12.1

Damage Control Surgery

Chapter 12

Damage Control Surgery

Introduction

The traditional approach to combat injury care is surgical

exploration with definitive repair of all injuries. This approach

is successful when there are a limited number of injuries.

Prolonged operative times and persistent bleeding lead to the

lethal triad of coagulopathy, acidosis, and hypothermia,

resulting in a mortality of 90%.

Damage control is defined as the rapid initial control of

hemorrhage and contamination, temporary closure,

resuscitation to normal physiology in the ICU, and

subsequent re-exploration and definitive repair. This

approach reduces mortality to 50% in some civilian

settings.

 What might increase the life and limb salvage rate in troops

in the field setting is the application of the damage control

concepts described above in patients with favorable

physiology.

 Tactical Abbreviated Surgical Control (TASC).

ο Damage control techniques in a tactical environment.

ο Abbreviated, focused operative interventions for peripheral

vascular injuries, extensive bone and soft tissue injuries,

and thoracoabdominal penetrations in patients expected

to survive, instead of definitive surgery for every casualty.

ο This may conserve precious resources, such as time,

operating table space, and blood.

 This TASC philosophy relies on further definitive surgical

care at the next echelon of care.
12.2

Emergency War Surgery

Damage control techniques should be considered in all multisystem casualties at the onset of surgical therapy. When initially

rejected, reconsideration should occur when unexpected

findings are discovered or natural breaks in the surgical therapy

occur, following an initial decision to perform a definitive repair.

The goal of damage control is to restore normal physiology

rather than normal anatomy. It is used for the multiple injured

casualty with combinations of abdominal, vascular, genitourinary, neurologic, orthopedic, and/or thoracic injury in three

separate and distinct phases:

1. Primary Operation and Hemorrhage Control – surgical

control of hemorrhage and removal of contamination;

laparotomy terminated, abdomen packed and temporary

closure; definitive repair is deferred.

2. Critical Care Considerations – normal physiology restored

in ICU by core rewarming, correction of coagulopathy, and

hemodynamic normalization.

3. Planned Reoperation – re-exploration to complete the

definitive surgical management or evacuation.

 General Considerations

 Philosophy of damage control is “a live patient above all else.”

ο Avoid hypothermia.

ο Rapidly achieve hemostasis.

ο Perform only essential bowel resections.

ο Close or divert all hollow viscus injuries, only performing

reconstruction at the second operation after the patient has

stabilized and can tolerate a prolonged operation.

 When to employ damage control.

ο Use damage control in patients who are present with or at

risk for developing:

♦ Multiple life-threatening injuries.

♦ Acidosis (pH < 7.2).

♦ Hypothermia (temp < 34°C).

♦ Hypotension and shock on presentation.

♦ Combined hollow viscus and vascular or vascularized

organ injury.

♦ Coagulopathy (PT > 19 sec and/or PTT > 60 sec).
12.3

Damage Control Surgery

♦ Mass casualty situation.

ο Take into account ability to control hemorrhage, severity

of liver injury, and associated injuries.

ο Pack before massive blood loss (10–15 units of pRBCs) has

occurred.

ο Injuries that typically require damage control techniques.

♦ Upper abdominal injuries that are not isolated spleen

injuries (duodenal, large liver injuries, pancreas, and

so forth).

♦ Major penetrating pelvic trauma of more than one

system.

♦ Any retroperitoneal vascular injury.

To reiterate, damage control is practiced in three phases:

1. Primary operation and hemorrhage control.

2. Critical care resuscitation.

3. Planned reoperation.

Phase 1: Primary Operation and Hemorrhage Control

Phase 1 of damage control includes 5 distinct steps:

1. Control of hemorrhage.

2. Exploration to determine extent of injury.

3. Control of contamination.

4. Therapeutic packing.

5. Abdominal closure.

 Control of hemorrhage/Vascular injury repair.

ο Control of hemorrhage is best done with ligation, shunting,

or repair of injured vessels as they are encountered.

ο The primary goal is hemorrhage control, not maintenance

of blood flow.

ο For the patient in extremis, clamping or shunting of major

vessels is recommended over repair.

♦ THINK: ligate/shunt ⇒ fasciotomy.

ο Additional methods of hemorrhage control include balloon

catheter tamponade of vascular or solid viscus injuries.

 Exploration to determine extent of injury.

ο Damage control laparotomy.

♦ Rapidly achieve hemostasis.
12.4

Emergency War Surgery

♦ Perform only essential resections or pack solid organs

to diminish blood loss.

♦ Close or divert all hollow viscus injuries.

♦ Rapidly terminate the procedure to correct hypovolemia, hypothermia, and acidosis to prevent

coagulopathy.

♦ Perform definitive reconstruction only after the patient

has stabilized and can tolerate a prolonged operation.

 Control of Contamination.

ο Contamination control also proceeds as injuries are

encountered, utilizing clamps, primary repair or resection

without reanastomosis.

ο With multiple enterotomies, if the area of injury represents

less than 50% of the length of the small bowel, a single

resection can be undertaken.

ο At this stage of the operation, the surgeon must decide

whether or not to proceed with definitive repair of the

identified and controlled injuries. Careful communication

with the anesthesiologist is critical to this decision.

♦ If aggressive resuscitation has been successful in

maintaining normal temperature, coagulation, and acid

base status, then definitive repair may proceed.

♦ If any of these interrelated factors are abnormal, the

procedure should be terminated (contamination

controlled without reanastomosis) and the patient taken

to the ICU for further resuscitation.

♦ The presence and status of extra-abdominal injuries

needs to be taken into consideration when deciding how

much physiologic reserve the patient has left.

 Therapeutic Packing.

ο Resuscitative vs Therapeutic Packing.

♦ Resuscitative packing is manual compression of the

bleeding site as an initial measure in controlling or

minimizing blood loss.

♦ Therapeutic packing provides long-term tamponade of

liver, pelvic, and retroperitoneal bleeding.

ο Do not use the “pack and peek” technique wherein the

liver is packed and the patient resuscitated; the packs are

removed to identify the source of bleeding, but rebleeding
12.5

Damage Control Surgery

occurs before the site can be identified; the liver is packed

again; the patient is resuscitated again; and the entire cycle

is repeated.

ο Definitive therapeutic packing is based on three basic

principles.

♦ Pressure stops bleeding.

♦ Pressure vectors should recreate tissue planes (attempt

to recreate the pressure vectors created by the capsule

of a solid organ or fill the space of that organ, not

random pack placement).

♦ Tissue viability must be preserved.

ο 6–12 laparotomy pads are the best commonly available

packing material.

ο An intervening layer, such as a bowel bag, sterile drape,

absorbable mesh, or omentum, can be placed between

packs and the tissue to aid in easy pack removal at

relaparotomy.

 Abdominal Closure.

ο Leave the fascia open.

ο Vacuum pack (preferred technique — easy, keeps patient

dry, allows for expansion).

♦ With fascia open, place fully plastic-covered (bowel bag,

X-ray cassette bag, Ioban drape) sterile operating room

(OR) towel circumferentially under the fascia to cover

the viscera. Place a small number of central perforations

to allow fluid to egress to the drains.

♦ Place closed-suction drains (Jackson-Pratt, modified

Foley, small chest tube) above the plastic at the level of

the subcutaneous tissue brought out through separate

stab wounds or the inferior portion of the wound.

♦ Place lap sponges to fill in the wound.

♦ Cover the entire wound with a large Ioban drape.

♦ Place drains on low suction and secure to the skin.

ο A silastic sheet or 3-liter IV bag, sewn to the skin or fascia,

can accomplish abdominal closure in virtually every

instance.

ο Skin closure is not recommended, but may be quickly

accomplished with skin staples, towel clips (reliably

stronger), or running monofilament suture.
12.6

Emergency War Surgery

Skin closure may lead to abdominal compartment

syndrome.

Thoracic injuries

 The goal of abbreviated thoracotomy is to stop the bleeding

and restore a survivable physiology; contamination is

usually not a problem.

 In the exsanguinating patient, formal lung resection gives

way to using large staplers in a nonanatomic wedge resection

to rapidly achieve hemostasis and control of air leaks.

 In pulmonary tractotomy, the lung bridging the wound tract

is opened between long clamps or with a linear stapler. The

tract can thus be directly inspected, bleeding points selectively

ligated, and air leaks controlled.

 Vascular injuries can be treated with intraluminal shunts or

Fogarty balloons to achieve distal control in inaccessible areas.

 Tracheal injury can be treated with airway control placed

through the site of injury.

 Extensive bronchial repairs are not feasible in the patient in

extremis; therefore, rapid resection of the affected lobe or lung

would be best.

 When dealing with esophageal injury, diversion, and wide

drainage, not definitive repair, is the best course of action.

 A single en masse suture closure of the chest wall is best

because wound closure of skin with towel clips may result in

significant blood loss from the musculature.

Phase 2: Critical Care Considerations

 Physiologic support in the post-op TASC patient is

paramount to survival.

ο Core rewarming: warmed resuscitative fluids, blankets,

ventilator air, and environment, or commercially available

products such as Bair Hugger, Chill Buster.

ο Reversal of acidosis: appropriate/aggressive resuscitation

with crystalloid, colloid, and blood products.

ο Reversal of coagulopathy: at many locations, only ultrafresh whole blood is available to correct coagulopathy.

 Abdominal compartment syndrome.
12.7

Damage Control Surgery

ο Abdominal compartment syndrome is a condition in which

increased intra-abdominal pressure adversely affects the

circulation and threatens the function and viability of

the viscera.

ο Measurement is performed using urinary bladder pressure

(normal = zero).

♦ Several methods are available for performing bladder

pressure.

◊ Place 100–150 cc of sterile saline in the bladder and

clamp the foley.

◊ Access the needle port on the catheter and attach to a

pressure monitor (central venous pressure transducer).

◊ Access the needle port and create a column of water

via plain IV tubing held vertically or use of the

pressure gauge from a lumbar puncture kit.

◊ If there is no needle port, clamp the foley proximal

and the distal end of regular IV tubing in the usual

drainage end of the catheter until firmly in place.

♦ Measurement of bladder pressure is a good variable to

test and follow; however, intervention for abdominal

compartment syndrome (ACS) should occur when

suspected or clinically indicated.

ο Occurs in abdominal trauma accompanied by visceral

swelling, hematoma, or abdominal pack use.

ο Physiology of abdominal compartment syndrome.

♦ Cardiac output and venous return are decreased.

♦ Reduction in blood flow to liver, intestines, and kidneys

can result in anuria.

♦ The two hemidiaphragms push upward, decreasing

thoracic volume, and compliance leading to elevated

peak airway pressures.

♦ Central venous, pulmonary capillary wedge, and right

atrial pressures increase with intra-abdominal pressure

(can lead to false PA catheter pressures).

♦ PO2 is decreased due to increases in airway pressures

and ventilation/perfusion abnormalities that worsen

with positive end-expiratory pressure (PEEP).
12.8

Emergency War Surgery

Abdominal Pressure Degree of Elevation Clinical Effect

10–20 mm Hg Mild Insignificant

20–40 mm Hg Moderate Oliguria and organ dysfunction

>40 mm Hg Severe Requires immediate attention

Phase 3: Planned Reoperation

 Packs should be left in place until the patient’s hemodynamics

are stable and all major sites of hemorrhage have had time to

clot.

 Reoperation should be scheduled when the probability of

achieving definitive organ repair and complete fascial closure

are highest.

 Timing must coincide with reversal of hypotension, acidosis,

hypothermia, and coagulopathy. Typically occurs 24–48 hours

following the primary insult when brisk diuresis, negative

fluid balance, diminishing abdominal girth, and decreasing

peripheral edema indicate reduction in visceral and parietal

edema.

 This surgery may occur at the next echelon of care.

ο Stratevac should be weighed carefully because transit

operative care is minimal. Surgical expertise is generally not

available and transit times are often greater than 24 hours.

 Timing can, however, be dictated by other pressing clinical

concerns such as abdominal compartment syndrome, limb

ischemia, and suboptimal control of spillage at primary

operation.

 In cases of a packed and drained duodenum, pancreas, kidney

or bladder, or liver injuries with gross bowel contamination,

packs should be retrieved within 36–48 hours.

 It is sometimes necessary to perform this type of operation

at the bedside, as the patient’s cardiopulmonary status does

not allow a trip to the OR.

Conduct of Relaparotomy

 It is to be presumed that injuries were missed.

 A complete laparotomy must be performed in search of

missed injury.
12.9

Damage Control Surgery

 The surgeon must exercise caution and sound judgment

before performing full reconstruction of the GI tract because

the patient is typically still critically ill and catabolic, making

the patient less likely to heal anastomoses and even less likely

to tolerate a leak or uncontrolled fistula.

 Feeding tube placement, either transabdominal or nasoenteric, should be placed at this time.

 Repacking may be re-employed if other measures fail to

control hemorrhage.

 An abdominal film should be obtained to insure all packs

have been removed from the abdomen. Sponge counts should

be considered unreliable in this situation.

 Unplanned Reexploration.

ο Emergent, unplanned reexploration should be performed

in any:

♦ Normothermic patient with unabated bleeding (> 2

units of PRBCs/h).

♦ Patient who develops severe intra-abdominal compartment syndrome.

♦ Patient requiring postoperative transfusion of > 10 units

of PRBCs.

♦ Patient with persistent lactic acidosis.

Austere Field and Military Surgical Considerations

 Due to severe physiological insult, the typical civilian damage

control patient requires 2 surgeons and 1 nurse, at a minimum,

at the bedside for the first 6 hours. An example of the magnitude of the ICU problem that may be encountered is a casualty

who requires a pulmonary artery catheter, 3 operations, 33

units of PRBCs, and an ICU stay of 23 days. In mass casualty

scenarios, this patient would likely be triaged as expectant.

Tactical Abbreviated Surgical Control philosophy allows

the surgeon to apply damage control techniques when the

limitations of reserve exist outside the patient, in the

tactical environment, not just to patients about to exhaust

their physiological reserve (classic damage control

scenario).
12.10

Emergency War Surgery

Summary Points

 Damage control is not a procedure of last resort. The

consideration of damage control techniques should be made

at the initiation of operative intervention in any multitrauma

casualty and reconsidered during any case where extensive

injuries are involved.

 Consider damage control in patients with severe liver injury,

combined vascular and hollow viscus injuries, multiple sites

of hemorrhage, diminished physiological reserve, and combinations of severe injury involving multiple organ systems

(eg, CNS, orthopedic, vascular, or thoracoabdominal).

 Consider damage control early, ISS > 35, pH < 7.2, temperature < 34°C, shock, or coagulopathy.

 Avoid: hypothermia, ‘pack and peek’, tight abdominal

closure, abdominal compartment syndrome, delayed

relaparotomy for surgical bleeding, and getting stuck in a

conventional thinking mode.

 Think: vascular shunts/fasciotomy, abdominal packing,

external fixators, angiographic embolization (when available), temporary closure, nonanatomic resections, and missed

injury.

 Plan sequence of operation in stable patients to allow for use

of damage control if instability develops.