Damage Control Laparotomy

Most damage control procedures are performed in the abdomen. In fact, the earliest descriptions of what subsequently became known as damage control surgery were in patients with major hepatic injuries, in whom the placement of perihepatic packing and staged operative management resulted in decreased morbidity and mortality. The most common injuries that trigger a damage control approach are major liver injuries and major vascular injuries.

The primary method of controlling hepatic hemorrhage is packing. The technique of pack placement is of the utmost importance and depends on the anatomic nature of the liver injury. Major hepatic lacerations require complete mobilization of the liver and inflow occlusion (the Pringle maneuver) to minimize blood loss. Direct ligation of bleeding vessels in the depth of the laceration is necessary to obtain surgical hemostasis. Once major vessel bleeding has been controlled, perihepatic packs should be placed anteriorly and posteriorly, compressing the liver between the two beds of packs and providing tamponade. In penetrating injuries, balloon tamponade of the missile tract, in conjunction with perihepatic packing, can be life saving.

There are several options available for the management of major vascular injuries. Some venous injuries will respond to packing. Ongoing bleeding, however, requires direct surgical intervention. Many abdominal vascular injuries can be managed with simple ligation of the bleeding vessel (Table 2). Ligation, however, is not tolerated in aortic or proximal superior mesenteric artery injuries, and is not technically feasible in retrohepatic caval injuries. These injuries are typically initially approached by an attempt at repair or the placement of a temporary intraluminal shunt, with planned repair at a second operation (phase 3). Commonly, Argyle carotid shunts and Javid shunts have been used for this purpose. Chest tubes may be used when larger conduits are necessary. The shunts should be secured using umbilical tapes, vessel loops, or suture, and do not require anticoagulation to maintain patency. Another technique for the management of exsanguinating vascular injury is the use of endoluminal balloon catheters to obtain proximal and distal control of hemorrhage. The catheters are inserted into the vessel at the site of injury, and the balloon inflated. This technique allows repair of the injured vessel in a relative dry operative field.

Table 2 Abdominal Vessel Ligation and Expected Complications

Candidates for damage control surgery often have associated hollow viscus injury. The goal in management of these injuries is the control of contamination. Intestinal lacerations may be controlled by linear stapling or by stapled resection. After enterectomy, the gastrointestinal tract is left in discontinuity, and the decision to perform an anastomosis or stoma is postponed until the patient is stabilized and able to return to the operating room for definitive management (phase 3). Associated biliary or pancreatic injuries can often be managed with judicious placement of closed suction drains, with plans to address the injury at the second procedure (phase 3).

Hemodynamic instability caused by splenic lacerations should be managed with expeditious splenectomy. Similarly, hemorrhagic shock resulting from extensive renal lacerations or pedicle injuries should be managed by nephrectomy, especially if attempts at perinephric packing have failed. Ureteral injuries diagnosed during the damage control procedure should be ligated or drained with a percutaneous urostomy. Intraperitoneal bladder injuries should be rapidly oversewn with definitive management delayed until the second operation.

Given the volume of resuscitation after a damage control procedure, and the edema that results from reperfusion of previously ischemic tissue, formal closure of the abdomen is not an option. Forced closure of the abdomen is associated with a prohibitively high risk of subsequent abdominal compartment syndrome, adult respiratory distress syndrome (ARDS), and multisystem organ failure (MSOF). Multiple options exist for the temporary closure of the abdomen. The goals of temporary closure should be containment of the abdominal viscera, control of abdominal ascites, maintenance of tamponade on areas that have been packed, and optimization of later fascial closure.

Simple techniques involve closure of only the skin, with suture or towel clips. This technique will facilitate the tamponade of bleeding while coagulopathy, acidosis, and hypothermia are corrected. However, it does not expand abdominal volumes significantly and is often associated with development of secondary abdominal compartment syndrome. When this occurs, it can be managed in the ICU by simply reopening the skin. Techniques which expand the abdominal volume include coverage of the viscera with the Bogota bag, a 3-liter urologic bag that is stapled or sewn to the skin. The benefit of the Bogota bag over the vacuum-assisted techniques described below is that it allows visualization of the underlying viscera and assessment of viability, which may be important after the use of shunting or ligation for a major vascular injury.

Vacuum-assisted techniques for temporary abdominal closure have been well described. The vacuum-assisted wound coverage is constructed beginning with a nonadherent fenestrated drape placed over the viscera, followed by the application of a sterile surgical towel. Following placement of two closed suction drains, the wound is sealed with an adhesive plastic sheet applied to the skin. The benefits of this technique include maintenance of some tension on the abdominal wall fascia to minimize the risk of loss of domain and to facilitate subsequent delayed fascial closure at a later time. Commercial devices capable of similar functions are available. Another potential technique for temporary closure involves the use of Velcro, which is sutured to the fascia and sequentially tightened. In the acute setting, there is little role for prosthetic material for temporary closure of the abdomen. As there are no prospective trials comparing methods of temporary abdominal closure, the method used is at the discretion of the trauma surgeon and is often institution specific.