Damage control surgery (DCS) is a strategy that prioritizes physiological recovery over anatomical repair for critically injured patients. It follows a four phase approach: DC0 involves damage control resuscitation in the field and emergency room; DC1 is concurrent resuscitation and surgery to control hemorrhage through packing and temporary closure; DC2 focuses on intensive care stabilization and reversal of acidosis, hypothermia and coagulopathy; DC3 performs definitive repair once physiology is normalized within 24-36 hours. DCS indications include massive transfusion, severe acidosis, hypothermia, long operative times, coagulopathy and high lactate levels.

1. DAMAGE CONTROL
Dr. Sudhanshu Goyal,
PGY-1, General Surgery,
Civil Hospital Aizawl

2. Why Damage Control?
"The modern operation is safe for the patient. The
modern surgeon must make the patient safe for the
modern operation" - Lord Moynihan

3. Principles
 Lethal Triad:
 Acidosis, Hypothermia and Coagulopathy
 Damage Control Resuscitation (DCR)
 Novel resuscitative strategies to limit
physiological derangement
 Damage Control Surgery (DCS)
 Treatment strategy of TEMPORIZATION by
prioritizing Physiological Recovery before
Anatomical Repair
Four phase strategy
 DC0: DCR, RSI, early rewarming
and expedient transport to OR
 DC1: concurrent DCR and DCS
 DC2: ICU resuscitation and
stabalization
 DC3: Definitive surgery

4. Indications
 Massive Blood Transfusion
 >10 unit PRBC
 Severe Metabolic Acidosis
 pH< 7.30
 Hypothermia
 <35 degree C
 Operative time
 >90 mins
 Coagulopathy
 Either on lab results or ‘non surgical’ bleeding
 Lactate
 >5 mmol/L
Estimates show
10% of the
major trauma
patients to
benefit from
DCS

5. DC0
 Extends from pre-hospital setting to ER
 DCR
 Deleterious effect of excessive fluid and Acute
traumatic coagulopathy
 Consist of
 <C>ABC (RSI)
 Permissive hypotension
 Limitation of crystalloid and early transfusion
 Early use of TXA
 Early use of Blood and Blood products
 Blood components targeting ATC
 Optimal ratio of PRBS,PC, FFP and other
products
 Massive transfusion protocol
 Prevent delay in accessing blood
 E.g.
 1 pack of un-crossmatched blood in ER
 f/b protocoled transfusion to prevent clotting factor
depletion
 Imaging
 RSI f/b chest x-ray
 Spinal precations
 Pelvic binder
 If stabilized CT scan
 Primary and secondary surverys

6. DC1 (DCS)
 Objectives
 Haemorrhage control
 Limitation of contaimination
 Temporary abdominal closure
 Preperation
 OT prepped before taking patient
 Criciform position
 Prepped from chin to mid thigh
 RT, Foley’s
 Don’t delay for central line
 Incision
 Midline laparotomy
 In pelvic fracture limit just
below umbilicus
 Easy to extend superiorly or
laterally

7. DC1 (DCS) cont…
 Haemorrhage control
 Large clots removed manually
 Retract and pack each quadrant
sequentially
 While packing assess degree and location
of significant injuries
 If still hypotensive – suspect significant
arterial source
 Occlude aorta sequentially to gain control
 Major vascular injuries
 Arterial either ligation or
temporary shunt
 Venous majority can be
ligated, if not shunting
 Definitive reconstruction to
be avoided

8. DC1 (DCS) cont…
 Haemorrhage control cont…
 Solid organ injuries
 Prolonged repair to be avoided
 Splenic, Renal and Pancreatic injuries best
by partial or total resection
 Liver bleeding managed by packing, tropical
hemostatic agents
 Consider angioembolization whenever
available
 Contamination control
 Control spillage of intestinal
content and urine
 Simple bowel perforation in
limited number may be
repaired, else resection
 Reconstruction, stoma
creation and feeding tube
avaoided
 Biliary/ Pancreatic duct
injury: controlled fistula

9. DC1 (DCS) cont…
 Abdominal closure
 Fascial closure not
recommended
 Temporary closure to avoid
IAH/ACS
 Contamination control cont…
 Biliary/ Pancreatic duct injury: controlled
fistula
 Bladder injury: Primary suturing with foleys
drainage, if large packing with foley’s
drainage
 Ureteric injuries: drained over IFT
 Abdominal packing: sufficient to provide
tamponade but not impeding vascular
return or arterial suppy

10. DC2
 Goal:
 Reverse hypotension related metabolic failure
 Support physiological and biochemical
restoration
 Normalise lactate within 24 hrs
 Aggressive Core Rewarming
 Improves perfusion and reverses coagulopathy
 Correct Coagulopathy
 FFP, Platelets and Cryoprecipitates
 Complete physical examination
and relevant imaging
 Repair planning
 Usually require 24 to 36 hrs
 Unplanned re-operation
 Ongoing transfusion despite
normal clotting and core temp.
 ACS: sustained or repeated IAP >20
mm Hg + new single/multiple
organ failure

11. DC3
 Maximum impact on achieving successful
outcome
 Normothermic, normal coagulation, pH and
lactate (24 – 36 hrs)
 Operative game plan
 Handover (if different surgeon)
 Irrigate packs to avoid clot disruption
 Complete re-examination and definitive
repair
 Additional sites of bleeding controlled,
vascular repairs done and intestinal
continuity is restored
 Abdominal closure
 Formal abdominal closure
without tension should be
done
 If airway pressure >10 cm H2O
temporary closure to be done
 Can be closed within 1 week

12. THANK
YOU