypothermia <35°C, acidosis (base deficit >15 mmol/L), elevated lactate, prolonged hypotension on pressors.
- Bleeding from difficult to control injuries (complex liver injuries, retroperitoneum, mediastinum, neck, and complex vascular).
- In suboptimal environments, such as the rural or battlefield setting or with inexperienced surgeons without the adequate skillset to definitively manage the injury.
- Patients in “extremis,” with coagulopathy, hypothermia <35°C, acidosis (base deficit >15 mmol/L), elevated lactate, prolonged hypotension on pressors.
- For maximum benefit, damage control should be considered early, before the patient reaches the “in extremis” condition! Consider the nature of the injury, the physiologic condition of the patient, comorbid conditions, the available resources, and the experience of the surgeon. The timing of DC surgery is critical in determining the outcome.
General Principles
Damage Control (DC) initially referred to surgical techniques used in the operating room. This concept has now been expanded to include damage control resuscitation, which includes permissive hypotension, early empiric blood component therapy, and the prevention and treatment of hypothermia and acidosis.
DC techniques can be applied to most anatomical areas and structures, including the neck, chest, abdomen, vessels, and fractures.
DC surgery is an abbreviated procedure with the goal of rapidly controlling bleeding and contamination so that the initial procedure can be terminated, decreasing surgical stress and allowing a focus on resuscitation. This should be considered in patients with progressive physiologic exhaustion, who are at risk of irreversible shock and death. After physiologic resuscitation, the patient is returned to the operating room for definitive reconstruction and eventual definitive closure of the involved cavity.
The standard indications for DC include:
Patients in “extremis,” with coagulopathy, hypothermia <35°C, acidosis (base deficit >15 mmol/L), elevated lactate, prolonged hypotension on pressors.
Bleeding from difficult to control injuries (complex liver injuries, retroperitoneum, mediastinum, neck, and complex vascular).
In suboptimal environments, such as the rural or battlefield setting or with inexperienced surgeons without the adequate skillset to definitively manage the injury.
For maximum benefit, damage control should be considered early, before the patient reaches the “in extremis” condition! Consider the nature of the injury, the physiologic condition of the patient, comorbid conditions, the available resources, and the experience of the surgeon. The timing of DC surgery is critical in determining the outcome.
Damage Control in the Abdomen
In abdominal DC surgery, the goal of the initial exploration is temporary control of bleeding and spillage from a hollow viscus injury. The definitive reconstruction is performed semi-electively, at a later stage, ideally within 24–48 hours, after physiological stabilization.
Temporary closure can be obtained by use of a vacuum-assisted closure system.
Temporary Control of Abdominal Bleeding
Temporary bleeding control can be achieved by tight gauze packing of the source of the bleeding (liver, retroperitoneum, or pelvis), application of local hemostatic agents, balloon tamponade in some cases (i.e. bleeding from a deep penetrating tract in the liver or the retroperitoneum), ligation instead of repair of major venous injuries, temporary shunting of injured arteries, or any combination of the above (see appropriate chapters for specific DC techniques for the liver or vessels).
Technique of liver gauze packing (see Chapter 27) following ligation of major sites of bleeding and nonanatomical resection of nonviable liver, DC with tight packing tamponade should be considered if there is persistent bleeding. The liver is wrapped with absorbable mesh and gauze packing is applied around it. The mesh may stay permanently in the abdomen and can facilitate the removal of the gauze at the second-look laparotomy, without causing bleeding.
Figure 23.1 Severe liver injury requiring damage control (DC) with packing. After ligation of major bleeders and nonanatomical debridement (a), the liver is tightly wrapped with absorbable mesh (b). DC for severe liver injury. The liver injury is tightly packed with gauze (c) and temporary abdominal wall closure achieved with ABThera negative pressure system (d).
Local hemostatic agents are usually effective in controlling minor bleeding, but they rarely work in major hemorrhage.
Control of Intestinal Spillage
Ligation or stapling of the injured bowel, without reanastomosis, has been recommended for temporary control of intestinal content spillage (Figure 23.2). Definitive reconstruction is performed at a later stage, usually about 24–36 hours after the initial operation. Some surgeons do not support this approach because of the concern for creating a closed-loop intestinal obstruction, which may promote bacterial and toxin translocation and aggravate bowel ischemia, especially in patients requiring vasopressors (Figure 23.3a, b). Therefore, bowel left in discontinuity should be reanastomosis within 24 hours to mimimize complications. With anticipation of the discontinuity lasting longer than 24 hours, primary anastomosis or ostomy should be considered. We support reconstruction of the bowel or ostomy diversion during the DC operation whenever possible.
