the idea of damage control is described when to be obliged to use it and the methods to apply this technique without losing your patient

1. DAMAGE CONTROL
HAMED RASHAD
Professor of Surgery -Egypt

2. Damage control
 US navy defines it as the capacity of the
ship to absorb damage and maintain its
mission integrity

3. Damage control

4. Damage control

5. Evolution of damage control in
surgical patients
 1908 Pringle: Compression and hepatic packing for
portal venous hemorrhage. Ann Surg 1908;48:541

6. Evolution of damage control in
surgical patients
1983 Stone et al. : Coagulopathy contributed to poor
outcomes. Proposed truncation of laparotomy, reversal of
coagulopathy and then return to OR for definite surgical
repair. Ann Surg : 1983 May; 1979(5) : 532

7. Evolution of damage control in
surgical patients
1990S

8. Evolution of damage control in
surgical patients
 Burch, et al 1992 Ann Surg : 1992 May;
215 (5) :476

9. Evolution of damage control in
surgical patients
 1993 Rotondo et al coined “ Damage Control
Laparotomy “
 20 year review : 52% mortality – 40% morbidity

10. The lethal triad
Hypothermia
Acidosis Coagulopathy

11. The lethal triad
Bleeding coagulopathy
Acidosis hypothermia

12. Effects of hypothermia
 100% mortality if core temp < 32C
 Diminished cardiac function
 Coagulopathy: clotting cascade is a temp.
dependent reaction, fibrinolysis, platelet
dysfunction/sequestration

13. Acidosis
 Lactate production from anaerobic
metabolism
 Failure to normalize lactate concentration
by 48 hours, mortality between 86 to 100%
 Systemic effects: decreased contractility,
impaired response to catecholamines and
ventricular arrhythmias
 Coagulopathy worsened

14. Coagulopathy
 Dilution worsens coagulopathy
 Dilution and hypothermia additive
 Acidosis worsens coagulopathy

15. Control or not?
 Damage control surgery: an alternative approach
for the management of critically injured patients
Kouraklis G, Spirakos S, Glinavou A Surg Today.
2002;32(3):195-202
…These observations have led to the development
of a new surgical strategy that sacrifices the
completeness of immediate repair in order to
adequately address the combined physiological
impact of trauma and surgery

16. Control or not?
 Coagulopathy, hypothermia and acidosis in trauma
patients: the rationale for damage control surgery
De Waele JJ, Vermassen FE. Acta Chir Belg.
2002 Oct;102(5):313-6.
Over the past 20 years, it has gradually become
apparent that the results of prolonged and
extensive surgical procedures performed on
critically injured patients are often poor, even in
experienced hands…

17. Damage control
 Definite surgery is time-consuming and may be
not executed
 Surgical insult may waste functional reserve
 Aims:
– Damage control operation
– Resuscitation in SICU
– Planned reoperation in 24-48 hours

18. Damage control in surgical
patients : Who needs it ?
 Bleeding caused by coagulopathy
 Severe metabolic acidosis (pH <7.3)
 Hypothermia during operation (T° <34°)
 Shock
 Massive transfusion : >10 units PRBCs

19. Damage control in surgical
patients : Who needs it ?
 Surgeon gestalt : --High energy blunt torso trauma
–Multiple visceral injuries – Multiple torso
penetrating injuries – Multi regonal injuries
 Inability to control the haemorrhage (hepatic,
retroperitoneal, pelvic, thoracic or cervical)
 Inability to formally close the abdomen because of
intestinal edema

20. DAMAGE CONTROL SURGERY

21. DAMAGE CONTROL SURGERY

22. DAMAGE CONTROL SURGERY

23. DAMAGE CONTROL SURGERY

24. Technique of damage control :Components
 A- Abbreviated surgery for rapid control of
hemorrhage and contamination
 B- Resuscitation in ICU with correction of
physiological abnormalities
 C- Subsequent definitive repair and
abdominal wall closure

25. Damage Control Surgery
 Phase I
– Rapid termination of operative procedure
– Arrest of bleeding
– Removal of contamination
 Phase II
– Correction of physiologic abnormalities
– Acidosis, hypothermia, coagulopathy
 Phase III
– Definitive surgery

26. What is different?
 Surgical dogma: complete the operation
– 1908: Pringle packing of liver injury
– Fell out of favour, not used in Vietnam war
– 1981: Feliciano 90% survival by packing in severe liver
injury
– 1983: Stone abbreviated laparotomy, 11/17 survivors
 Rotundo: damage control surgery, 1990s

27. Damage control : Technique
A-Abbreviated resuscitative surgery :
-- Do only necessary procedures
1-- Control bleeding :
0- Ligation
0- Shunting
0- Packing
2--Excision/Stapling of bowel to prevent further
contamination
3-- Temporary closure of abdominal wall defect
--Limit heat loss

28. Abdomen
 Liver packing
 Ligation of blood vessels
 Placement of intraluminal shunts
 Chest tubes in to aorta or IVC
 Inflatable balloon catheters

29. Abdomen II
 Resect hollow viscus with a stapler
 Biliopancreatic injuries by closed suction drainage
 Ligation of ureter or tube ureterostomy
 Formal closure
– Abdominal compartment syndrome
– ARDS
– MOF
 Closure of skin, mesh

30. Damage Control Surgery
•Prep surgical field from neck to knees and from flank to
flank
•Longitudinal incision form xiphoid to pubis
•Cell saver to reinfuse autologous blood if possible
•Urgent exploration with packing of all four quadrants of
abdomen
•Serial controlled examination of each quadrant and organ
•Pack liver injuries and splenic injuries
•Control vascular injuries
•Close off perforated gastrointestinal tract
•Examine retroperitoneal structures

31. DAMAGE CONTROL SURGERY
•Avoid hypotension, hypothermia, acidosis
leading to coagulopathy
•Repair or ligate vascular injuries
•Splenectomy if injured
•Repair or resect intestines
•Pack liver hemorrhage
•Pack and leave open abdomen if necessary

35. Damage control in surgical
patients
1- Control of bleeding :
* Temporary stenting
* Packing/ Tamponade
* Angio-embolization
* Recombinant FactorVIIa
* Ligation of vessels rather than repair

36. Contrast “blush” on CT

37. Lap pad packing

38. Lap pad packing

39. Lap pad packing

40. Solid organ
tract
haemorrhage:
Balloon tamponade

41. Total hepatic
vascular
occlusion

42. Angio-embolization

43. Angio-embolization

44. Extraperitoneal pelvic packing

45. Damage control: Control of bleeding
 Recombinant Factor VIIa :
--Dilutional coagulopathy
--Stored blood product
--Clot promotion; activates factor Xa
--Throbo-embolic risk ?

46. Damage control : Contamination control
 2- Contamination control
– Hollow viscus ligation instead of repair
– External tube drainage of biliary and pancreatic
injury instead of pancreatoduodenectomy
– ERCP for diagnosis and treatment
– Avoidance of formal colostomy

47. Temporary bowel closure

48. Duodenal injury
Pyloric exclusion

49. Combined Duodenal
pancreatic-Biliary
injury
Duodenal
Diverticularization

50. Biliary Leak
Diagnosis and treatment by ERCP

51. Damage control : Closure
 3- Temporary closure of abdominal
wall defect

52. Temporary abdominal closure
 Towel clips

53. Temporary abdominal closure
 Cystoscopy irrigation bag or IV bag

54. Temporary abdominal closure
 Silastic sheeting

55. Temporary abdominal closure
 Gore-Tex or Vicryl Mesh

56. Temporary abdominal closure
 VAC pack

57. B-ICU Resuscitation
 Warm the patient
 Correct the acidosis
 Correct the coagulopathy

58. Resuscitation
 End points of resuscitation
 Adequate urinary output
 Haematocrit >20%
 Restoration of vital signs
- Normal mixed venous O2
- Normal or high cardiac output
 Clearance of lactic acidosis/base deficit
 Normalize pH preferably without NaHCO3

59. Resuscitation
 IV volume restoration best accomplished
using FFP in 1:1 ratio with PRBCs
 Crystalloid use is more limited

60. Metabolic acidosis
 Usually correct on its own once the patient
is warm and volume resuscitated
 O2 debt repaid
 Anaerobic Aerobic metabolism
 Need for NaHCO3 is rare – but
If cadiotonic agents are needed, keep pH>7.2

61. Pitfalls
 Continued hemorrhage:
Especially in a warm non-coagulopathic patient
Vessels that were constricted and NOT ligated at the time of
operation may begin bleeding as the patient is warmed and
resuscitated
Return to the OR

62. Pitfalls
 Continued shock :
--Missed injury
--Failed repair with leakage
Return to the OR

63. C- Definitive repair
 When to return to the OR ?
-- When patient is warm and acidosis and
coagulopathy has been corrected
-- 36-72 hours had reduced risk of
rebleeding for patients with perihepatic
packing

64. C- Definitive repair
 Bowel injuries
-- Colostomy or anastomosis ?
* Delayed anastomosis as safe as colostomy
-- Stapled or hand sewn anastomosis
* Controversial
* Surgeon comfort with the technique
* Presence of bowel oedema
Oedematous bowel is more prone to anastomotic leak
Wait for oedema to resolve to do anastomosis

65. C- Definitive repair : Closure
Velcro patch

66. C- Definitive repair : Closure
Vaccuom closure
92% of patients closed in 9.9 _+ 1.9 days
Garner et al, Am J Surg 2001; 132 : 630

67. Closure
 When the abdomen can not be closed
 Bowel becomes “stuck”
 Multiple solutions :
* Permanent mesh
* Absorbable mesh
* Prosthetic patches
* Bioprosthetic patches
* STSG directly on granulated bowel
* Component separation

68. Summary
 Organ injury patterns and survival from
penetrating abdominal injury have remained
similar over the last decade
 Death from refractory hemorrhage in the
first 24 hours remain the common cause of
mortality.

69. Summary
 DCS and use of open abdomen are being
used more frequently with imporved
survival, but result in more morbidity.
 Evidence-based analysis will be the ultimate
guideline to determine the optimal
management.

70. THANK YOU
for your attention!