Damage control in trauma and abdominal sepsis

Abstract

Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.

An outcome prediction model for exsanguinating patients with blunt abdominal trauma after damage control laparotomy: a retrospective study

“…DCL is an initial laparotomy performed to address hemorrhage and contamination, and it may include gauze packing for hemorrhage control, vascular pedicle ligation, contamination control, and the establishment and maintenance of an abdominal wall opening covered with plastic, with or without a vacuum device [1,2]. Following this initial emergent management, the patient is admitted to the intensive care unit (ICU) to correct hypothermia, coagulopathy, acidosis, and electrolyte imbalances.…”

“…Within 48 to 72 hours after the first laparotomy, a second laparotomy is performed for definitive treatment and abdominal closure. DCL was first applied in patients with hepatic injuries during the early 20 th century, and this technique was further developed during the 1980s [2,3]. Currently, DCL is widely used in the emergency setting for patients with uncontrolled intra-abdominal bleeding or severely contaminated intestinal or urological trauma.…”

Inadequate Source Control and Inappropriate Antibiotics are Key Determinants of Mortality in Patients with Intra-Abdominal Sepsis and Associated Bacteremia

“…Indeed, some less invasive techniques now being utilized, such as laparoscopic drainage without resection for Hinchey Class III and IV diverticulitis [17] might have been considered to be inadequate source control just a few years ago. There is also an appreciation that damage control laparotomy is an acceptable measure for initial management of many critically ill patients with intraabdominal sepsis, even though this obligates further procedures for definitive management [18].…”

Use of local pro-coagulant haemostatic agents for intra-cavity control of haemorrhage after trauma

“…The principles of damage control surgery are now well established both in the civilian [3,4] and military [5] settings. Trauma systems, such as in the British military, address haemorrhage control at each stage of care from the point of wounding onwards.…”