Damage Control Laparotomy

The principles of damage control surgery are:

1. Control haemorrhage
2. Prevention contamination
3. Avoid further injury

Damage Control Surgery

Overview
Metabolic failure
Damage control laparotomy
Organ-specific techniques
Critical Care
Abdominal Compartment Syndrome
Reoperation

Preparation
Prehospital and emergency department times should be minimized in these patients. All unnecessary and superfluous investigations that will not immediately affect patient management should be deferred. Cyclic fluid resuscitation prior to surgery is futile and will worsen hypothermia and coagulopathy. Colloid solutions will also interfere with clot quality.

These patients should be transferred rapidly to the operating room without repeated attempts to restore circulating volume. They require operative control of haemorrhage and simultaneous vigorous resuscitation with blood and clotting factors.

Anaesthesia should be induced on the operating table once the patient is prepped and draped and the surgeons ready. The shocked patient usually requires minimal anaesthesia and a careful, haemodynamically-neutral induction method should be used. An arterial line is valuable for patient monitoring peroperatively but small-calibre central venous access is of limited use. Blood, fresh frozen plasma, cryoprecipitate and platelet transfusions should be available but clotting factor therapy should be administered rapidly only once control of major vascular haemorrhage has been achieved. All fluids should be warmed and as much of the patient covered and actively warmed as possible.

General Conduct and Philosophy
The patient should be rapidly prepped from neck to knees with large abdominal packs soaked in antiseptic skin preparation solution. The incision should be made from the xiphisternum to the pubis. This incision may require extension into the right chest or as a median sternotomy depending on the injury pattern.

Relief of intraperitoneal pressure with muscle paralysis and opening of the abdominal wall may result in dramatic haemorrhage and hypotension. Immediate control is necessary and this is initially achieved with four quadrant packing with multiple large abdominal packs.

Aortic control may be necessary at this stage. This is generally best achieved at the diaphragmatic hiatus with blunt finger dissection and finger pressure by an assistant followed by aortic cross-clamping. The aorta may be difficult to identify in the severely hypovolaemic patient and direct visualization by division of the right crus of the diaphragm may be necessary. Some surgeons prefer to perform a left anterolateral thoracotomy to control the descending thoracic aorta in the chest. However this requires the opening of a second body cavity and further heat loss and is rarely necessary. The next step is to identify the main source of bleeding. Careful inspection of the four quadrants of the abdomen is necessary. A moment of silence may allow the bleeding to be heard. Immediate control of haemorrhage is with direct, blunt pressure using the surgeons hands, swabs on sticks or abdominal packs. Proximal and distal control techniques are rarely useful in the acute stage. Bleeding from the liver, spleen or kidney can generally be achieved by applying pressure with several large abdominal packs.

Examination of the abdomen must be complete. This includes, where necessary, mobilization and delivery of retroperitoneal structures using several medial visceral rotation manoeuvers. All intraabdominal and most retroperitoneal haematomas require exploration and evacuation. Even a small perienteric or peripancreatic haematoma may mask a serious vascular or enteric injury. Exploration should proceed regardless of whether the haematoma is pulsatile, expanding or stable or due to blunt or penetrating trauma. Nonexpanding perirenal haematomas, retrohepatic haematomas or blunt pelvic haematomas should not be explored and may be treated with abdominal packing. Subsequent angiographic embolization may be required.

Right medial visceral rotation

Left medial visceral rotation (Mattox)

Prevention of contamination is achieved by the rapid closure of hollow viscus injury. This may be definitive if there are only a few enterotomies requiring primary suture, but more complex techniques such as resection and primary anastomosis should be avoided and bowel ends stapled, sewn or tied off. Inspection of the ends and reanastomosis is performed at the second procedure.

Abdominal closure
Abdominal closure is rapid and temporary. If possible, the skin only is closed with a rapid continuous suture or even multiple towel clips. Abdominal compartment syndrome is common in these patients and if there is any doubt the abdomen should be left open as a laparostomy with a silo-bag or vacuum-pack technique.

Organ specific techniques