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DAMAGE CONTROL SURGERY

Dr. Damodhar.M.VResident SurgeonSecurity Forces Hospital Dammam

Concept of Damage control

“ …keeping afloat a badly damaged ship by procedures to limit flooding , stabilize the vessel, isolate fires and explosions and avoid their spreading”

Surface ship survivability, Naval war publication3-20.31, Washington, DC. Department of defense; 1996

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Etymology

• Stone and colleagues: Technique of ‘truncated laparotomy’ in 1983.

• Rotondo and colleagues: coined term DCS as a 3 phase technique in 1993.

• Johnson and schwab: 4 phase technique ( pre-theatre phase).

Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993; 35: p. 375-82; discussion 382-3.Stone HH, Strom PR, Mullins RJ (May 1983). "Management of the major coagulopathy with onset during laparotomy"Annals of Surgery. 197 (5): 532–5. doi:10.1097/00000658-198305000-00005. PMC 1353025 . PMID 6847272

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Definition

• Damage control surgery(DCS) is a concept of abbreviated laparotomy,

designed to prioritize short-term physiological recovery over anatomical

reconstruction in the seriously injured and compromised patient.

• Damage control resuscitation (DCR) : A systematic approach to major

trauma combining the ABC paradigm with a series of clinical techniques

from point of wounding to definitive treatment in order to minimize blood

loss, maximize tissue oxygenation, and optimize outcome.

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Lethal Triad

Burch JM, Ortiz VB, Richardson RJ, Martin RR, Mattox KL, Jordan Jr GL. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg 1992;215(5):476–83.

Hypothermia

Cosgriff N, Moore FE, Sauaia A, Kenny-Moynihan M, Burch JM, Galloway B. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidosis revisited. J Trauma 1997;42:857–62.

COAGULOPATHY

endothelialabnormalities and alterations in the fibrinolytic system.

platelet dysfunction

inactivation of the temperature-sensitive, enzyme-activated serine esterases, coagulation factors

Temp<36 C for >4hours, clinically significant

suppresses immune system.

cardiac arrhythmias, decreased CO, increased SVR

severe exsanguinating injury, IV fluidsHypoperfusion Decreased tissue oxygenation

Acidosis

COAGULAOPATHY

Metabolic acidosis

Lactic acid production

Anaerobic metabolism

Inadequate cellular perfusion

Uncorrected Haemorrhagic shock

CoagulopathyMassive

blood transfusion

Hypothermia

Acidosis

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DCS Approach ?

Damage Control SurgeryKarim Brohi, trauma.org 5:6, June 2000

Staged Laparotomy in DCS

Standard Surgical Teaching

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Phases of DCS

Stage I: Ground 0 ( additional)- Pre Hospital And Hospital Phase

Stage II: Abbreviated Laparotomy

Stage III: ICU Resuscitation

Stage IV: Definitive surgery

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Phase I– Ground Zero• Prehospital care & Initial resuscitation: • Built on fundamentals of ATLS guidelines. • Rapid Transport to definitive care. • Rapid Evaluation. • FAST, Tube Thoracotomy, CXR, Pelvis X-ray• Damage Control Resuscitation to systolic 80-90 mmHg.(permissive

hypotension)

• This phase should take 20-30 min.

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Phase II- Abbreviated Laparotomy

• Damage Control Laparotomy Principles

• Control haemorrhage

• Prevention contamination

• Avoid further injury

• Aims to restore physiology at the expense of anatomical reconstruction.• On- going DCRThis phase should take 90 mins.

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Phase III- ResuscitationDCR: This may only require 12 h , many will require 24–36 h • Require collaborative efforts of multiple critical care physicians, nurses, and ancillary staff. • GOAL: reverse the sequelae of hypotension related metabolic failure. • Physiological and biochemical restoration. • Adequate oxygen delivery to body tissues• Intensive monitoring• aggressive core rewarming• Aggressive approach to correction of coagulopathy• Tertiary SurveyPhase II unplanned re-exploration:ongoing transfusion requirements or persistent acidosis despite normalized clotting and

core temperature.ACS symptoms.

Damage Control Resuscitation

• Definition:• A systematic approach to major exsanguinating trauma incorporating several

strategies to decrease mortality and morbidity:

1. Permissive hypotension (Minimal Normotension)

2. Haemostatic resuscitation (Massive Transfusion Protocol)

3. Haemorrhage Control (Damage control surgery)

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Phase IV- Definitive Surgery• Timing is critical.

• With focused, critical care management and resuscitation one may obtain this physiological state within 24–36 hours.

• Look for hidden injuries

• Addresses the definitive repair and tension free abdominal closure.

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DCS Timeline

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Indications for DCS Hypothermia on presentation (< 35°C)

Hemodynamic instability

Coagulopathy on presentation or during operation

Severe metabolic acidosis (pH < 7.2 or base deficit > 8

High energy Blunt trauma

Multiple penetrating torso injuries

Prohibitive operative time required for definitive repair(> 90 min)

Multiple visceral injuries with major vascular trauma

Multiple injuries across body cavities

Massive transfusion requirements (> 10 units packed red blood cells)

Presence of injuries better treated with nonsurgical adjunctsRev. Col. Bras. Cir. 2012; 39(4): 314-321

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Damage control LaparotomyPrinciples• Control haemorrhage  operative control of haemorrhage and simultaneous vigorous resuscitation with blood and clotting factorsAvailability of Blood, FFP, cryoprecipitate, platelet• Prevention contamination• Avoid further injury

• Evacuation of blood. • Four quadrant packing.• Full exposure of the injuries.

• Kocher maneuver• Cattell-Braasch• Mattox

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Damage control Laparotomy• Solid organs: such as spleen and isolated kidney , are sacrificed in

damage control if repair prolongs surgical times.• Bleeding vessel : Ligation /shunting.• Bowel injury: stapler/ ligation.• Intra-abdominal Packing • No reconstructive surgery undertaken• Temporary abdominal closure

Liver• peri-hepatic packing- anteroposterior plane , hepatorenal space • Pringles manouvre• transfer to angiography suite immediately after the operation to

identify any ongoing arterial haemorrhage which may be controlled with selective angiographic embolization.

Spleensplenectomy Minor splenic injuries- direct suture techniques

Organ Specific techniques

Damage Control SurgeryKarim Brohi, trauma.org 5:6, June 2000

GIT• control of haemorrhage • prevention of further contamination by controlling spillage of gut

contents. • Small gastrotomies or enterotomies rapidly closed primarily with a

single layer continuous suture.• colonic injuries, multiple small bowel lesions resect non-viable bowel, close the ends, relook at 2nd procedure. • linear stapler• Ileostomy, colostomy avoided if abdomen to be left open

Organ Specific techniques

Damage Control SurgeryKarim Brohi, trauma.org 5:6, June 2000

Pancreas rarely requires or allows definitive surgery • Minor injuries not involving the duct (AAST I,II,IV) require no

treatment. • Distal Injury(Left of SMV- AAST III) with extensive tissue

destruction including pancreatic duct-- rapid distal pancreatectomy.• Massive injuries to the pacreaticoduodenal complex (AAST V) -

debrided only.• Duodenal injuries- single suture/ temporarily close ends(major)

Organ Specific techniques

Damage Control SurgeryKarim Brohi, trauma.org 5:6, June 2000

Organ Specific techniques- GIT

Damage Control SurgeryKarim Brohi, trauma.org 5:6, June 2000

Arterial • “Ligatable” arteries: Common and external carotid • Subclavian, axillary • Internal iliac • Celiac axis, IMA • ICA ligation 10-20% risk of CVA • EIA, CFA, SFA ligation >> high risk limb ischemia • SMA: gut necrosis Venous • Almost all veins (including the IVC) can be ligated when needed

Abdomen Vasculature

WWW.DOWNSTATESURGERY.ORG

Abdomen Vasculature

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• Full exposure of the injuries.• Kocher maneuver• Cattell-Braasch• Mattox

Aorta• direct suture• transposition PTFE graft• Intravascular shunts

Kocher Maneuver

Cattell-Braasch- Right medial Visceral rotation

Mattox- Left medial Visceral rotation

Retroperitoneal Zones

Zone I Mandatory exploration Supramesocolic: Prox. control: Supraceliac aorta Inframesocolic: Prox. control: Infrarenal aorta / IVC

Zone II , IIISelective exploration (if penetrating)Leave alone if from blunt trauma

Opening a pelvic retroperitoneal haematoma in the presence of a pelvic fracture is almost universally fatal!! 

• ACS• Enterocutaneous fistula• Sepsis• Pancreatic injury can be recognised by the presence of a tensely distended• abdomen, elevated peak airway pressures, inadequate ventilation,• hypoxia and oliguria or anuria. The clinical diagnosis can be• Normal intra-abdominal• pressure is 0 cm of H20. Pressure over 35 cm of H20 is diagnostic

Complications of DCS

• ACS• recognised by the presence of a tensely distended abdomen• elevated peak airway pressures• inadequate ventilation, hypoxia • oliguria or anuria. • Normal intra-abdominal pressure is 0 cm of H20. Pressure

over 30 cm of H20 is diagnostic(25cm suggestive)

Complications of DCS- ACS

ACS Sudden release ACS leads to :• ischaemia-reperfusion injury-- acidosis, vasodilatation,

cardiac dysfunction and arrest.• Prior, pre-load with crystalloid solution, Mannitol and

vasodilators such as dobutamine

Complications of DCS

Principles • Timing is critical: 24-48hours• removal of clots and abdominal packs • Copious Lavage • complete inspection of the abdomen to detect missed injuries• Haemostasis and restoration of intestinal integrity • Abdominal wound closure-- Temporary vs. definitive closure

Phase IV: Reoperation

• Temporary closure of the open abdomen is best accomplished :• VAC Dressing.• fascial tensioning.

• Abdominal closure is best accomplished by hospital day 8 to reduce morbidity.

• Barker D, Green J, Maxwell R, et al. J Am Coll Surg 2007;204:784–92.

• Offner P, de Souza A, Moore E, et al. Arch Surg 2001; 136: 676–81.

• Garner G, Ware D, Cocanour C, et al. Am J Surg 2001; 182:630–8.

Closure of Wound

Temporary Abdominal Closure -VAC

Temporary Abdominal Closure with Mesh

1. WJES, Abdominal damage control surgery andreconstruction: world society of emergencysurgery position paperLaura Godat, Leslie Kobayashi, Todd Costantini and Raul Coimb.

Recommendations• 1. DCL for trauma or acute general surgical patients under physiologic stress• requiring a “second-look” after ischemic or embolic events• intra-abdominal infections – necrotizing pancreatitis.• 2. Initial abdominal closure -- “vacuum pack” method or its commercially

available alternative.• 3. After 5-7 days --Wittman patch or modified V.A.C.

Journals

2. IJS 2009: Review Damage control surgery• S.S. Jaunoo*, D.P. Harji• Department of General Surgery, Worcestershire Royal Hospital,

Charles Hastings Way, Worcester WR5 1DD, United KingdomConclusion• damage control sequence represents an evolving attitude in the

management of trauma patients with the focus being on physiological optimisation prior to anatomical repair and restoration.• led to improved survival rates

Journals

• 3. Damage Control Surgery in the Era of Damage Control Resuscitation

C. M. Lamb; P. MacGoey; A. P. Navarro; A. J. BrooksBr J Anaesth. 2014;113(2):242-249.

Journals

• Management of exsanguination requires prompt thinking and aggressive surgical intervention.

• Delays in the decision to perform DC contribute to a higher morbidity and mortality.

• DCS is a vital part of the management of the multiply injured patient and should be performed before metabolic exhaustion.

Take Home Message

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"The modern operation is safe for the patient.

The modern surgeon must make the patient safe for the modern

operation"

- Lord Moynihan

Damage Control SurgeryKarim Brohi, trauma.org 5:6, June 2000

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Thank you