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

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

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

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

5. 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 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 May;66(5):338-9.

6. 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 May;197(5):532-5.

7. 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 Sep;35(3):375-82; discussion 382-3
10/13 Vs 1/9

8. Lethal Triad
Acidosis
Hypothermia
Coagulopathy

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

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

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

12. 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.

13. 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

14. 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 Nov;172(5):

15. Stage 1: Patient Selection
WHO?
WHO?

16. 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:

17. 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

18. 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.

20. 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

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

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

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

24. Temporary Closure

25. 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

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

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

28. 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

29. 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

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

31. Stage 5: Formal Closure
May not be feasible due to significant bowel edema or risk of abdominal compartment syndrome
% 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 Jun;70(6):
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 Mar;36(3):
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.

32. Evidence

33. ˜

34. 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 Jan 20;(1):CD

35. 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 Jan 20;(1):CD
DCS still remain an useful tool for surgeon to deal with patients with multiple trauma and exhausted physiological resource

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

37. 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 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 Dec;71(6):
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 Sep;43(9): => poorer physical and mental QOL

38. Damage Control Resuscitation

39. 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:
Holcomb J, Jenkins D, Rhee P et al. Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma. J Trauma 2007; 62:
Hodgetts TJ, Mahoney PF, Kirkman E. Damage control resuscitation. J R Army Med Corps Dec;153(4):
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

40. 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

41. 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 Dec;155(4):323-6.

42. 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

43. Thank You!