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DavidRayVelez andAnthonyJosephDuncan

Damage control surgery is a surgical technique that involves a brief initial opera­tion aimed at quickly controlling severe bleeding and/or contamination in critically ill patients [4]. Following the initial surgery, patients are admitted to the intensive care unit where their condition is stabilized with the objective of returning them to their pre-injury state before denitive repair can be carried out [4]. While advance­ments in technology have led to signicant improvements in this technique over the years, the fundamental principles of damage control surgery have remained unchanged.

There are 5.8million traumatic deaths every year across the globe [5]. Trauma is the third leading cause of death in the United States with 150,000 deaths per year [6]. Trauma is largely a disease of young males with over 50% between the ages of 10 and 24years and over 66% male [7]. Trauma is the most common cause of death between ages 1 and 44years [8].

The most common causes of traumatic death in the United States are motor vehi­cle collision (37,991 deaths/year), falls (37,455 deaths/year), and gunshot wounds with suicide (24,432 deaths/year) accounting for almost twice that of homicide (13,958 deaths/year) [9]. Blunt abdominal trauma (BAT) accounts for 90% of patients presenting but only 67% of those requiring laparotomy [10]. Penetrating abdominal trauma (PAT) accounts for only 10% of patients presenting but 33% of those requiring laparotomy [9, 10]. Of penetrating mechanisms, stab wounds are the most common, although gunshot wounds are approximately eight times more lethal [11].

13]. Regarding patients without peritonitis or evisceration, management will then

The rst steps of an efcient trauma laparotomy are access and exposure to facili­tate the ensuing procedure. The typical access is through a long midline incision from xiphoid to pubis. However, every effort should be made to enter through virgin territory to avoid scars and internal adhesions. This may be accomplished by extend­ing the incision superiorly or inferiorly if able. If unable, an alternative incision can be chosen such as the chevron incision which resembles the military chevron insig­nia just under the rib cage bilaterally. This is also known as a bilateral subcostal, double Kocher, or rooftop incision. For additional access, a Mercedes Incision can be made by adding a small midline extension toward the xiphoid from the chevron incision, therefore, resembling a Mercedes-Benz automobile emblem. Immediately upon entry into the abdomen, the bowel should be eviscerated early. Incision should be done rapidly but in a controlled manner as a major pitfall during this step would be iatrogenic injury to the liver, bowel, or bladder.

The exsanguinating patient should be approached by obtaining supraceliac con­trol of the Aorta. This is done through division of the Gastrohepatic ligament. Although normally avascular, care should be taken to watch for a replaced left hepatic artery. The stomach and esophagus are then reected to the left to allow access to the aorta. Division of the diaphragmatic crura may be required. The aorta can then be bluntly dissected and occluded. Aortic occlusion is typically with a vascular clamp although it can also be compressed against the spine either manually or with an aortic root compressor.

For inframesocolic exposure, the transverse colon is lifted cranially and the bowel is run from the ligament of Treitz down to the rectum. Each loop of bowel is systematically ipped between hands inspecting both sides as well as the associated mesentery. Notorious sites of missed injury include the proximal jejunum near the ligament of Treitz, posterior transverse colon, hepatic exure, and splenic exure. Once nished, the bladder and pelvis are inspected. The transverse colon is then pulled caudally for supramesocolic exposure. Typically, structures are inspected from the patient’s right-to-left as if reading a book. First the liver and gallbladder are palpated, the right kidney is palpated, the stomach is evaluated from the gastro­esophageal junction down through the duodenal loop, and then the spleen and left kidney are palpated. The gastroesophageal junction and retroperitoneal duodenum are also at higher risk for missed injury and should allocate special attention. Next the lesser sac is accessed by blunt dissection through the greater omentum, allowing inspection of the posterior stomach and pancreas.