Damage control surgery
Executive Summary
Damage control (DC) surgery represents a paradigm shift in trauma care, moving away from immediate definitive repair toward an abbreviated surgical approach focused on life-saving physiological stabilization. Originally limited to operative techniques, the concept now encompasses "damage control resuscitation," which includes permissive hypotension, early empiric blood component therapy, and the aggressive prevention of the "lethal triad": hypothermia, acidosis, and coagulopathy. The primary objective is to rapidly control hemorrhage and contamination, allowing the patient to be resuscitated in an Intensive Care Unit (ICU) before returning for definitive reconstruction. Evidence indicates that early application—before a patient reaches a state of irreversible "in extremis"—is critical to improving survival outcomes.
General Principles and Indications
The core of DC surgery is the realization that the physiological status of a trauma patient often precludes long, complex reconstructive procedures.
Core Objectives
Rapid Control: Immediate cessation of bleeding and containment of gastrointestinal spillage.
Abbreviated Procedure: Terminating the initial surgery quickly to minimize surgical stress.
Staged Management: Focusing on resuscitation first, followed by definitive reconstruction and closure once physiological exhaustion is reversed.
Standard Indications
Damage control should be considered for:
Patients "in extremis": Those presenting with coagulopathy, hypothermia (< 35 °C), or severe acidosis (base deficit >15 mmol/L).
Anatomic Complexity: Injuries involving difficult-to-control areas such as the complex liver, retroperitoneum, mediastinum, or major vascular structures.
Environmental/Resource Factors: Settings with limited resources (battlefields/rural areas) or when the surgeon’s skillset is not suited for immediate definitive management of a specific injury.
Anatomical Applications of Damage Control
DC techniques are versatile and can be applied across most anatomical regions:
Vascular and Extremity Trauma
Vascular: Standard elective technical principles often do not apply. Options include temporary intraluminal shunting, ligation, balloon catheter occlusion, and extremity amputation. Complex repairs like end-to-end anastomosis are deferred.
Extremities: Management focuses on external fixation for fractures, vascular shunting, and gauze packing.
Thoracic Trauma
Techniques include non-anatomical lung-sparing resections, hilar clamping or twisting, and gauze packing of the posterior mediastinum.
Temporary closure of sternotomy or thoracotomy incisions may be necessary, particularly for patients at high risk for postoperative cardiac arrest requiring immediate access for cardiac massage.
Abdominal Trauma
Hemorrhage Control: Achieved through tight gauze packing (liver, pelvis, retroperitoneum), local hemostatic agents, balloon tamponade for deep tracts, and ligation or shunting of major vessels.
Liver Specifics: Severe liver injuries may require ligation of major bleeders and non-anatomical resection of non-viable tissue. A specific technique involves wrapping the liver in absorbable mesh and applying gauze packing around it to facilitate later removal without causing re-bleeding.
Contamination Control: Intestinal spillage is managed via ligation or stapling of the injured bowel without reanastomosis. While some surgeons favor this to save time, others caution against the risk of closed-loop obstruction and bacterial translocation, preferring reconstruction or ostomy during the initial operation if possible.
Management of the Open Abdomen
Following a DC procedure, the abdominal fascia or skin must never be closed primarily due to the high risk of Abdominal Compartment Syndrome (ACS) or intra-abdominal hypertension (IAH). Temporary abdominal closure (TAC) is mandatory.
Evolution of TAC Techniques
Bogota Bag: A simple construct using a 3-liter sterile irrigation bag or X-ray cassette cover sutured to the skin. It prevents evisceration but fails to remove contaminated fluid or preserve the abdominal wall domain.
Negative-Pressure Therapy (NPT): NPT has revolutionized management by improving survival and primary fascia closure rates.
Barker’s Vacuum Pack: A fenestrated polyethylene sheet is placed over the bowel and under the peritoneum, covered with moist gauze and silicone drains, then sealed and connected to suction.
V.A.C. Abdominal Dressing System: Utilizes polyurethane foam and a computerized pump to pull fascia edges together and remove inflammatory fluids.
ABThera (KCI): A specialized NPT device featuring a visceral protective layer with radiating foam extensions.
Comparative Efficacy of NPT Modalities
The distribution of negative pressure significantly impacts clinical outcomes. Research highlights the following:
Definitive Closure and Postoperative Care
The ultimate goal after physiological stabilization is early, definitive closure of the abdomen to reduce complications.
Timing: Primary fascia closure is often possible within a few days once packing is removed, infection is cleared, and bowel edema subsides.
Technique: If early closure is not possible due to persistent edema, surgeons should attempt to approximate the fascia at the top and bottom of the defect during every return to the operating room for dressing changes.
Large Defects: For persistent large defects, definitive reconstruction may require synthetic or biological meshes, or autologous tissue transfer with component separation.
Clinical Tips and Pitfalls
Early Intervention: The timing of the decision to switch to damage control is critical; it should be made before the patient reaches an irreversible physiological state.
Radiology: Interventional radiology (angiography) is a vital adjunct and should be utilized early if available.
Postoperative Monitoring: Do not assume postoperative bleeding is merely coagulopathic; continuous bleeding requires immediate surgical re-exploration.
NPT Safety: When applying NPT (especially ABThera), ensure the foam does not come into direct contact with the bowel to prevent fistula formation.
Pressure Management: Avoid high negative pressure in cases of incomplete hemostasis, as it may aggravate bleeding. Monitor bladder pressure routinely to detect IAH during NPT application.
