Damage control surgery

DAMAGE CONTROL SURGERYDAMAGE CONTROL SURGERY
IN ABDOMINAL TRAUMAIN ABDOMINAL TRAUMA
Zeka

CONTENTSCONTENTS
- The principles in Damage Control surgery
- When to decided from standard surgical approach to
damage control surgery
- Preparation of the patient
- Approach of organ injuries
- Complications
- Re- laparatomy
- Case
- Referrences

MULTIPLE TRAUMA PATIENTS ARE MORE
LIKELY TO DIE FROM THEIR
INTRAOPERATIVE METABOLIC FAILURE
THAT FROM A FAILURE TO COMPLETE
OPERATIVE REPAIRS

MULTIPLE TRAUMA PATIENTS DIE FROM A TRIAD:
COAGULOPATHY
METABOLIC
ACIDOSIS
HYPOTHERMIA

STANDARD SURGICAL APPROACH
DAMAGE CONTROL APPROACH
It is better to cure in more phases
than to kill in one …

PRINCIPLES
1. CONTROL OF HAEMORRHAGE
2. PREVENTION OF CONTAMINATION
3. PROTECTION FROM FURTHER INJURY

HYPOTHERMIA
Trauma patients are hypothermic due to
enviromental conditions at the scene.
Inadequate protection, IV fluid administration,
and blood loss worse hypothermia.
Shock leads to decreased cellular perfusion
and inadequate heat production.
Hypothermia has multiple effects on the body
funcions and exacerbates coagulopathy.

ACIDOSIS
Shock leads to decreased cellular perfusion,
anaerobic metabolism and the production of
actic acid.
This leads to profund metabolic acidosis which
promotes coagulopathy.

COAGULOPATHY
-Hypothermia, metabolic acidosis and
massive
blood transfusion lead to coagulopathy.
-Coagulopathy worsen haemorrhagic shock
and in turn it worsens hypothermia and
acidosis, prolonging the vicious circle.

WHEN TO DO DAMAGEWHEN TO DO DAMAGE
CONTROL SURGERYCONTROL SURGERY
STANDARD SURGICAL APPROACH
DAMAGE CONTROL APPROACH
- pH below 7.2
- Core temperature below 32/ 34 C
- More than 5 transfusion
?
Do not wait !!

PREPARATION
These patients should be transferred rapidly
o the OR.
All investigations that will not immediately affect
patient management should be deferred.
These patients require operative control of
haemorrhage and simultaneous vigorous
esuscitation with blood and clotting factors.
All fluids should be warmed and the patient
overed and actively warmed as possible.

LAPAROTOMY
The incision should be made from the xiphoid
o the pubis.
Opening the abdomen may result
n dramatic haemorrhage and hypotension,
ontrol is initially achieved with multiple
abdominal packs.
f there is continued haemorrhage with packs
n place, aortic control may be necessary.

LAPAROTOMY
Aortic control is generally
achieved at the
diaphragmatic hiatus with
blunt finger dissection and
finger pressure by an
assistant followed by aortic
clamping.

LAPAROTOMY
.The next step is to identify the source of
bleeding.
.Examination of the abdomen must be
complete.
.Immediate control of haemorrhage is with
direct blunt pressure using the surgeon
hands or abdominal packs.
.Vessels which can not be ligated without
loss of life/limb are treated with indwelling

LAPAROTOMY
LIVER, 1
The basic technique
for control of hepatic
hemorrhage is peri-
hepatic packing.

LAPAROTOMY
LIVER, 2
The liver parenchyma can be compressed manually
initially, followed by ordered packing in the
anteroposterior plane.
Even retrohepatic venous and IVC injuries may be
controlled in this manner.
The patient with hepatic packing should be
considered for transfer to the angiography suite ( if
applicable) immediately after operation to identify and
control with embolization any arterial haemorrhage.

LAPAROTOMY
SPLEEN
Splenectomy is the treatment of choice for
spleen injuries in this setting.
Attempts at splenic conservation are too time-
consuming and prone to failure.

LAPAROTOMY
RETROPERITONEUM
Non-expanding, stable retroperitoneal and
pelvic hematomas should not be explored and
may be treated with abdominal packing.
Subsequent angiographic embolization may
be required.
Only expanding hematomas require
evacuation and exploration for serious
vascular injury.

LAPAROTOMY
GASTROINTESTINAL TRACT, 1
Once control of haemorrhage has been obtained,
prevention of contamination is achieved by the
rapidly closure of hollow viscus injury.
This may be definitive if there are only small
enterotomies requiring primary suture.
With extensive damage to the bowel it is wiser to
resect non-viable bowel and close ends, leaving them
in the abdomen for anastomosis at the second
procedure.

LAPAROTOMY
GASTROINTESTINAL TRACT, 2
Ileostomies or colostomies should preferably
not be performed in a damage control setting,
especially if the abdomen is to be left open, as
control of contamination is almost impossible.

LAPAROTOMY
PANCREAS
Minor pancreatic injuries require no treatment.
In case of massive injuries, the pancreas
should be debrided only, because patients will
not survive complex operation such as
pancreaticoduodenectomy.

LAPAROTOMY
ABDOMINAL CLOSURE
Abdominal closure is rapid and temporary.
The abdomen should be left open as a
laparostomy with a bag or vacuum-pack
technique to avoid abdominal compartment
syndrome.

LAPAROTOMY
ABDOMINAL CLOSURE

COMPLICATIONS OFCOMPLICATIONS OF
Damage control SurgeryDamage control Surgery
Failure to recognize non-coagulopathic
hemorrhage which leads to exsanguination
Abdominal compartmental syndrome which
leads to multi organ failure
Formation of enteric fistulas esp in pts with
M.O.F and open abdomens for a long time
ARDS, intraabdominal abcesses, sepsis
Mortality at 60%

CRITICAL CARE
The priority of the critical care phase of
treatment is rapid reversal of metabolic failure.
The patient must be actively warmed,
coagulopathy and acidosis must be corrected.
The next 24-48 hours are crucial if the patient
requires a second surgical procedure.

REOPERATION
Timing of reoperation is crucial.
There is a window of opportunity between
correction of metabolic failure and the onset of
a multiple organ failure.
This window occurs at 24-48 hours after the
first procedure

REOPERATION
The principles of reoperation are:
• removal of packs
• complete inspection of the abdomen
• haemostasis
• restoration of intestinal integrity
• abdominal closure

REOPERATION
Packs, especially around the liver or spleen, should
be removed cautiously as removal may lead to
further bleeding. Soaking the swabs may aid this
process.
Any intestinal repair should be inspected and repair
with anastomosis undertaken.
Copious washout should be performed and the
abdomen closed with standard technique.

CASECASE
B.M,
D.O.A 28/10/13
Hx : hit by a lorry on the left side of
abdomen, no L.O.C
Exam: RR 22, PR 101, Bp 80/50, GCS
15/15,
Hb 10, WBC 17.8
FAST: liver trauma

Mx: Hrly vitals signs, repeat FBC 4 hrly
30/10/13: RR 22, Bp 123/65, PR 91, Hb 7.7
and signs of peritoneal irritation
31/10/13: laparatomy, 4000cc of blood
harvested, packing of liver injury
4/11/13: re- lap, repair of liver injury,
sphincteroplasty
5/11/13: multi organ failure
6/11/13 : Died

referencesreferences
 Physiologic rationale for abbreviated laparotomy. Surg Clin North
Am. (1997);77:779–782. [PubMed]
 ‘Damage control’: An approach for improved survival in
exsanguinating penetrating abdominal injury. J Trauma.
(1993);35:375–383. [PubMed]
 The abdominal compartment syndrome. Surg Clin North Am.
(1996);76:833–842. [PubMed]
 Delayed gastrointestinal reconstruction following massive abdominal
trauma. J Trauma. (1993);34:233. [PubMed]
 Planned reoperation for trauma: A two year experience with 124
consecutive patients. J Trauma. (1994);37:365. [PubMed]

Damage control surgery

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Damage control surgery

Similar to Damage control surgery (20)

Recently uploaded

Recently uploaded (20)

Damage control surgery