The Concept of Damage Control Surgery Dr. Derek TL Fung Department of Surgery Queen Elizabeth Hospital

Damage Control Surgery (DCS) Multiple abdominal trauma Thoracic injury Vascular surgery Orthopaedics Abdominal sepsis

Damage Control Originated in the US Navy, refers to the capacity of a ship to absorb damage and maintain mission integrity

In 1970s & 1980s, surgeons tended to perform complex and lengthy operation in multiple trauma case Extensive resection Extensive reconstruction Aggressive resuscitation Extracorporeal support

History Idea originated from liver trauma Pringle published a case series of packing liver injuries in 1908 Pringle JH. V. Notes on the Arrest of Hepatic Hemorrhage Due to Trauma. Ann Surg. 1908 Oct;48(4):541-9. Calne in 1979 published a series of liver trauma patients whose abdomens were packed prior to transfer and definitive surgery at another centre Calne RY, McMaster P, Pentlow BD. The treatment of major liver trauma by primary packing with transfer of the patient for definitive treatment. Br J Surg. 1979 May;66(5):338-9.

Stone et al. Coagulopathy in trauma patient leads to exsanguination and mortality In his series, 31 patients with major bleeding tendency 11 out of 17 patient who was managed with packing and staged re-laparotomy survived. 1 out of 14 patients with standard treatment survived Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983 May;197(5):532-5.

Rotondo et al. Rotondo and co-workers published a further series and coined the phrase ‘damage control surgery’ in 1993 7-fold of improvement in survival in a subgroup of patient with major vascular injury and 2 or more visceral injuries if they were managed with damage control approach 10/13 (77%) survived with damage control surgery 1/9 (11%) with traditional definitive laparotomy Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, Latenser BA, Angood PA. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993 Sep;35(3):375-82; discussion 382-3 10/13 Vs 1/9

Lethal Triad Acidosis Hypothermia Coagulopathy

Hypothermia Central thermoregulation lost Platelet dysfunction Metabolic activity Cold IV fluid Platelet dysfunction Clotting factors kinetics disturbance Cardiac dysfunction Vasoconstriction Hypoperfusion

Acidosis  Cardiac contractility Dysrhythmias Synergize with hypothermia in its detrimental effect on the coagulation cascade

Coagulopathy Uncontrolled bleeding from all cut surfaces Platelet dysfunction Clotting cascade disturbed Haemodilution

6 causes: tissue trauma, shock, hemodilution, hypothermia, acidemia, and inflammation. Hypoperfusion->inflammatory and metabolic change->acidosis-> affect innate coagulation system consumptive coagulopathy hypothermia begins to have an impact on the body’s ability to alter fibrin and form clots.

Principles of DCS Quickly abort the vicious cycle by haemorrhage and contamination control Minimize further trauma created by Surgeon Restore normal physiology before definitive surgery in reoperation

Stages of Damage Control Surgery 1. Patient selection 2. Intraoperative stage 3. Critical care stage 4. Return to the operating theatre 5. Formal closure Moore EE. Thomas G. Orr Memorial Lecture. Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am J Surg. 1996 Nov;172(5):405-10.

Stage 1: Patient Selection WHO? WHO?

Other factors to be consideredno No definitive†standard†to†allow†objective†evaluation†when†abbreviated laparotomy†is†necessary¨†as†different†authors†have†different†criteria Rotondo M, Zonies D. The damage control sequence and underlying logic. Surg Clin N Am 1997; 77: 761-777.

No Definite Selection Criteria Too Liberal  Unnecessary staged operation Too Strict  Adverse physiological outcome established  Too late to salvage Experience, rapid surgical assessment and liaison with anesthetist are the keys in decision making

Stage 2: Intraoperative Aim: Controlling Haemorrhage Limiting contamination Haemorrhage control may be achieved by ligation, suture, tamponade (by packing or balloon), or shunting. Definitive vascular repair by grafting or anastomosis is not considered a DCS procedure.

Solid organ injuries management should be similarly directed at achieving haemorrhage control. This may be by removal without attempt at preservation in those organs where this is feasible (such as the spleen and kidney) or by therapeutic packing such as in the liver, Packing the liver is most effectively accomplished by packing pads above the liver under the costal margin and under both the right and left hepatic lobes

Bowel ends are closed without attempt to regain gastrointestinal continuity, by tapes, staples or suture.

duodenum and bile duct may be dealt with by simply placing drainage tubes to control leakage

exsanguinating from pelvic trauma pre-peritoneal pelvic packing can be performed to gain control of bleeding.

Temporary Closure

Risk of abdominal compartment Syndrome Ineffective Drainage Skin approximation by suture/ clips Bogota bag/ silo bag Absorbable/ non-absorbable mesh Risk of abdominal compartment Syndrome Ineffective Drainage

Negative Pressure Therapy System, eg. VAC 3 layers: protective barrier against the viscera, surgical towel, drains, and occlusive adhesive drape

Negative Pressure Therapy Evacuation of abdominal fluid Minimize risk of Intra-abdominal hypertension Low fistula rates Good early closure rates

Stage 3: Critical Care Stage Active rewarming Correction of Acidosis Correction of Coagulopathy Monitor the need for early return to theatre Ongoing surgical bleeding Abdominal compartment syndrome

Stage 4: Return to the Theatre Timing: 24-48hrs later when Base deficit < 4 mmol/L Lactate of < 2.5 mmol/L Core temperature > 35 C INR < 1.25

Stage 4: Return to the Theatre Definitive surgery Removal of packs Anastomoses or stomas Vascular repairs Solid organ debridement Placement of feeding tube

Stage 5: Formal Closure May not be feasible due to significant bowel edema or risk of abdominal compartment syndrome 30 - 80% closure rate in the 1st reoperation Hirshberg A, Wall MJ, Mattox KL. Planned reoperation for trauma: a two-year experience with 124 consecutive patients. J Trauma 1994;37(3):365– 9. Hatch QM, Osterhout LM, Ashraf A, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Current use of damage-control laparotomy, closure rates, and predictors of early fascial closure at the first take-back. J Trauma. 2011 Jun;70(6):1429-36. The highest closure rates are achieved during the first 7–10 days Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg. 2012 Mar;36(3):497-510. Hirshberg A, Wall MJ, Mattox KL. Planned reoperation for trauma: a two-year experience with 124 consecutive patients. J Trauma 1994;37(3):365– 9.

Evidence

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A total of 1523 studies were identified DCS Vs Immediate and definitive repair (in patients with major abdominal trauma) A total of 1523 studies were identified A total of 1521 studies were excluded because they were not relevant to the review topic Targets were not suffering from major abdominal trauma/ narrow spectrum Not directly comparing DCS Vs definitive repair Two studies were excluded because they were case-control studies. (Rotondo 1993, Stone 1983) Cirocchi R, Abraha I, Montedori A. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007438.

Evidence No RCT, systemic review could not be done Most of the studies were case series Different patient groups Different methodology Conclusion: Evidence is LIMITED. Cirocchi R, Abraha I, Montedori A. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007438. DCS still remain an useful tool for surgeon to deal with patients with multiple trauma and exhausted physiological resource

Complication Surgical site infection & intraabdominal abscess: up to 83% of cases Enterocutaneous fistula: 5-19% Chronic Ventral Hernia 13-80% Smith BP, Adams RC, Doraiswamy VA. Review of abdominal damage control and open abdomens: focus on gastrointestinal complications. J Gastrointestin Liver Dis. 2010 Dec;19(4):425-35. Review.

Overuse of DCS Complications Long intensive care unit stays Increased use of blood products Multiple operations Higher hospital cost Higa G, Friese R, O'Keeffe T, Wynne J, Bowlby P, Ziemba M, Latifi R, Kulvatunyou N, Rhee P. Damage control laparotomy: a vital tool once overused. J Trauma. 2010 Jul;69(1):53-9. Hatch QM, Osterhout LM, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma. 2011 Dec;71(6):1503-11. With the advancement of DCR, the need of DCS may be decreased Codner PA, Brasel KJ, Deroon-Cassini TA. Staged abdominal repairs reduce long-term quality of life. Injury. 2012 Sep;43(9):1513-6. => poorer physical and mental QOL

Damage Control Resuscitation

Damage Control Resuscitation Proactive early treatment to address the lethal triad (by rapid reversal of acidosis, prevention of hypothermia and coagulopathy) on admission to combat hospital. Assumption that coagulopathy is actually present very early after injury Holcomb J, Jenkins D, Rhee P et al. Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma. J Trauma 2007; 62: 307-310. Holcomb J, Jenkins D, Rhee P et al. Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma. J Trauma 2007; 62: 307-310. Hodgetts TJ, Mahoney PF, Kirkman E. Damage control resuscitation. J R Army Med Corps. 2007 Dec;153(4):299-300. UK group: A systematic approach to major trauma combining the catastrophic bleeding, airway, breathing and circulation (<C>ABC) paradigm with a series of clinical techniques from point of wounding to definitive treatment in order to minimize blood loss, maximize tissue oxygenation and optimize outcome

Damage Control Resuscitation Permissive Hypotension Satisfied with MAP = 50-60mmHg Minimize dilution effect and hypothermia secondary to overzealous fluid replacement Early use of blood product over isotonic fluid for volume replacement Early correction of coagulopathy with components, ie. Massive transfusion protocol PRBCs: FFP: Platelet = 1:1:1 Danger of over resuscitation Hypothermia Dilution of clotting compounds Reverse important homeostatic reflex, exert pressure on extravascular clots, increase blood loss

This resuscitation strategy begins from ground zero in the emergency room (ER) and continues through the OR and into the ICU Thromboelastometry allows early diagnosis of coagulopathies and monitoring of therapy.12 Other near patient tests of acidebase status and electrolyte abnormalities are also available together with other monitoring techniques such as near infra-red spectroscopy (NIRS)13 to measure tissue oxygenation allow near continuous physiological monitoring and tailoring therapeutic approaches to individual casualty responses Recent reports of this in vascular surgery in a combat support hospital setting have allowed extended operating (median time 4.5 hours) with more definitive revascularization to be undertaken Fox Charles J, Gillespie David L, Cox EDarrin, et al. Damage control resuscitation for vascular surgery in a combat support hospital. J Trauma 2008; 65: 1e9. Midwinter MJ. Damage control surgery in the era of damage control resuscitation. J R Army Med Corps. 2009 Dec;155(4):323-6.

Conclusion Damage control surgery was an useful tool in handling patients with multiple injury, though high level of evidence is lacking DCS is not without risk and complication, over- utilization may lead to more harm than benefit With DCR integrating into DCS, the need of DCS may reduce as coagulopathy is corrected earlier

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