Damage control surgery (DCS) is an approach used for complex trauma patients involving temporary measures to control bleeding and contamination followed by ICU resuscitation and later definitive repair. The key phases are: 1) recognition of need for DCS, 2) immediate laparotomy for rapid bleeding control and temporary closure, 3) ICU resuscitation, and 4) re-exploration for definitive repair. DCS aims to restore physiology over anatomy by limiting operative time to allow ICU resuscitation and correction of hypothermia, acidosis and coagulopathy before definitive repair. Temporary measures include packing, shunting, stapling, and ligation to control bleeding and spillage until the patient is stabilized.

1. DAMAGE CONTROL
SURGERY
(DCS)

2. The concepts of DCS were initially applied to
complex trauma patients with combined
vascular and visceral injuries.
Improved outcomes were seen following DCS
principles compared with conventional
definitive surgery.
The DCS approach is to restore physiology
over anatomy.

3. Phases
1. Recognition of injury severity and need for
damage control management , both surgical
and resuscitative.
2. Immediate laparotomy with rapid control of
bleeding and contamination, abdominal
packing and temporary wound closure.

4. 3. Movement to the intensive care unit (ICU) for
ongoing resuscitation with normalization of
biochemical and physiological parameters.
4. Re-exploration in theatre to perform
definitive repair of all injuries.

5. Indications
o Refractory hypothermia (<35°C) .
o Profound acidosis (pH <7.2).
o Refractory coagulopathy.
o Blood loss and anticipated operative time
should all be considered

6. o The purpose of DCS is to limit operative time
so that the patient can be returned to the
SICU for physiologic restoration and the cycle
thereby broken.

7. o The goal of DCS is to control surgical bleeding
and limit GI spillage
o The operative techniques used are temporary
measures, with definitive repair of injuries
delayed until the patient is physiologically
replete
o Controlling surgical bleeding while preventing
ischemia is of utmost importance during DCS.

8. 1.Control surgical bleeding
o Aortic injuries must be repaired using an
interposition PTFE graft.
o Although celiac artery injuries may be ligated,
the SMA must maintain flow, and the early
insertion of an intravascular shunt is
advocated.

9. o Similarly, perfusion of the iliac system and
infrainguinal vessels can be restored with a
vascular shunt, with interposition graft
placement delayed.
o Arterial reconstruction following shunt
placement should be done optimally within 6
hours.

10. o Venous injuries are preferentially treated with
ligation damage control situations, except for
the suprarenal inferior vena cava and popliteal
vein.

11. Solid organ injuries
o Spleen or one kidney, excision is indicated
rather than an attempt at operative repair.

12.  Hepatic injuries
o Perihepatic packing of the liver will usually
tamponade bleeding
o Translobar gunshot wounds of the liver are
best controlled with balloon catheter
tamponade
o Deep lacerations can be controlled with Foley
catheter inflation deep within the injury track

15.  Thoracic injuries
o Bleeding peripheral pulmonary injuries,
wedge resection using a stapler is performed.
o Penetrating injuries, pulmonary tractotomy is
used to divide the parenchyma individual
vessels and bronchi are then ligated and the
track is left open

16. o Patients who sustain more proximal injuries
may require formal pulmonary resection.
o Cardiac injuries may be temporarily controlled
using a running nonabsorbable suture or skin
staples.

18. 2.Limiting GI spillage
o Small injuries to the bowel may be controlled
by rapid repair.
o Complete transaction of the bowel or
segmental damage is controlled using a GIA
stapler, often with resection of the injured
segment.
o Alternatively, open ends of the bowel may be
ligated using umbilical tapes to limit spillage.

19. o Pancreatic injuries, regardless of location, are
packed and the evaluation of ductal integrity
postponed.
o Urologic injuries may require catheter
diversion.

20. o Before the patient is returned to the SICU, the
abdomen must be closed temporarily.
o Temporary closure of the abdomen is
accomplished using an antimicrobial surgical
incise drape (Ioban, 3M Health Care, St Paul,
MN)

23. o Return to the OR within 24 hours is planned
once the patient clinically improves, as
evidenced by normothermia, normalization of
coagulation test results, and correction of
acidosis.

24. Thank you