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RESUSCITATION
ABDOMINAL TRAUMA
CRITICAL CARE

 

 

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

"The modern operation is safe for the patient. The modern surgeon must
make the patient safe for the modern operation" - Lord Moynihan

Overview

Damage control surgery is one of the major advances in surgical technique in the past 20 years. The principles of damage control have been slow to be accepted by surgeons around the world, as they contravene most standard surgical teaching practices - that the best operation for a patient is one, definitive procedure.

Damage Control Surgery

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

However it is now well recognized that multiple trauma patients are more likely to die from their intra-operative metabolic failure that from a failure to complete operative repairs. Patients with major exsanguinating injuries will not survive complex procedures such as formal hepatic resection or pancreaticoduodenectomy. The operating team must undergo a paradigm shift in their 'mindset' if the patient is to survive such devastating injuries.

Standard surgical teaching

er, emergency room; or, operating room;

The central tenet of damage control surgery is that patients die from a triad of coagulopathy, hypothermia and metabolic acidosis. Once this metabolic failure has become established it is extremely difficult to control haemorrhage and correct the derangements. If the patient is to survive the operation must be foreshortened so that they can be transferred to a critical care facility where they can be warmed and the hypothermia and acidosis is corrected. Once this is achieved the definitive surgical procedure can be carried out as necessary - the 'staged procedure'.

Staged Laparotomy

er, emergency room; or, operating room; icu, intensive care unit

The principles of the first 'damage control' procedure then are control of haemorrhage, prevention of contamination and protection from further injury. Damage control surgery is the most technically demanding and challenging surgery a trauma surgeon can perform. There is no margin for error and no place for careless surgery.

Metabolic Failure

 

Further Reading:

1. Rotondo MF, Schwab CW, McGonigal MD et al. 'Damage Control - an approach for improved survival in exsanguinating penetrating abdminal injury' J Trauma 1993;35:375-382

2. Hirshberg A, Mattox KL. 'Planned reoperation for severe trauma' Ann Surg 1995;222:3-8

3. Moore EE. 'Staged laparotomy for the hypothermia, acidosis and coagulopathy syndrome' Am J Surg 1996;172:405-410

4. Cue JI, Cryer HG, Miller FB et al. 'Packing and planned reexploration for hepatic and retroperitoneal hemorrhage - critical refinements of a useful technique' J Trauma 1990;30:1007-1013

5. Carvillo C, Fogler RJ, Shafton GW. 'Delayed gastrointestinal reconstruction following massive abdominal trauma' J Trauma 1993;34:233-235

6. Richardson JD; Bergamini TM; Spain DA et al. 'Operative strategies for management of abdominal aortic gunshot wounds' Surgery 1996; 120:667-671

7. Reilly PM, Rotondo MF, Carpenter JP et al. 'Temporary vascular continuity during damage control - intraluminal shunting for proximal superior mesenteric artery injury' J Trauma 1995;39:757-760

8. Velmahos GC; Baker C; Demetriades D et al. 'Lung-sparing surgery after penetrating trauma using tractotomy, partial lobectomy, and pneumonorrhaphy' Arch Surg 1999;134:86-9

9. Wall MJ Jr; Villavicencio RT; Miller CC et al. 'Pulmonary tractotomy as an abbreviated thoracotomy technique' J Trauma 1998;45:1015-23

10. Schein M, Wittman DH, Aprahamian CC, Condon RE. 'The abdominal compartment syndrome - the physiological and clinical consequences of raised intra-abdominal pressure' J Am Coll Surg 1995;180:745-753

11. Morris JA, Eddy VA, Blinman TA. 'The staged celiotomy for trauma - issues in unpacking and reconstruction' Ann Surg 1993;217:576-586

*line drawings in this article are modified from 'Trauma Surgery', Arthur Donovan (ed), Mosby Year Book 1994