Reoperation

The principles of reoperation are removal of clots and abdominal packs, complete inspection of the abdomen to detect missed injuries, haemostasis and restoration of intestinal integrity and abdominal wound closure.

Damage Control Surgery

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

Timing of reoperation is critical. There is usually a window of opportunity between correction of metabolic failure and the onset of the systemic inflammatory response syndrome and multiple organ failure. This window usually occurs at 24-48 hours after the first procedure. There is a tradeoff between earlier re-operation, when the patient may be less stable and bowel-well oedema marked, and delaying the procedure to a point where cardiovascular, respiratory and renal failure make the procedure hazardous. Vascular shunts should be removed and grafts inserted at the earliest opportunity as these may dislodge or clot once coagulopathy is corrected. If packs are left in the abdomen it is generally recommended that these are removed at 48-72 hours, although there is little evidence to suggest that leaving them longer is detrimental.

Abdominal packs, especially around the liver or spleen should be removed cautiously as they may be stuck to the parenchyma and removal may lead to further bleeding. Soaking the swabs may aid this process. The bleeding is rarely dramatic however and may be controlled with argon-beam diathermy or fibrin glue. Occasionally repacking will be necessary.

Any intestinal repairs carried out at the first procedure should be inspected to determine their continued integrity. Bowel ends that were stapled or tied off should be inspected, necrotic tissue debrided and primary repair with end-to-end anastomosis undertaken. With a haemodynamically stable, warm patient, colostomy is rarely necessary.

Copious washout should be performed and the abdomen closed with standard mass closure to the sheath and routine skin closure. If the sheath cannot be re-approximated temporary silo closure can be reinstated or an absorbable PDS or vicryl mesh applied which can be skin grafted at a later stage. The resulting incisional hernia can be closed at a later procedure.

Damage Control Surgery