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Damage Control Surgery
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RiaanPretorius, FrankPlani,KennethD.Board,
and VickyJennings
47
47.1 Introduction
In 1992, M.Rotondo and C.Schwab coined the term “damage control” to describe abbreviated surgery for exsanguinating penetrating abdominal injury. The concept of abbreviated
surgery has been practised since World War II.Damage control surgery is indicated for critically ill patients with extensive or multiple cavity injuries, where severe physiological
derangements are identied early, and physiological restoration is prioritised above denitive anatomical reconstruction.
Prolonged surgery has been shown to exacerbate physiological injury and is associated with an increase in cytokine
release, multiple organ failure, surgical morbidity and mortality. The principles of damage control surgery include abbreviated surgery to control haemorrhage and limit contamination
followed by resuscitation strategies to improve the physiology before completing denitive repair of all injuries.
As time progressed, a better understanding of the physiological insult of trauma was developed. It resulted in novel
resuscitation strategies, acceptance of permissive hypotension, limited use of crystalloid uids, using blood and blood
products earlier in the resuscitation phase, lower incidence
of abdominal compartment syndromes, less relook laparotomies and improved patient outcomes.
In 1982, Kashuk described the lethal triad that has been
used by surgeons as a guide in the decision-making algo-
R. Pretorius · V. Jennings (*)
Trauma Directorate, Chris Hani Baragwanath Academic Hospital,
University of the Witwatersrand Medical School,
Johannesburg, South Africa
e-mail: vicky@drjennings.co.za
F. Plani
Netcare Alberton Hospital, Alberton, South Africa
K. D. Boffard
Milpark Hospital Trauma Academic Unit, University of the
Witwatersrand Medical School, Johannesburg, South Africa
e-mail: kdboffard@pixie.co.za
rithm of when damage control surgery is indicated. The triad
consists of:
– Hypothermia
– Acidosis
– Coagulopathy
Recent evidence has reviewed the important role that
hypocalcaemia plays in damage control resuscitation strategies and coagulopathy. Trauma induced hypocalcaemia has
historically been underappreciated in patients with a extensive injuries. Calcium plays an vital role in the coagulation
cascade as well as myocardial contractility. Patients presenting with severe haemorrhagic shock or requiring massive
blood transfusion, should have their calcium levels checked
and replaced on an ongoing basis until the resuscitation process has been completed, from the time of presentation to the
emergency department. Hypocalcaemia has subsequently
been added by some to the well known “lethal triad” as a
potential fourth component, subsequently changing the
lethal triad into the “diamond of death”. Whether hypocalcaemia is caused by major trauma or a consequence of massive blood transfusion is not yet well established, however
calcium should be replaced in all severely injured trauma
patients with hypocalcaemia, from initial presentation. This
should be a guide to consider using damage control techniques; however, unanticipated intraoperative ndings can
also function as independent indicators for damage control
surgery, i.e. extensive liver or pancreatic injuries and associated intra-abdominal vascular or pelvic injuries. If a preoperative decision was taken that damage control surgery is
required, one should not change to denitive surgery intraoperatively, as this might lead to adverse outcomes, due to
underestimation of the initial physiological insult.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_47
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47.1.1 Hypothermia
A temperature of less than 35°C is dened as hypothermia.
Due to the nature of trauma, a large percentage of patients are
hypothermic on arrival to hospital. Factors that contribute to
the hypothermia are prolonged external environmental exposure, uid and blood resuscitation with products that are not
pre-warmed, vasodilatation induced by intoxication and cold
resuscitation room or operating theatre temperatures. Trauma
operating theatres should be set to a minimum 26 °C, but even
despite having a higher temperature, prolonged operation
times in large body cavities can still result in hypothermia.
Hypothermia, as part of the original lethal triad (commonly referred to as the “bloody, vicious cycle”), has a profound impact on acidosis and coagulopathy:
1. Decreased oxygen delivery and increased oxygen con-
sumption are associated with worsening acidosis and can
be attributed to:
(a) Hypoventilation
(b) Peripheral vasoconstriction
(c) Oxygen dissociation curve shift to the left further
decreasing oxygen delivery
(d) Increased oxygen consumption due to shivering
2. Coagulopathy
(a) Decreased platelet count and function
(b) Decreased synthesis of clotting factors
Hypothermia can be addressed using two approaches
depending on the patient’s temperature on presentation.
1. External rewarming strategies
(a) Removal of wet and cold clothes (passive)
(b) Blankets (passive)
(c) External warming blankets (active)
2. Internal rewarming strategies
(a) Administration of pre-warmed intravenous uids,
blood or blood products
(b) Intracorporeal warm uid lavage into the stomach via
the nasogastric or orogastric tube, into the bladder
via the urinary catheter, intrapleural via intercostal
drains and intra-peritoneally during laparotomy or by
placing an intraperitoneal lavage catheter
(c) Active commercially available blood rewarming
devices or haemodialysis
tors and platelet function, as well as oxygen release to tissues.
The critical pH is 7.1, but the trend and response of the patient
to resuscitation should also be taken into consideration.
With a drop of the pH to 7.0, the activity of factor VIIa
decreases by 90% and that of factor Xa/Va complex by 70%.
The best way of managing acidosis is to stop any haemorrhage, use a protocolised resuscitation strategy and only use
bicarbonate replacement if the pH is less than 7.1 to support
enzyme function.
47.1.3 Coagulopathy
In a polytrauma patient, the cause for the coagulopathy is
multifactorial and can be divided into:
1. Intrinsic causes
(a) Consumption coagulopathy is caused by exposed
sub-endothelium that activates the clotting cascade
and depletes clotting factors.
(b) Hypothermia and acidosis (as discussed above) affect
clot formation.
(c) Hypocalcaemia caused by depletion of calcium
required in the clotting cascade or the citrate, contained within stored red packed cells to increase shelf
life, binding calcium during a massive transfusion.
2. Extrinsic causes
(a) Dilutional coagulopathy is caused by using excessive
clear uids for resuscitation purposes or the replacement of blood loss with packed red cells only, without platelet or fresh frozen plasma replacement.
47.2 Damage Control Resuscitation
The aim of damage control resuscitation is to accept lower
than normal blood pressure until control of haemorrhage is
obtained, to decrease the amount of clear uids given—thus
reducing coagulopathy—therefore resulting in early return
of normal physiology and decreased incidence of open
abdomen.
Damage control resuscitation has two main components:
– Hypotensive resuscitation
– Haemostatic resuscitation
47.1.2 Acidosis
Metabolic acidosis is caused by anaerobic metabolism. This
impacts the function of regulatory enzymes and the more
severe the acidosis, the less these enzymes are able to function. These regulatory enzymes play an integral role in the
body’s response to inotropes, the functioning of clotting fac-
47.2.1 Hypotensive Resuscitation
In penetrating truncal trauma, maintaining a lower systolic
BP (<90mmHg) until haemorrhage control is achieved has
shown improved patient outcomes, due to less blood loss and
less clear uid administration. This prevents clot dislodgement, dilutional coagulopathy, cardiac dysfunction, abdomi-
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Fig. 47.1 Application of massive transfusion protocol
nal compartment syndrome, severe inammation, ARDS and
multiple organ failure.
In patients with blunt trauma and associated head injury,
the role of permissive hypotension is less clear, as cerebral
perfusion pressure (CPP) must be maintained to avoid secondary brain injury. Usually, a systolic blood pressure (SBP)
of 100mmHg or a mean arterial blood pressure (MAP) of
70mmHg should be adequate.
Permissive hypotension should only be practised for
90–120min to avoid organ injury. The use of vasopressors to
negate this hypoperfusion has a worsen outcome due to the
capillary vasoconstriction and increasing cellular ischemia.
47.2.2 Haemostatic Resuscitation
Identifying at an early stage during resuscitation, a patient,
who will require massive transfusion using blood and blood
products, has shown to reduce mortality by 46%. The ideal
resuscitation uid is whole blood with all its components,
despite a higher risk of a transfusion reaction. On the other
hand, due to limited blood availability (e.g. after the COVID
pandemic) and short shelf life, most institutions only have
access to component therapy.
Massive blood transfusion (MBT) is dened as ten or
more units in a 24-h period or more than 50% of the patient’s
blood volume in 3 h. All hospitals that deal with major
trauma patients should have massive blood transfusion
protocols in place, be able to identify patients that would
require MBT early and activate blood and blood products on
an emergent basis (Fig.47.1).
The PROPPR trial reviewed the optimal ratio of blood
and blood products to use during MBT.It compared using a
1:1:1 vs. 1:1:2 ratio of plasma, platelets and red blood cells.
389
Primary outcomes, which were considered, were the 24-h
and 30-day all-cause mortality. There was no signicant difference in 24-h or 30-day all-cause mortality, but patients in
the 1:1:1 group achieved reversal of coagulopathy earlier and
fewer experienced death from exsanguination within 24h.
Even though the 1:1:1 ratio is the advised ratio for MBT protocols, viscoelastic studies like thromboelastography (TEG)
or rotational thrombo-elastometry (ROTEM) should be used
as a guide to reverse coagulopathy.
Following the development of a better understanding of
component therapy, the focus has changed to individual
component therapy:
– Factor VIIa
– Factor VIIa plays a major role in the initiation of clotting
in the clotting pathway. Without surgical control, it
decreases transfusion requirements but shows no differ-
ence in mortality.
– Fibrinogen
– Fibrinogen is depleted the earliest during the clotting cas-
cade, but studies have shown that replacement without the
guide of thromboelastography did not improve outcome.
– Tranexamic acid
– Tranexamic acid inhibits plasmin which plays a vital role
in the later phases of coagulation and inammation.
Despite very large, randomised control trials (CRASH
studies), further high-power studies are required to con-
rm the role of tranexamic acid.
– Calcium
– Calcium levels should checked at presentation and con-
stantly monitored during the active resuscitation phase of
polytrauma patients.
– Fresh frozen plasma
– Multiple studies show that the early administration of
fresh frozen plasma allows the reconstitution of the cel-
lular glycocalyx, prevents uid creep and decreases the
effect of systemic uid overload.
Use of commercial devices, surgical adjuncts and topical
factors.
The below are used for “mechanical” early control of
haemorrhage, followed by operative control:
– Emergency room thoracotomy and resuscitative endovas-
cular balloon occlusion of the aorta (REBOA)
– Emergency room thoracotomy still has a high morbidity
and mortality rate. The introduction of a less invasive
technique, REBOA, challenged the indications for emer-
gency room thoracotomy. Penetrating chest trauma out-
comes are better with emergency room thoracotomy,
while abdominal, pelvic and junctional vascular traumas
have better outcomes with REBOA.
– Tourniquet
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R. Pretorius et al.
– Tourniquets have been reintroduced in civilian practice as a
“life-over-limb” strategy to avoid mortality due to excessive
blood loss. Their use should be limited to controlling arterial
bleeding, where other attempts at control have failed and
should be placed as close as possible to the injury.
– Factor concentrates (brin or thrombin)
– These products are used as concentrated factors in combina-
tion with or without human gelatine and applied topically.
They are activated by contact with blood and contain bio-
– Muco-adhesive
– Muco-adhesives adhere to the adjacent tissues to form a
mechanical plug in the bleeding wound.
– Pro-coagulant
– These products contain pro-coagulants. Cellulose mini
sponges can be used in cavities with incompressible
haemorrhages and has shown to decrease transfusion
requirements and improve mortality. Argon beams can be
used on raw bleeding surfaces.
logical active products that serve as an aid in haemostasis.
This table shows the progression from past therapies and
potential future therapies:
Past Current Future
Surgery Aggressive denitive surgery Damage control surgery Prehospital control of haemorrhage
Haemostatic agents Improved haemostatic agents
Improved interventional radiology with
hybrid theatres
Coagulopathy “Catch up” and correction in
coagulopathy
Perfusion/BP Aggressive resuscitation with
clear uids
Inammation None Decreased uid administration
Massive transfusion protocols Genetic guidance to treatment
TEG Early treatment (prehospital)
Early blood and blood product
transfusion
Restricted use of clear uids
leads to a decrease in
inammation
Development of the optimal oxygen carrier
Target genetic factors
Early treatment
47.3 Stages ofDamage Control
Damage control surgery was initially divided into ve stages:
– Stage 1: Indication/patient selection
– Stage 2: Operative control of haemorrhage and
contamination
– Stage 3: Resuscitation in the intensive care unit
– Stage 4: Denitive surgery
– Stage 5: Closure of the abdomen
47.3.1 Stage 1: Indication/Patient Selection
ofDamage Control Surgery
When considering performing damage control surgery, the
pros and cons of such a procedure should be reviewed. The
overzealous use of damage control surgery does come with
its own risks. The surgeon should take into consideration that
the decrease in mortality comes with a potential increase in
morbidity, length of hospital stay and amount of subsequent
surgical procedures.
If a preoperative decision was made to perform damage
control surgery based on the abnormal patient physiology, it
is safer not to alter that decision. However, if denitive sur-
gery was initially planned, and during the operation, the
patient’s haemodynamic physiology has deteriorated, and the
denitive procedure can be altered to damage control surgery
after consultation between the surgeon and the anaesthetist.
Parameters indicative that damage control surgery is
required:
1. Physiology
(a) No responder to resuscitation with systolic BP
<70mmHg
(b) Temp <35 ° C
(c) pH<7.2
(d) Lactate >5mmol/L
(e) Worsening of intraoperative acidosis, hypothermia
and coagulopathy
(f) Increased inotropic requirements during surgery
2. Anatomical injuries
(a) Injury severity score (ISS)>25
(b) Multiple cavity injuries or multiple injuries that will
require prolonged or extensive surgery for denitive repair
(c) Massive blood transfusion or uid resuscitation, risking
the development of abdominal compartment syndrome
(d) Packing necessitated to control haemorrhage
(e) Severe contamination
3. In the presence of mass casualties, damage control is the
standard to allow for the maximum use of resources.
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47.3.2 Stage 2: Operative Control
ofHaemorrhage andContamination
47.3.2.1 General Principles
In damage control surgery, the aim is to perform abbreviated
surgery to control bleeding and contamination, while resuscitation is ongoing to improve the patient’s physiology. This
is a team approach whereby every member in the team plays
a vital role and clear communication between all team members is important.
The following principles should be practised:
1. The operating theatre’s ambient temperature needs to be
higher than normal (not less than 26 °C).
2. The nursing staff must ensure that everything needed for
damage control (i.e. nasogastric tubes for shunting, GI
staplers, topical haemostatic agents, packs for packing) is
available. The patient should be cleaned and draped from
the torso to the knee area– areas that are not operated on
should be covered to prevent heat loss.
3. The anaesthesiologist must continue with haemostatic
resuscitation principles and depending on the type of
injuries, administration of autologous blood, if a cell
saver is available. A repeat dose of prophylactic antibiotics should be administered, if the patient has lost his/her
total blood volume. There should be continuous communication between the anaesthesiologist and the surgeon,
keeping the surgeon informed regarding the physiology
(inotropic requirements, blood loss and vital signs) so the
surgeon can change the operative strategy if the patient is
not responding.
4. At the same time, the surgeon must keep the whole the-
atre team informed with regard to injuries found, the
strategy going forwards and any surgical manoeuvres that
could alter the haemodynamic status of the patient,
including cross clamping of major vessels. The surgeon
must stay calm and speak clearly so everyone knows what
is expected.
5. The hospital and blood bank must have a massive blood
transfusion protocol, so blood and blood products are
readily available and distributed in the right ratios.
6. The laparotomy incision should not be primarily closed
until the denitive procedures take place. Instead, a
VAC Pack should be applied until the nal operation
(Fig.47.2).
7. By the end of the operation, the intensivist must be kept
informed in detail about the patient’s physiological
parameters, the injuries sustained and their management,
as well as the uid/blood administration.
8. In cases where embolisation (liver or pelvis) is required
as an adjunct to damage control surgery, the radiologist
should be informed, as soon as this requirement is
identied.
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Fig. 47.2 Application of Vac Pack
47.3.2.2 Thoracic Damage Control
In the chest, damage control often ends up as denitive surgery, due to the nature of the injuries sustained. Cardiac tamponade, massive haemorrhage and a large air leak from the
lung are common causes that can be addressed denitively in
an expedient manner. An emergency room thoracotomy for
unstable patients is usually to release a cardiac tamponade,
control massive thoracic haemorrhage, get pulmonary hilar
control or cross clamp the aorta to allow volume resuscitation while perfusing vital organs.
The most important part in the management of thoracic
injuries is the choice of incision used. That will be determined by the stability of the patient and the suspected
injuries.
A median sternotomy is the preferred approach for anterior mediastinal, cardiac and zone 1 neck injuries. However,
with this incision, access to the posterior mediastinum is
very limited. For any penetrating wound that is located on
the anterior chest wall, medial to the midclavicular line (also
referred to as “the cardiac box”), a sternotomy is the incision
that gives you best access.
The left anterior-lateral thoracotomy is often used as an
emergency procedure to gain access to the left chest contents. It provides good exposure of the left side of the heart,
lung, aorta and proximal subclavian artery. Right anterolat-
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R. Pretorius et al.
eral thoracotomy gives excellent access to the right lung, as
well as haemorrhage for the left thoracic cavity. For transmediastinal gunshot wounds, a left anterolateral thoracotomy can be extended through the sternum to the right side,
the so-called clamshell thoracotomy. It gives excellent exposure to the entire chest cavity and mediastinal structures but
is associated with high morbidity.
The posterolateral thoracotomy is the best incision for
posterior mediastinal injuries which include the trachea/
bronchus, oesophagus, descending aorta and posterior intercostal arteries. The posterior lateral thoracotomy is not used
in unstable patients as the preparation and adequate positioning of a patient for this procedure is time consuming.
In case of penetrating trauma, the thoracic cavity is not
amenable to haemostatic packing. For packing to be successful as a haemostatic measure, pressure and counter-pressure
from solid organs or another rigid structure is required.
Attempts at packing the chest can result in impaired ventilation or lead to haemodynamic instability. Contrary to penetrating trauma, in blunt trauma, if there is signicant
uncontrollable oozing from the chest wall (e.g. secondary to
multiple rib fractures), packing of the thoracic cavity can be
a “bail out”.
non-anatomical wedge resection, which is greatly facilitated
by the use of staplers.
Large bronchial injuries can be repaired, and pneumonec-
tomy is very seldom indicated.
Cardiac Injuries
The priorities in treating penetrating cardiac injuries are to
release any tamponade and proceed control of the haemorrhage. Depending on the physiological status of the patient,
access to the injury can be obtained by a median sternotomy
or a left anterolateral thoracotomy—the former obtains better operative exposure and the latter is recommended in the
physiologically grossly unstable patient, as it gives more
rapid access to the injury site. This incision can be converted
to a clamshell incision, if access to the heart is not satisfactory (Fig.47.3).
Prior to surgery, always make sure you have warm saline
and internal debrillators available. On opening the pericar-
Lung Injuries
Emergency surgery for lung injuries is often due to a large air
leak that doesn’t allow the lung to expand or a massive haemothorax that continues to bleed.
Ideally, when operating on the lung, intubation with a
double-lumen endotracheal tube will make the surgery easier, but if the patient is physiologically too unstable to allow
for the extra time it takes to insert a double lumen endotracheal tube, then control of the lung hilum is essential at the
start of the surgery. With obtaining pulmonary hilar control
rst, the risk of air embolism is decreased, the lung is collapsed and the haemorrhage is decreased, thus improving
visualisation of the operative eld, resulting in facilitated
suturing or stapling of the parenchyma. Obtaining hilar control can be succeeded by dividing the inferior pulmonary
ligament while taking care to avoid injury to the inferior pulmonary vein. A less tedious procedure of obtaining hilar control is succeeded by applying a vascular clamp from a
cephalad to a caudal direction, in which case severing of the
pulmonary ligament is not necessary. With very proximal
hilar injuries, you might need to obtain proximal hilar vascular control from inside the pericardial sac.
Central air leaks and bleeding should be addressed by
doing a tractotomy to lay the full tract of the injury open. The
tractotomy can be done with either GI staplers or soft bowel
clamps. Once the tract of the stab or gunshot wound is open,
you can identify air leaks from smaller bronchial or lung
injuries, as well as bleeding vessels, which are dealt with.
Injuries on the periphery of the lung can be treated with a
Fig. 47.3 Clamshell incision for repair of through and through injury
to the heart (apex—right ventricle)
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dium, it is important to identify and preserve the phrenic
nerve. With an anterolateral thoracotomy, it is important to
identify the phrenic nerve and open the pericardium anterior
to it.
Temporary control of ventricular cardiac haemorrhage
can be obtained initially by digital occlusion or insertion of a
Foley’s catheter followed by ination of the balloon with
saline—gentle traction should be applied, and the catheter
secured with a haemostatic clamp ush to the cardiac muscle
(Fig.47.4). Denitive closure of the injury should be done
with Prolene sutures, making sure that the coronary arteries
are not included in those sutures. For atrial injuries, temporary control can be obtained by placing a side-biting Satinsky
clamp just below the injury, without completely occluding
venous return (Fig.47.5).
Tracheobronchial Injuries
The indication for emergency surgery in tracheobronchial
injuries is a large bronchopleural stula that doesn’t allow
the lung to expand and compromise ventilation. The best
approach is a right posterolateral thoracotomy with a doublelumen tube. The trachea or bronchus can be repaired with an
absorbable monolament suture.
393
Oesophageal Injuries
The greatest determining factor in the outcome of oesophageal injuries is early diagnosis and repair. The strongest layer
of the oesophagus is the mucosa, and adequate mucosal
opposition is imperative to achieve a successful repair. If
there is an associated tracheal injury, an interposition muscle
ap (mobilisation of a strap muscle or creation of a ap from
part of the sternocleidomastoid muscle) must be placed
between the two injuries to decrease the risk of stula formation. Always leave drains after repair. If an oesophageal
injury is amenable to stenting, it can be managed with a covered stent. In late presentation of the injury (more than 24h),
primary repair is precarious, and the management relies on
drainage and isolation of the injury site.
47.3.2.3 Abdominal Damage Control (Solid
Viscera)
Liver
Although the liver constitutes 2.5% of the total body weight,
it receives nearly 25% of the cardiac output– total hepatic
blood ow ranges between 800 and 1200mL/min. Therefore,
liver injuries are often a source of major haemorrhage, leading to haemodynamic instability, requiring damage control
surgery.
Fig. 47.4 Occlusion of cardiac defect with a Foley’s catheter balloon
Fig. 47.5 Satinsky clamp applied on defect of cardiac auricle
The approach to injury of the liver should be in an organ-
ised way—by the “4 P’s” approach:
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– “Push”—Opposing the surfaces of the liver laceration by
manual compression—restoring the gross liver anatomy.
This will often stop or slow the bleeding down and allow
time for denitive procedures.
– “Pringle”—The purpose of the Pringle manoeuvre is to
control the haemorrhage inow into the liver by control-
ling the hepatic artery and portal vein at the free edge of
the lesser sac. This can be succeeded by digital occlusion
and application of a soft bowel or vascular clamp or a
Foley’s catheter as a temporary tourniquet (Figs.47.6 and
47.7) When the bleeding stops, the individual vessels can
be identied within the liver parenchyma and suture
ligated or clipped with a Ligaclip. If the Pringle manoeu-
vre fails to control the haemorrhage, it is indicative that it
originates from the hepatic veins or the retro-hepatic IVC.
– “Plug”—Haemorrhage from cavities or wound tracts can
be controlled by plugging with haemostatic agents, omen-
tum, the oesophageal balloon of a Sengstaken-Blakemore
tube or homemade “sausage” balloons by using a naso-
gastric tube or Foley’s catheter in combination with a
Penrose drain, the nger of a surgical glove or a condom
(Fig.47.8).
– “Packing”—With packing the liver, compression is cre-
ated to restore the anatomy and compress bleeding ves-
sels. When packing the liver, folded dry swabs should be
used to press the liver up and laterally. Packing the liver
can cause ventilatory compromise due to pressure on the
diaphragm or haemodynamic instability due to pressure
on the IVC.Continuous communication with the anaes-
thetist should be ensured to review the patient’s response
to liver packing. Packing for injury of the IVC should be
R. Pretorius et al.
Fig. 47.7 Pringle manoeuvre using a Foley’s catheter
Fig. 47.6 Pringle manoeuvre by application of soft bowel clamp
Fig. 47.8 Plugging of a gunshot wound with a homemade Sengstaken-
Blakemore tube (using a Foley’s catheter and a Penrose drain)
undertaken before any severing of the ligaments of the
liver. Packing does not control arterial bleeding. In that
case, if operative control is not successful, angio-
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395
embolisation can be considered. The hepatic artery can be
ligated; however, portal vein ligation should be avoided as
it is associated with a very high mortality. If both are
injured, at least one should be repaired.
Spleen
Within the setting of damage control surgery, a splenectomy
for an actively bleeding spleen remains the treatment of
choice. Splenic-preserving procedures should be reserved
for patients who are not coagulopathic and who do not
require damage control surgery, as the risk of continuous
bleeding from the spleen in coagulopathic patient outweighs
the benet of preserving splenic function.
Kidney
In penetrating trauma, all tracts involving retroperitoneal
Zone II should be explored unless prior imaging has been
obtained and showed, that the kidney has not been injured or
its injury can be managed conservatively. Damage control
surgery for injury of the kidney involves a nephrectomy.
Pancreas
The management of penetrating trauma to the pancreas is based
on the location of the injury in relation to the superior mesenteric vessels and the presence or absence of ductal involvement.
In desperate situations, packing of the injured area to control
haemorrhage and insertion of drains is sufcient. In less desperate situations, if the injury is on the left of the superior mesenteric vessels and does not involve injury of the main duct,
insertion of drains is adequate. If the main duct is involved, the
surgeon can proceed to distal pancreatectomy and splenectomy
with a use of staplers to expedite the procedure. There is no
place for splenic preservation in damage control surgery. If the
pancreatic injury is located to the right of the superior mesenteric vessels, drains should be placed to remove the pancreatic
efuent. There is no place for a Whipple’s procedure in damage
control surgery, except if it necessitated for the control of torrential haemorrhage. In that case, anastomoses will not be performed during the original operation and will be postponed for
the timing of the relook laparotomy.
47.3.2.4 Abdominal Damage Control (Hollow
Viscera)
Stomach
Damage control surgery of the stomach often entails primary
denitive repair, due to its excellent blood supply and the
ease with which these injuries can be accessed.
breaks down. Pyloric exclusion should be considered if the
duodenal repair is precarious, if there is delayed presentation
of the injury related to a septic collection or if there is concomitant signicant injury to the head of the pancreas.
Small Bowel
Perforations of the small bowel can be primarily repaired. If
these are too many, and the patient’s physiological condition
is not ideal, a damage control approach can be considered.
Resection of injured small bowel without anastomosis or
“clip and drop” of the small bowel is the standard damage
control procedure for small bowel injuries. Special attention
should also be given to mesenteric vascular injury, as these
vessels can retract in a shocked patient and start bleeding
again, once the blood pressure has been restored. Transected
mesenteric vessels should be ligated even if active haemorrhage is not identied at the initial surgery.
Colon
Damage control of colonic injuries is similar to that of the
small bowel. If primary repair is considered unsafe, “clip and
drop” should be practised. Fashioning of stomas should be
avoided at the damage control scenario, as it is time consuming and is not desirable in the presence of an open
abdomen.
Rectum
Intraperitoneal rectal injuries should be dealt with as a
colonic injury. In extraperitoneal rectal injuries, diversion
with a sigmoid loop colostomy sufces. This is the standard
management in civilian penetrating trauma. Extensive
debridement with a Hartmann’s colostomy and possible
insertion of a presacral drain should be considered in a very
severe injury, as such secondary to close high-energy gunshot wounds as seen in the military environment.
Biliary Tract Injuries
A gall bladder injury is treated with a cholecystectomy.
Minor bile duct injuries can be controlled by a T-tube, if the
diameter of the common bile duct can accommodate the
T-tube. In severe bile duct injuries, (a) external drainage can
be obtained by insertion of a suction drain next to the site of
the injury or by insertion of an umbilical catheter, through
the biliary defect, at the proximal part of the bile duct; and
(b) if the previous cannot be applied, the severed common
bile duct can be ligated and at the relook laparotomy, by
which time the duct is distended, the surgeon can proceed to
a Hepp-Couinaud operation.
Duodenum
Up to 90% of penetrating injuries to the duodenum can dealt
with by primary repair and drainage at the site of the suture
line to potentially create a controlled stula if the repair
Ureter andUrinary Bladder Injuries
Damage control surgery related to the ureter has several
options, including simple drainage at the site of the injury,
external drainage by insertion of an umbilical catheter at the
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proximal part of the injury or ligation of the ureter. It is
important not to lift the ureter from its bed extensively, as it
might become necrotic due to inadvertent injury to its blood
supply. In any patients with gunshot wounds within close
proximity to the ureter, a drain should be left as there is a
potential for delayed leaks due to shockwave injury.
All intraperitoneal urinary bladder injuries must be
repaired. Extraperitoneal bladder injuries should be treated
by insertion of an indwelling catheter.
47.3.2.5 Vascular Injuries
In a damage control environment, arterial vascular injuries
are dealt with by insertion of an arterial vascular shunt.
Although certain arteries can be ligated with impunity, e.g.
the celiac and the inferior mesenteric artery, in most major
arteries like the aorta, the superior mesenteric artery, the
arteries of the limbs down to the level just below the elbow
and knee, etc., the continuity in the physiologically unstable
patient should be restored by a vascular shunt (Fig.47.9a, b).
In the scenario of vascular injury of the limb related to an
unstable fracture, the distal blood supply is restored by insertion of a vascular shunt, and the stability of the fracture by
external xation should follow.
The infrarenal inferior vena cava (IVC), the common iliac
vein, the external iliac vein, the internal iliac vein, the inferior mesenteric vein and the splenic vein can be ligated with
impunity. Ligation of the right renal vein will necessitate a
right nephrectomy and the left renal vein distal to the gonadal
vein, a left nephrectomy. Ligation of the hepatic veins will
necessitate follow-up for liver ischaemia. The suprarenal/
perirenal IVC should be ligated only in a life-saving scenario—an effort to insert a shunt should be made. Also, only
in life-saving scenarios the portal vein and the superior mesenteric vein should be ligated, in which case, a second-look
laparotomy for gut ischaemia is necessary.
47.3.3 Stage 3: Resuscitation inICU
Following damage control surgery, the patient should be
transferred to the ICU as soon as possible. The goal is to
reverse the lethal triad of acidosis, coagulopathy and hypothermia with continuous resuscitation in a favourable environment. At the same time, if the patient’s physiological
condition allows/requires, further diagnostic/therapeutic
measures (angiography/angio-embolisation) can be taken,
Fig. 47.9 (a and b) Patient exsanguinating from gunshot wound to left
axilla had a cardiac arrest on arrival to the trauma resuscitation area. He
underwent successful emergency department thoracotomy, followed by
transfer, in a physiologically unstable condition, to the operating theatre
where the severed left axillary artery was shunted with a piece of nasogastric tube
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