Damage control surgery for abdominal emergencies

Abstract

Background: Damage control surgery is a management sequence initiated to reduce the risk of death in severely injured patients presenting with physiological derangement. Damage control principles have emerged as an approach in non-trauma abdominal emergencies in order to reduce mortality compared with primary definitive surgery.Methods: A PubMed/MEDLINE literature review was conducted of data available over the past decade (up to August 2013) to gain information on current understanding of damage control surgery for abdominal surgical emergencies. Future directions for research are discussed.Results: Damage control surgery facilitates a strategy for life-saving intervention for critically ill patients by abbreviated laparotomy with subsequent reoperation for delayed definitive repair after physiological resuscitation. The six-phase strategy (including damage control resuscitation in phase 0) is similar to that for severely injured patients, although non-trauma indications include shock from uncontrolled haemorrhage or sepsis. Minimal evidence exists to validate the benefit of damage control surgery in general surgical abdominal emergencies. The collective published experience over the past decade is limited to 16 studies including a total of 455 (range 3-99) patients, of which the majority are retrospective case series. However, the concept has widespread acceptance by emergency surgeons, and appears a logical extension from pathophysiological principles in trauma to haemorrhage and sepsis. The benefits of this strategy depend on careful patient selection. Damage control surgery has been performed for a wide range of indications, but most frequently for uncontrolled bleeding during elective surgery, haemorrhage from complicated gastroduodenal ulcer disease, generalized peritonitis, acute mesenteric ischaemia and other sources of intra-abdominal sepsis. Conclusion:Damage control surgery is employed in a wide range of abdominal emergencies and is an increasingly recognized life-saving tactic in emergency surgery performed on physiologically deranged patients.

A Randomized Controlled Trial on Intra-Abdominal Irrigation during Emergency Trauma Laparotomy; Time for Yet Another Paradigm Shift

“…In addition, the use of larger volumes of intraoperative peritoneal irrigation render no additional benefit for the prevention of intraabdominal sepsis, wound complications (including wound infections and evisceration episodes), or anastomotic dehiscence and enterocutaneous fistula formation events. This is also in line with the most current literature on the subject [41][42][43][44][45][46][47][48][49][50].…”

“…While there is experimental evidence of at least one benefit to the use of irrigation in trauma victims [39], our results strongly suggest an upper limit of 5L for the effluent. This has relevance for today's practice, since epidemiological evidence exist for the current use of Intraoperative Peritoneal Lavage for this indication in surgical practice [41][42][43][44][45][46][47][48][49][50]. Our trial has several limitations: Since damage control techniques were utilized when indicated (as per the contemporary accepted standard of care) it is very possible that the potential benefits and/or harms (or lack thereof) that the intervention has in this population remain unknown.…”

Results of emergency management of acute abdomen in adults based on clinical assessment and basic imaging investigations: are advanced imaging techniques always necessary for successful treatment?

“…Minimal evidence exists to validate the benefit of damage control surgery in general surgical abdominal emergencies. Therefore, immediate surgical intervention has to be planned in well selected patients and should be used prudently 16 .…”

Management of abdominal sepsis — a paradigm shift?

“…Occasionally the management of severe cases can require such extensive and prolonged surgery that some patients may succumb intraoperatively. In managing such severe cases the damage control approach allows for temporary control of the source of insult (whether bleeding or contamination) [7]. Leaving the abdomen open allows for the patient to be transferred to an ICU for restoration of homeostasis followed by return to the operation theatre 1−2 days later for the definitive repair of organ defects.…”