Damage Control Laparotomy - an evidence based approach
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Dr. Yasser Abbas outlines the concept of damage control surgery, which involves temporarily controlling bleeding and contamination through techniques like packing and temporary abdominal closure, to allow time for resuscitation before definitive repair. Damage control is indicated for patients who are hemodynamically unstable, coagulopathic, acidotic, or hypothermic and involves three phases - initial surgery to control bleeding, ICU resuscitation to correct physiological derangements, and a second surgery for definitive repair once stabilized. The goal of damage control is to prevent the "lethal triad" of acidosis, coagulopathy, and hypothermia in order to improve survival rates.
Damage Control Laparotomy - an evidence based approach
- 1. Dr. Yasser Abbas Department of General surgery
- 2. Outlines Concept of Damage control History Indications of Damage Control. Damage Control Sequence. Complications. Summary.
- 3. Concept of Damage control “ …keeping afloat a badly damaged ship by procedures to limit flooding , stabilize the vessel, isolate fires and explosions and avoid their spreading” Surface ship survivability, Naval war publication 3-20.31, Washington, DC. Department of defense; 1996
- 4. Definitive Surgery Approach? “The operation was a success but the patient died anyway.” – Anonymous
- 5. Damage Control Approach ? “He who fights and runs away, may live to fight another day.” – JA Aulls, 1876
- 6. History
- 7. In 1983, Stone was first to describe the “bailout” approach . 14 patients : Per-operative correction of coagulopathy Definitive surgery 1 survivor 17 patients: OR and packing Correction of coagulopathy in ICU Re exploration in OR 11 survivors
- 9. The Concept Expansion The concept of DC was initially described for intra-abdominal trauma, it has been expanded to : Thoracic. Extremity vascular. Orthopedic injuries. “Damage Control Resuscitation”. 1c
- 10. Indications of DC High-energy blunt torso trauma Multiple penetrating torso injuries Hemodynamic instability Coagulopathy on presentation or during operation Severe metabolic acidosis (pH < 7.2 or base deficit > 8) Hypothermia on presentation (< 35°C) Prohibitive operative time required to repair injuries (> 90 min) Multiple visceral injuries with major vascular trauma Multiple injuries across body cavities Massive transfusion requirements (> 10 units packed red blood cells) Presence of injuries better treated with nonsurgical adjuncts
- 11. The Lethal Triad
- 12. It is Better to Cure in Phases rather than to Kill in one - Anonymous
- 13. DC Sequence Ground 0 Prehospital care & Initial resuscitation: Built on fundamentals of ATLS guidelines. Rapid Transport to definitive care. Rapid Evaluation. FAST, Tube Thorocostomy , CXR, Pelvis X-ray, etc… Damage Control Resuscitation to systolic 80-90 mmHg. This phase should take 20-30 min.
- 14. How do We Predict in ED ? A DC approach should be taken with any patient in the ED who has : Revised Trauma Score ( RTS ) ≤ 5 Requires ≥ 2,000 ml of crystalloids for resuscitation in the ER. Requires ≥ 2 units of PRBCs for resuscitation in the ER. A pH of ≤ 7.2 Strength of evidence: C. Asensio J, et al. Am J Surg 2001; 182: 743–51.
- 15. DC Sequence Part 1(OR) Control of Hemorrhage and Contamination: Laparotomy Evacuation of blood. Four quadrant packing. Full exposure of the injuries. Kocher maneuver Cattell-Braasch Mattox
- 16. DC Sequence Part 1(OR) Solid organs: such as spleen and isolated kidney , are sacrificed in damage control if repair prolongs surgical times. Bleeding vessel : Ligation /shunting. Bowel injury: stapler/ ligation. Intra-abdominal Packing Temporary abdominal closure This phase shouldn`t take more than 90 min.
- 17. Incisions in DC
- 19. Kocher Maneuver
- 20. Cattell-Braasch
- 21. Mattox
- 22. Liver Packing
- 23. Intraoperative ; How to identify the patient for DC ? Patients who require ≥ 4,000 ml PRBCs. Patients who have had an ED or OR. thoracotomy. pH ≤ 7.2 Temperature of ≤ 34°C Inaccessible major venous injury
- 24. Intraoperative ; How to identify the patient for DC ? If the surgeon cannot achieve hemostasis owing to coagulopathy If the definitive operative repair is a time-consuming procedure in the patient with suboptimal response to resuscitation If the patient requires the management of an extra-abdominal life-threatening injury
- 25. Intraoperative ; How to identify the patient for DC ? If the patient will require a reassessment of intra-abdominal contents If the surgeon cannot re-approximate the abdominal fascia due visceral edema. Strength of recommendation: D. Shapiro M, Jenkins D, Schwab C, et al. J Trauma 2000; 49: 969–78. Rotondo M, Zonies D. Surg Clin N Am 1997; 77: 761–77. Loveland J, Boffard K. Br J Surg 2004; 91: 1095–101
- 26. When We Terminate the Surgery? Core temperature ≤ 34°C pH ≤ 7.2 Prothromin time ≥ twice normal Partial thromboplastin time ≥ twice normal Strength of recommendation: B. Ferrara A, MacArthur J, Wright H, et al. Am J Surg 1990; 160: 515–18. Cosgriff N, Moore E, Sauaia A, et al. J Trauma 1997; 42: 857–61; discussion 861–2. Garrison J, Richardson J, Hilakos A, et al. J Trauma 1996; 40: 923–7; discussion 927–9.
- 27. Part 2: Resuscitation(ICU) Correct Acidosis and Coagulopathy Rewarm the patient Optimize oxygenation and ventilation Measure Intra abdominal pressure. ( 1A)
- 28. Part 3: (OR 2) Careful removal of packs Inspection of all injuries Control of bleeding points Definitive GIT repair Thorough washout Avoid stomas and tube entrostomies if possible Temporary vs. definitive closure
- 29. Part 4: Open Abdominal Wounds Temporary closure of the open abdomen is best accomplished : VAC Dressing. and a fascial tensioning. Abdominal closure is best accomplished by hospital day 8 to reduce morbidity. Strength of recommendation: C. Barker D, Green J, Maxwell R, et al. J Am Coll Surg 2007;204:784–92. Offner P, de Souza A, Moore E, et al. Arch Surg 2001; 136: 676–81. Garner G, Ware D, Cocanour C, et al. Am J Surg 2001; 182:630–8.
- 31. Mesh closure and Tightening
- 33. Outcome Before After
- 35. Outcome
- 36. DC Timeline Reuven Rabinovici, et al. , Trauma, Critical care & surgical emergency. 2010
- 37. Complications of DC Expected complication rate from damage control ranges from 25% to 40% . The most common complications : Intra-abdominal abscesses Enterocutaneous fistulae. Strength of recommendation: C. Abikhaled J, Granchi T, Wall M, et al. Am Surg 1997; 63: 1109–12; discussion 1112–13. Sharp K, Locicero R. Ann Surg 1992; 215: 467–74; discussion 474–5.
- 38. Summary The management of exsanguination requires leadership, prompt thinking and aggressive surgical intervention. Delays in the decision to perform DC contribute to a higher morbidity and mortality. DC is a vital part of the management of the multiply injured patient and should be performed before metabolic exhaustion.