Dr. Brijesh Mathur

President ASI (Rajasthan Chapter)

Professor of surgery

J.L.N. Med. College & Hospital,

Ajmer(RAJ).

JAWAHAR LAL NEHRU MEDICAL COLLEGE, AJMER

DAMAGE CONTROL is the term used in the Merchant Marine , Maritime industry and Navies for the emergency control of situations that may hazard the sinking of the ship.

Simple measures may stop flooding…

Damage control operations are performed in injured patients with profound hemorrhagic shock and preoperative or intraoperative metabolic sequelae that are known to adversely affect survival.

Damage control surgery, “abbreviated laparotomy “, “staged laparotomy “ , temporary abdominal closure “ are synonymous.

The term Damage control is applied when the initial laparotomy is ended and expeditious indirect methods are applied to control massive bleeding or soiling or both.

Patients are more likely to die from their intraoperative metabolic failure than they are from the failure to complete organ repairs.

1908 Pringle; compression and hepatic packing for portal venous hemorrhage.

BACKGROUND:- The concept of damage control laparotomy

for seriously injured trauma patients was promulgated in 1983.

Stone & colleagus described managing life threatening blood loss and vascular injury quickly followed by immediate closure of the abdomen without completing definitive management.

In severe trauma hypothermia occurs due to:1.Inadequate protection of the patients.

2.Blood loss → shock → worsening of hypothermia.

3.I.V. fluid & blood transfusion. Hypothermia has dramatic effects on body

functions, exacerbates coagulopathy and interferes with blood homeostatic mechanisms.

• Uncorrected hemorrhagic shock will lead to production of lactic acid.

• This leads to profound metabolic acidosis which interferes with clotting mechanisms causing more blood loss.

•Hypothermia, acidosis, massive blood transfusions all lead to coagulopathy.

•Patient continues to bleed even when mechanical control of bleeding achieved.

•This worsens hemorrhagic shock and so worsening of hypothermia and acidosis; produce a vicious circle.

ACS is the result of acute increase in intra-abdominal pressure after major surgery or DCS.Causes:-Perihepatic packing.Bowel edema and congestion in major trauma.Accumulation of blood in the mesentery and/or retro-peritoneal space. Persistent intraabdominal bleeding.

It can occur in the absence of intra-abdominal injuries.This “secondary” abdominal compartment syndrome is thought to be due to an ischemia and reperfusion injury in the gastrointestinal tract as well as a capillary leak syndrome from abdominal viscera who present with severe injuries, sepsis, or massive burns.

Direct measurement of intra-abdominal pressure is accomplished by inserting an intraperitoneal catheter attached to a manometer or transducer.

Indirect measurement is possible through a catheter inserted into the urinary bladder, stomach, or inferior vena cava at the level of the symphysis pubis through a saline column (50 to 100 mL) by three-way Foley catheter; this technique may theoretically allow for a more timely identification of elevated intraabdominal pressures.

oACS suspected in any multiple trauma patient.

oFall in urine output.oElevated central venous pressure.oConfirmed by measurement of intraabdominal

pressure, through Foley catheter in the bladder.oNormal intraabdominal pressure is zero; a

pressure > 25 cm water is diagnostic of ACS

• Anticipate development of ACS and use an alternate technique of wound closure.

1. Management is entirely surgical decompression.

2. Before surgical decompression; maximize intravascular volume status.

3. Maximize O2 delivery, correct hypothermia and coagulation defect.

:

. Administration of crystalloid solution containing bicarbonate and mannitol to avoid side effect of releasing the product of anaerobic metabolism.

. Return of normal hemodynamic and pulmonary parameters occurs immediately, including return of renal function.

. Be aware of good preparation because sudden decompression can cause hypotension or rarely asystole and death.

1.Identify injuries.

2.Control hemorrhage.

3.Control of intestinal spillage.

So that the operation ends as soon as possible before establishment of the triad.

1.Initial laparotomy in Operative room.

2.Resuscitation phase in SICU.

3.Definitive operation in Operative room. (Reopertion)

Part I - OR•Control of hemorrhage•Control of contamination•Intraabdominal packing•Temporary closure

Part II - ICU•Core Rewarming•Correct coagulopathy•Maintain hemodynamic status•Ventilatory support•Injury identification

Part III - OR•Pack removal•Definitive repair

control of hemorrhage from the heart or lung. conservative management of injuries to solid

organs; resection of major injuries to the

gastrointestinal tract without reanastomosis; control of hemorrhage from major arteries and

veins in the neck, trunk, or extremities; packing of organs or spaces to control the

inevitable coagulopathy; use of an alternate closure of a cervical

incision, thoracotomy, laparotomy, or site of exploration

of an extremity.

- Decision for DCS should

ideally be made within

the first 15 minutes of the operation.

Liver : The liver has a blood supply of 1500 mL/min and is the major site of synthesis of all the coagulation factors except factor VIII.

Hepatorrhaphy Hepatotomy with selective vascular ligation, Resectional debridement with selective vascular

ligation, or rapid resectional debridement , Control of hemorrhage with the finger fracture

technique. Balloon catheter tamponade, absorbable mesh

tamponade, and perihepatic packing.

Spleen :American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) grade 3,4,5 – Splenectomy otherwise splenorrhaphy

G I T: Multiple perforation with mesentry bleed controlled by using metallic clips for mesenteric hemostasis and staples to transect the bowel.

Life-threatening arterial hemorrhage- insert a Fogarty balloon catheter into the internal iliac artery beyond a proximal tie on the side of the hemorrhage.

Venous hemorrhage- ligation, inserting fibrin glue, or placing a Foley catheter.

The abdomen closed without tension by using Towel clips, Bogota bag or other methods.

•Bogota bag is transparent and allows inspection of intestine, hemorrhage ,leaks and gangrene.

Bogota bag

Vigorous rewarming of the hypothermic patient.

Restoration of a normal cardiovascular state by the infusion of fluids and blood and the

use of inotropic and related drugs.

Correction of residual coagulopathy after hypothermia is reversed

Supportive care for stunned lungs and kidneys

•Heat loss during major trauma patient

•may be as high as 4.5 ºC per hour.

•Thrombocytopenia results from massive blood

transfusion → coagulopathy; corrected by platelets transfusion.

Large volumes of crystalloids and packed RBCs → diluting coagulating proteins corrected by clotting factors and fibrinogen.

Coagulopathy is common in patients with haemorrhagic shock

In trauma patients predicted to require massive transfusion, administration of fresh frozen plasma, packed red blood cells, and platelets in a 1:1:1 ratio (of individual units) is associated with improved survival.

Recombinant factor VIIa, cryoprecipitate, and tranexamic acid can be considered adjunctive treatments for coagulopathy

•Metabolic acidosis induced by Lactic acid accumulation , produced by shock.

•Aggressive treatment of shock by fluids, blood, fresh frozen plasma, inotropic agents are needed.

•Use of i.v. sodium bicarbonate and follow the PH estimation.

•Following DCS, patients are intubated in ICU and maintained on mechanical ventilation.

•Goal is to achieve oxygen saturation more than 92%.

•These patients usually require deep sedation and pain relieving medications.

Re-operation done within 24 – 72 hours. Principles of re-operation:-

1. Removal of clots and abdominal packs.

2. Complete inspection of abdomen to detect missed injuries.

3. Restoration of intestinal integrity.

4. Abdominal wound closure.

Failure to attain the desired endpoints of resuscitation during the ICU phase of damage control may reflect continuing hemorrhage.

Decision ? mechanical or surgical

hemorrhage versus diffuse oozing from a coagulopathy.

Diffuse oozing due to hypothermia-related coagulopathy an early reoperation not indicated.

Another obvious indication for an early reoperation is the development of the previously described A.C.S.

Sudden release of A.C.S at the time of reoperation reperfusion phenomenon and a cardiac arrest.

Recommended that volume loading with 2 L

of a solution composed of 0.45% normal saline, 50 g mannitol per litre, and 100 meq

sodium bicarbonate per litre be perfused before release of the abdominal wall.

A complete examination of all abdominal contents is performed to detect any injuries missed at the damage control laparotomy.

Resections, anastomoses of the bowel, and maturation of colostomies are rapidly performed in the hemodynamically

stable patient.

During closure, the abdominal cavity is vigorously irrigated with saline solution containing antibiotics.

This solution is left in the abdominal cavity during the 3 to 5 minutes that it takes for the surgical team to change gloves and place towels around the wound.

The irrigating solution is then aspirated from the abdominal cavity, and drains are inserted as indicated.

Plastic silo may be reapplied at the reoperation in the distended patient as it protects the midgut, prevents evaporation, and allows for visual confirmation that the midgut is decreasing in size during the diuretic phase of recovery.

At the time of reoperation place a nonadherent dressing over the viscera and under the fascia, use fascial sutures to provide moderate tension, place a superficial sponge layer, followed by placement of the suction to the wound.

A nonadherent occlusive plastic barrier

Zipper closure of the abdominal wall was popularized in their open treatment of

patients with pancreatic abscesses.

The major advantage of using the skin in zipper closure preserves the fascia for formal wound closure at an appropriate time.

Two sheets of Velcro-like biocompatible material are sewn to the aponeurotic edges of the midline incision.

Closure is accomplished by the adherence between the overlapping Velcro-like sheets.

As edema of the midgut resolves, excess patch material is trimmed, and the fascial edges can be pulled closer together.

The major advantages of this system are in the ease of access for reoperations and the tension on the aponeurotic edges that prevents the usual lateral retraction

The primary clinical use of absorbable meshes as an alternate form of closure of the abdominal incision on the trauma service

has been in patients with marked distention of the midgut at the time of removal of a plastic silo or vacuum assisted closure

device.

Allows distention Prevent A.C.S. ;Erosion into the bowel, infection

of the mesh Help prevention of evisceration when gauze

packing is placed above the mesh Soft and pliable, Allow drainage of contaminated abdominal fluid

through the mesh, Permit the ingrowth of granulation tissue. Incisional hernia is inevitable and repaired later

on.

(a) coverage of the midgut, preferably with an absorbable mesh.

(b) removal of the mesh after granulation tissue has formed at two to three weeks

(c) split-thickness skin grafting of granulation

tissue or abdominal skin and subcutaneous flap closure over the granulation tissue several days later

(d) definitive reconstruction in 6 to 12 months.

Provided good results, With low recurrent hernia rates

Long-term functional abdominal wall dynamics.

Recently, the use of biomaterials for acute and chronic reconstruction shows promise in this area.

The use of human cadaveric acellular dermis for reconstruction (Alloderm,

LifeCell Corporation Branchburg, NewJersey).

This material acutely in a one-staged approach combined with local skin flaps advanced over the acellular dermis to avoid the need for extensive reconstruction

Early identification of uncontrolled bleeding is essential; treatment requires surgical haemostasis rather than aggressive fluid administration

In patients with haemorrhagic shock, early treatment with fresh frozen plasma and platelets in addition to packed red blood cells is initiated

Hypothermia prevention should be initiated as early as possible using fluid warmers, forced air blankets, and warming mattresses

"The modern operation is safe for the patient. The modern surgeon must make the patient safe for the modern operation"

- Lord Moynihan

Non operative management in all hemodynamically stable patients, irrespective of the grade of lesions.

Operative management in the form of Damage control surgery in hemodynamically unstable patients.

Trauma resuscitation must address all three components of the "lethal triad": coagulopathy; acidosis; and hypothermia

Damage control surgery is a surgical strategy aimed at restoring normal physiology rather than anatomical integrity.

Email: brijesh50@gmail.com