Not Just for Trauma Patients: Damage Control Laparotomy in Pancreatic Surgery

Background  

Damage control laparotomy (DCL) has been a major advance in modern trauma care. The principles of damage control which include truncation of operation to correct acidosis, hypothermia, and coagulopathy with subsequent planned definitive repair are applicable in managing patients undergoing abdominal operations. In order to define indications, technique, and outcome, we undertook a retrospective review and analysis of pancreatic surgery patients in whom DCL was utilized.     

Damage control for thoracic injuries

A critically injured chest trauma patient showing profound shock or cardiac arrest en route to the trauma center or in the emergency room sometimes requires emergency room thoracotomy and definitive repair. In some patients damage control must be performed because of the appearance of the deadly triad of hypothermia, acidosis, and coagulopathy. Indications for damage control are believed to be body temperature < 34 degrees C, pH < 7.2, and clinically uncontrollable bleeding. The strategy for damage control consists of three steps: step 1, rapid control of hemorrhaging and abbreviated surgery in the ER or OR; step 2, correction of hypothermia, acidosis, and coagulopathy and reevaluation of the injuries in the intensive care unit; and step 3, definitive surgery in the OR. Damage control procedures for chest injuries include aortic cross-clamping, hilar clamping, major vessel ligation, pulmonary tractotomy, simultaneously stapled pneumonectomy or lobectomy, cardiac stapling, balloon catheter tamponade, temporary intraluminal shunt, towel packing, towel clip closure, single en masse closure of the chest wall, etc. Every surgeon responsible for treating critical chest trauma patients should have knowledge of damage control and also be familiar with the techniques.     

Le concept de damage control resuscitation

Objective

Damage control is a strategy of care for bleeding trauma patients, involving minimal rescue surgery associated to perioperative resuscitation. The purpose of this review is to draw up a statement on current knowledge available on damage control.

Data sources

References were obtained from recent review articles, personal files, and Medline database research of English and French publications. All categories of articles on this topic have been selected.

Data synthesis

Historical damage control surgery, that consist of abbreviated laparotomy with second-look after resuscitation, is now included in a wider concept called “damage control resuscitation”, addressing the lethal triad (coagulopathy, hypothermia and acidosis) at an early phase. Care is focused on coagulopathy prevention. Early resuscitation, or damage control ground zero, has been improved: aggressive management of hypothermia, bleeding control techniques, permissive hypotension concept and early use of vasopressors. Transfusion practices also have evolved: early platelets and coagulation factors administration, use of hemostatic agents like recombinant FVIIa, whole blood transfusion, denote the damage control hematology. Progress in surgical practices and development of arteriographic techniques lead to wider indications of damage control strategy.     

Immediate Postoperative Angiographic Embolization After Damage Control Surgery for Liver Injury: Report of a Case

A multimodality strategy, including damage control and angioembolization techniques, has been reported to reduce the mortality associated with surgery for complex blunt hepatic injuries. However, the indications for angiographic evaluation and embolization in patients who require surgery for hepatic injury remain unclear. We report a case of blunt hepatic injury requiring emergency laparotomy, which we treated by damage control surgery because of an inaccessible major venous injury and the fact that coagulopathy was stopping hemostasis. The decision to perform immediate postoperative angiography was based on the hemorrhagic response to Pringle's maneuver and its release after perihepatic packing during surgery. Hepatic angiography revealed extravasation from a branch of the middle hepatic artery, which was embolized successfully. Although the definitive indications for immediate postoperative angioembolization for hepatic injury have not been established, the hemorrhagic response to Pringle's maneuver and its release after perihepatic packing during damage control surgery is an indication for immediate postoperative angioembolization.     

Damage control surgery in the abdomen: an approach for the management of severe injured patients

Damage control is well established as a potentially life-saving procedure in a few selected critically injured patients. In these patients the 'lethal triad' of hypothermia, acidosis, and coagulopathy is presented as a vicious cycle that often can not be interrupted and which marks the limit of the patient's ability to cope with the physiological consequences of injury. The principles of damage control have led to improved survival and to stopped bleeding until the physiologic derangement has been restored and the patient could undergo a prolong operation for definitive repair. Although morbidity is remaining high, it is acceptable if it comes in exchange for improved survival. There are five critical decision-making stages of damage control: I, patient selection and decision to perform damage control; II, operation and intraoperative reassessment of laparotomy; III, resuscitation in the intensive care unit; IV, definitive procedures after returning to the operating room; and V, abdominal wall reconstruction. The purpose of this article is to review the physiology of the components of the 'lethal triad', the indication and principles of abdominal damage control of trauma patients, the reoperation time, and the pathophysiology of abdominal compartment syndrome.     

Damage control surgery]

Trauma patients who receive exsanguinating torso injuries often develop hypothermia, metabolic acidosis, and coagulopathy before death. A new strategy for trauma surgery has been developed to avoid the occurrence of these events and hence prevent trauma deaths. The strategy is called "damage control surgery" and consists of three maneuvers: a) damage control; b) restoration of physiologic stability; and c) definitive surgery. The goals of damage control are to: a) identify injuries; b) control ongoing hemorrhage; and c) control intestinal spillage. Damage control is followed by intensive care to restore the physiologic reserve. Once secondary resuscitation in the ICU is accomplished, planned reoperation should be performed to repair anatomic injuries. Planned reoperation is usually possible within 36 hours after the initiation of intensive care. Some patients who undergo damage control develop abdominal compartment syndrome characterized by increased intraabdominal pressure, increased peak airway pressure, decreased urine output, and decreased cardiac output. Early decompression surgery should be considered in such patients.     

Damage control laparotomy in the Australian military

Damage control laparotomy (DCL) is a physiological approach to the management of selected critically injured patients where the surgical technique is directed at minimising the metabolic insult, rather than restoring anatomic integrity. DCL consists of an abbreviated initial laparotomy that is limited to control of haemorrhage and contamination, intra-abdominal packing, and temporary closure. Secondary resuscitation continues in the intensive care unit for 24-48 h until normal physiology has been restored. The subsequent reoperation involves removal of the packing with definitive repair and closure. Using this approach 50% of civilian patients who would previously have died undergoing a definitive trauma laparotomy will survive. Doctrinal change in Australia has yet to enshrine a strong focus on restoration of key physiological variables as a major objective in treatment of all wartime casualties. Yet the philosophy of damage control is uniquely suited to the Australian military environment. However, transition of DCL to the military setting has to take account of operational constraints. The most important unresolved issue is how to provide adequate postoperative intensive care. An evacuation capability incorporating critical care transport teams needs to be present, as the patient must reach definitive care within 48 h.     

Damage control surgery--a historical view

"Damage control surgery" is a surgical strategy to cope with the lethal triad of death, i.e., acidosis, hypothermia, and coagulopathy, often seen in severely injured patients. Perihepatic packing was attempted by some trauma surgeons during the 1970s as an alternative to hepatectomy for severe liver injury, with favorable results. The concept of bail-out surgery and reoperation was introduced during the 1980s as a treatment modality for severe abdominal trauma. This strategy of trauma care was named "damage control surgery" by Rotondo et al in 1993, which consists of initial laparotomy, secondary resuscitation, and definitive surgery. Angiography and TAE may be used during secondary resuscitation for hemostasis. The concept of damage control surgery is now applied not only to severely injured patients but also for other surgical patients in critical condition. Damage control surgery was introduced to Japan during the late 1990s. However, the Japanese experience has been limited because the volume of severe trauma cases is very small.     

Serial repeated laparatomy in severe trauma

Multivisceral trauma and exanguinating hemorrhage lead to hypothermia, coagulopathy and acidosis. Formal resections and reconstructions in these unstable patient is often result in irreversible physiologic insult. For the patients with life-threatening injuries the staged control and repair of injuries may be a saving surgical strategy. The initial phase of "damage control" involves an abbreviated laparotomy, which entails temporary hemorrhage control, perfusion of vital organs and avoidance of enteric or urinary spillage. The surgical procedure is rapidly terminated, with emphasis on a temporary physiologic equilibrium rather than anatomic integrity. That is, the damage control surgery represents an extension of resuscitation phase of trauma in the operating room. The second therapeutic phase involves standard resuscitation and control of hypothermia, coagulopathy and acidosis, combined with surveillance and management of the abdominal compartment syndrome. The last phase involves the definitive repair of all temporized injuries, homeostasis, vascular reconstruction and abdominal wall repair.     

„damage control surgery“ bei schweren abdominellen Verletzungen

The concept of treating severe abdominal trauma according to the principles of damage control surgery is becoming more widespread in Germany. Damage control surgery is indicated when evidence of AHC syndrome, meaning the combination of acidosis, hypothermia and coagulopathy, is found. The preferred surgical approach is the median laparotomy. In hollow organ injury a primary anastomosis should not be forced; contamination control is far more important. Methods of choice are construction of an anus preter or temporary blind closure. In the case of splenic injury total splenectomy is commonly performed. Liver injuries with massive bleeding should be controlled by packing or interim vascular occlusion, with subsequent temporary closure of the abdominal wall. Definitive organ repair should follow stabilization in the intensive care unit.     

Abbreviated laparotomy

The decision to perform damage control laparotomy in a critically injured patients depends on the risk of life-threatening coagulopathy. The main decision criteria are: presence of concomitant injuries, patient history, shock, transfusion volume, hypothermia and acidosis. The aim of surgery is to achieve satisfactory hemostasis, limit peritoneal thermal loss, and perform physiological restoration as rapidly as possible in the intensive care unit. This includes gauze packing of major liver or retroperitoneal injuries and ligation of injured blood vessels. Injuries to the intestine and the urinary tract are sutures, stapled or drained. If the skin borders cannot be reapproximated because of excessive abdominal tension, a wall prosthesis should be used to avoid abdominal compartment syndrome. Reoperation is a dangerous procedure in the immediate postoperative period but must be proposed later for reexploration or damage repair.     

Planned reoperation for severe trauma.

OBJECTIVE: The authors review the physiologic basis, indications, techniques, and results of the planned reoperation approach to severe trauma. SUMMARY BACKGROUND DATA: Multivisceral trauma and exsanguinating hemorrhage lead to hypothermia, coagulopathy, and acidosis. Formal resections and reconstructions in these unstable patients often result in irreversible physiologic insult. A new surgical strategy addresses these physiologic concerns by staged control and repair of the injuries. METHOD: The authors review the literature. RESULTS: Indications for planned reoperation include avoidance of irreversible physiologic insult and inability to obtain direct hemostasis or formal abdominal closure. The three phases of the strategy include initial control, stabilization, and delayed reconstruction. Various techniques are used to obtain rapid temporary control of bleeding and hollow visceral spillage. Hypothermia, coagulopathy, and the abdominal compartment syndrome are major postoperative concerns. Definitive repair of the injuries is undertaken after stabilization. CONCLUSION: Planned reoperation offers a simple and effective alternative to the traditional surgical management of complex or multiple injuries in critically wounded patients.     

论＂损伤控制性外科＂理念在胃肠外科中的应用

近年来,应用＂损伤控制性外科＂来救治一些危重的创伤患者取得了较大的成功.我们认为,损伤控制性外科这一理念也同样适用于胃肠外科危重患者的救治,因为这些危重患者与创伤患者有类似的病理生理改变--即低温、酸中毒和凝血功能障碍,这＂致命三联＂形成一个恶性循环,使得患者不能承受传统的常规大手术打击.对于胃肠外科危重患者,实施损伤控制性外科的理念,总体原则应该是先用最小的方式解决出血、梗阻和感染等危及生命的病况,待患者病情稳定后,再择期行确定性手术,从而提高患者的存活率.具体可分为3阶段,第一阶段：急诊手术用最小的创伤解决出血、梗阻和（或）感染等问题,改善患者状况 第二阶段：在监护病房恢复措施包括稳定血流动力学、纠正凝血功能障碍及酸中毒、复温和机械通气等 第三阶段：择期行确定性手术.     

The role of interventional radiology in patients requiring damage control laparotomy

BACKGROUND: Interventional angiography has been used as a less invasive alternative to surgery to control hemorrhage resulting from trauma. This retrospective study analyzed the role of interventional radiology in patients requiring damage control laparotomy. METHODS: Twenty patients underwent damage control laparotomy between January 1994 and May 2001. Eight of the 20 patients also underwent angiographic evaluation and treatment before or after the damage control laparotomy. RESULTS: Three patients underwent angiography before damage control laparotomy, because a large, pelvic retroperitoneal hematoma was seen on computed tomographic scan, and the amount of intraperitoneal blood seemed insufficient to account for the magnitude of the patient's hemodynamic instability. Five patients underwent angiography after damage control laparotomy. The indication was a nonexpanding retroperitoneal hematoma in three patients, a nonexpanding hepatic hilar hematoma in one patient, and a hepatic injury associated with cirrhosis in one patient. Lumbar artery injuries were identified and treated by embolization in three patients. Four of the eight patients who underwent both damage control laparotomy and angiography survived. CONCLUSION: Angiography before damage control laparotomy may be indicated to control retroperitoneal pelvic hemorrhage in hemodynamically unstable patients who have insufficient intraperitoneal blood loss to account for their hemodynamic instability. Angiography after damage control laparotomy should be considered when a nonexpanding, inaccessible hematoma is found at operation in a patient with a coagulopathy.     

Control of haemorrhage and damage control surgery

Major haemorrhage is associated with significant morbidity and mortality. Prompt recognition and resuscitation is key to improving short- and long-term outcomes and survival. Knowledge of mechanism of injury and potential trauma sustained assists identification of life-threatening bleeding. Management of the patient goes beyond the ‘ABCDE’ approach with a series of clinical interventions known as damage control resuscitation addressing complications of major haemorrhage (coagulopathy, hypothermia and acidosis).Investigations are reserved mostly for the haemodynamically stable patient. For unstable patients the operating theatre is the place to achieve haemostasis by endovascular approaches or damage control surgery (DCS). Damage control surgery sacrifices the completeness of the immediate surgical repair and restoration of anatomy in order to adequately address the combined physiological insult of trauma and subsequent surgery. Surgical strategy in a severely traumatised patient should be considered by the multidisciplinary team prior to operating.Regular discussion between the anaesthetist and surgeon allows progress to be reviewed and realistic goals set for initial surgery. Definitive surgery should be delayed until abnormal physiology is corrected.     

Damage control in vascular trauma

During the era of frequent occurrence of motor vehicle accidents and criminal injuries with lethal weapons, trauma surgeons have accumulated much experience in managing severely injured victims. Very often, efforts to proceed with definitive repair at initial surgery led to patient death despite the control of anatomic bleeding. Damage control methods were thus developed to save patients who otherwise would hove died. Damage control treatment for vascular trauma patients is still in its infancy in Japan. This paper presents an overview of the relevant reports form international journals dealing with the present status of damage control methods in vascular trauma patients.     

Damage Control Surgery: An Alternative Approach for the Management of Critically Injured Patients

Over the past 20 years, it has gradually become apparent that the results of prolonged and extensive surgical procedures performed on critically injured patients are often poor, even in experienced hands. The triad of hypothermia, coagulopathy, and metabolic acidosis effectively marks the limit of the patient's ability to cope with the physiological consequences of injury, and crossing this limit will frustrate even the most technically successful repair. These observations have led to the development of a new surgical strategy that sacrifices the completeness of immediate repair in order to adequately address the combined physiological impact of trauma and surgery. This approach is unfolded in three phases. During the initial operation, the surgeon carries out only the absolute minimum necessary to rapidly control exsanguination and prevent the spillage of intestinal contents and urine into the peritoneal cavity. Packing represents the traditional method for the management of major liver injuries. The second phase consists of secondary resuscitation in the intensive care unit, characterized by maximization of hemodynamics, correction of coagulopathy, rewarming, and complete ventilatory support. During the third phase, the intra-abdominal packing is removed and definitive repair of abdominal injuries is performed. The "damage control" concept has been shown to increase overall survival and is likely to modify the management of the critically injured patient. Received: March 12, 2001 / Accepted: September 11, 2001     

Damage control surgery for severe thoracic and abdominal injuries

OBJECTIVE: To investigate the application of damage control surgery in treatment of patients with severe thoracic and abdominal injuries. METHODS: A retrospective study was done on 37 patients with severe thoracic and abdominal injuries who underwent damage control surgery from January 2000 to October 2006 in our department. There were 8 cases of polytrauma (with thoracic injury most commonly seen), 21 of polytrauma (with abdominal injury most commonly seen) and 8 of single abdominal trauma. Main organ damage included smashed hepatic injuries in 17 cases, posterior hepatic veins injuries in 8,pancreaticoduodenal injuries in 7, epidural or subdural hemorrhage in 4, contusion and laceration of brain in 5, severe lung and bronchus injuries in 4, pelvis and one smashed lower limb wound in 3 and pelvic fractures and retroperitoneal hemorrhage in 6. Injury severity score (ISS) was 28-45 scores (38.4 scores on average), abbreviated injury scale (AIS) > or = 4.13. The patients underwent arteriography and arterial embolization including arteria hepatica embolization in 4 patients, arteria renalis embolization in 2 and pelvic arteria retroperitoneal embolization in 7. Once abbreviated operation finished, the patients were sent to ICU for resuscitation. Twenty-four cases underwent definitive operation within 48 hours after initial operation, 5 underwent definitive operation within 72 hours after initial operation, 2 cases underwent definitive operation postponed to 96 hours after initial operation for secondary operation to control bleeding because of abdominal cavity hemorrhea. Two cases underwent urgent laparotomy and decompression because of abdominal compartment syndrome and 2 cases underwent secondary operation because of intestinal fistulae (1 case of small intestinal fistula and 1 colon fistula) and gangrene of gallbladder. RESULTS: A total of 28 patients survived, with a survival rate of 75.68%, and 9 died (4 died within 24 hours and 5 died 3-9 days after injury). The trauma deaths at the early stage were caused by severe primary injuries resulting in failure of respiration and circulation, while mortality at the later stage was caused by multiple organ failure. CONCLUSIONS: Damage control surgery is important for the treatment against severe thoracic and abdominal injuries. It is suggested that the surgeon should select the reasonable auxiliary examination before operation, and take the proper time to perform damage control and definitive surgery.     

Damage control laparotomy for haemorragic abdominal trauma. A retrospective multicentric study about 109 cases

AIM OF THE STUDY: Damage control laparotomy is a new approach to the more severe abdominal traumas. It stems from a better understanding of the physiopathology of the haemorragic shock. PATIENTS AND METHODS: A national retrospective study from 27 centers about 109 trauma patients who underwent a damage control procedure between January 1990 and December 2001, is analysed. Surgical procedures included 97 hepatic packing, 10 abdominal packing, 4 exclusive skin closure, 1 open laparotomy technique and 3 digestive stapplings. RESULTS: The mortality rate is 42%. Eleven abdominal compartment syndromes have occurred with 7 decompressive laparomy (4 deaths). CONCLUSION: This study is based on the largest series of damage control laparotomy published in France. Results in terms of mortality and morbidity are similar to those of published studies from the USA.     

Damage control surgery and angiography in cases of acute mesenteric ischaemia

BACKGROUND: Acute mesenteric arterial occlusion typically presents late and has an estimated mortality of 60-80%. This report examines the evolution of a novel management approach to this difficult surgical problem at a teaching hospital in rural Australia. METHODS: A retrospective review of 20 consecutive cases that presented to Lismore Base Hospital, Lismore, New South Wales, between 1995 and 2003 was performed. RESULTS: Of the 16 patients who were actively treated, 10 survived. Mortality was associated with attempting an emergency operative revascularisation and not performing a second-look laparotomy. All three patients who had a damage control approach at the initial operation survived and in four cases endovascular intervention successfully achieved reperfusion of acutely ischaemic bowel. CONCLUSIONS: Evidence from the series of patients described suggests that damage control surgery and early angiography improve survival in patients suffering acute mesenteric ischaemia. A damage control approach involves emergency resection of ischaemic bowel with no attempt to restore gastrointestinal continuity and formation of a laparostomy. Patients are stabilised in the intensive care unit (ICU) and angiography can be arranged to either plan a definitive bypass procedure or alternatively endovascular therapies can be carried out in an attempt to arrest gastrointestinal infarction. Definitive surgery is then considered after 2-3 days. This approach is particularly attractive if immediate specialist vascular expertise is not available.