Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 926 - файл
.pdf
214 M. Quinn and C. W. Steele
https://t.me/med1917
Fig. 8.5 Coiling of internal
iliac stumps. Internal iliac
stumponleftcoiled
following total pelvic
exenteration followed by
urinary leakage, pelvic sepsis
and herald bleeding from
internal iliac system
is clean, then delayed flap closure can be considered often with a muscle only
gracilis flap to place well vascularised tissue in the defect.
There are some modifiable factors that can be addressed pre-operatively to
reduce the risk of a chronic perineal sinus including obesity, alcohol intake,
Fig. 8.6 Retained packing
as source of persistent
wound sinus
post-exenteration. Retained
packing placed in the
community was found to be
the cause of persistent failure
of perineal sinus/cavity to
heal thereafter
8 Empty Pelvis Syndrome Complication Management Following Pelvic … 215
https://t.me/med1917
and smoking [5]. Diabetes and obesity carry the greatest statistical risk for perineal wound healing issues [35]. Prehabilitation in this context is important with
attention paid to correction of iron deficiency [36]. It is belived by some that intraoperative positioning can influence rates of healing, with one group suggesting that
wound infection rates reduced from 22 to 3.5% when they moved from lithotomy
to prone position [37].
8.5.4 Enteroperineal Fistula
Whilst fistulae may not be as common as other complications with an incidence
around 1–2% [8], they can have a devastating effect on patient QoL and are often
complex to manage. The most commonly described fistula following pelvic exenteration is enterocutaneous, often perineal (see Fig. 8.7), however vesicovaginal,
rectovaginal and urinary fistulae may also occur [38]. Perineal enterocutaneous fistulae may ultimately result in patient mortality with 2 patients out of 15 dying from
complications of perineal fistulae in a case series of 315 pelvic exenterations [39].
The most common cause for delayed fistulation was malignancy, whereas in early
fistulae approximately 50% were due to unrecognised intra-operative enterotomy.
Radiation enteritis is another cause of delayed fistulation [40]. In this situation
serious consideration should be given to conservative management with the use of
home parenteral nutrition as the re-fistulation rate is extremely high. Residual small
bowel will be damaged and leak rates from any serosal tears and enterotomies
during mobilisation of pelvic small bowel loops can be disastrous.
Fig. 8.7 Enteroperineal
fistula. Fluoroscopy
demonstrating leakage of
contrast from small bowel
through vaginal remnant and
into perineum
216 M. Quinn and C. W. Steele
https://t.me/med1917
The SNAP approach for management of enterocutaneous and perineal fistulae
seems to work best. Safe control of sepsis via drains or, if required, return to theatre for creation of a proximal stoma may be required early in the patient’s course.
When creating a proximal stoma care must be taken not to disrupt the ureter to
conduit anastomosis. The fistulated pelvic loops should be left in the pelvis and
ideally a stoma brought out above this [42]. If the patient is in good nutritional
state and there is minimal risk of osteomyelitis then the pelvic loop can be closed
off by firing a TA 60 stapler across the afferent and efferent limb, leaving the
blood supply undisturbed, and then a 2 layer side to side hand sewn anastomosis
performed above this to restore intestinal continuity.. Nutrition is given via a designated feeding line for TPN with strict NBM, high dose loperamide up to 16 mg
QDS as buccal preparation plus liquid codeine to lower fistula output. Anatomical mapping with contrast imaging, often including oral contrast studies should be
performed ahead of finally a planning for definitive operative management [41].
8.5.5 Perineal Hernia
Perineal hernia can occur following pelvic exenteration. This is a hernia through
the pelvic floor musculature or myocutaneous reconstruction. These may present
in a number of ways with pain and bulge most common [43]. In a systematic
review of 22 case series that focused on perineal hernia management most patients
were subjected to surgical repair with a combination of laparotomy, combined
abdominal and perineal approaches, and perineal alone approaches utilised. Mesh
was used to prevent future herniation in 15 of 22 studies. Due to the paucity
of evidence here, a considered approach involving preoperative imaging, plastic
surgical discussion and careful preoperative planning is suggested. At present there
is no recognised standard approach for repair.
8.5.6 Conclusion
In summary, for all patients undergoing pelvic exenteration aggressive management of complications is paramount. Early recognition and intervention of pelvic
collections can avoid catastrophic complications. Urinary leakage should be management via a standard algorithm, similar to that presented above. Pelvic drains are
extremely valuable in pelvic extenteration patients and education of the entire unit
looking after them prevents inadvertent removal and the complications thereof.
Although rare, perineal fistulas are extremely difficult to manage and a combined
approach with plastic surgeons, and surgeons with a dedicated interest in intestinal
failure, especially in the context of radiation enteritis, is often extremely useful.
8 Empty Pelvis Syndrome Complication Management Following Pelvic … 217
https://t.me/med1917
References
1. Ng KS, Lee PJM. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg
Oncol. 2021;37:101546.
2. PelvEx C. Changing outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer. BJS Open. 2019;3(4):516–20.
3. Johnson YL, West MA, Gould LE, Drami I, Behrenbruch C, Burns EM, Mirnezami AH, Jenkins JT. Empty pelvis syndrome: a systematic review of reconstruction techniques and their
associated complications. Colorectal Dis. 2022;24(1):16–26.
4. PelvEx C. Empty pelvis syndrome: PelvEx Collaborative guideline proposal. Br J Surg. 2023.
5. Mori GA, Tiernan JP. Management of perineal wounds following pelvic surgery. Clin Colon
Rectal Surg. 2022;35(3):212–20.
6. Benedict KC, Songcharoen SJ, Stephens KL, Winter AL, Edwards SR, Campbell CA, Arnold
PB. Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis
musculocutaneous flaps in the reconstruction of perineal wounds. J Plast Reconstr Aesthet
Surg. 2023;84:514–20.
7. Venchiarutti RL, Solomon MJ, Koh CE, Young JM, Steffens D. Pushing the boundaries of pelvic exenteration by maintaining survival at the cost of morbidity. Br J Surg.
2019;106(10):1393–403.
8. Peacock O, Waters PS, Kong JC, Warrier SK, Wakeman C, Eglinton T, Heriot AG, Frizelle
FA, McCormick JJ. Complications after extended radical resections for locally advanced and
recurrent pelvic malignancies: A 25-year experience. Ann Surg Oncol. 2020;27(2):409–14.
9. de Jonge SW, Wolfhagen N, Boldingh QJ, Bom WJ, Posthuma LM, Scheijmans JC, van der
Leeuw BM, van der Hoeven JA, Hering JP, Sonneveld DJ, van Geffen OE, Hendriks ER,
Kluyver EB, Demirkiran A, van Lonkhuijzen LR, Slotema T, Draaisma WA, Koopman SJ, van
Rossem CC, Over LM, van Duijvendijk P, Dijkgraaf MG, Hollmann MW, Boermeester MA.
Enhanced PeriOperative Care and Health protection programme for the prevention of surgical site infections after elective abdominal surgery (EPOCH): study protocol of a randomised
controlled, multicentre, superiority trial. BMJ Open. 2020;10(5):e038196.
10. Weiser MR, Gonen M, Usiak S, Pottinger T, Samedy P, Patel D, Seo S, Smith JJ, Guillem JG,
Temple L, Nash GM, Paty PB, Baldwin-Medsker A, Cheavers CE, Eagan J, Garcia-Aguilar
J, Memorial Sloan Kettering Multidisciplinary Surgical-Site Infection Reduction T. Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections. Br J Surg.
2018;105(12):1680–7.
11. Fan CW, Chen PH, Jhou HJ, Cheng YC. Negative pressure wound management in perineal
wound status post abdominoperineal resection and extralevator abdominoperineal excision: a
meta-analysis and trial sequential analysis. Int J Colorectal Dis. 2023;38(1):73.
12. Devulapalli C, Jia Wei AT, DiBiagio JR, Baez ML, Baltodano PA, Seal SM, Sacks JM, Cooney
CM, Rosson GD. Primary versus flap closure of perineal defects following oncologic resection:
A systematic review and meta-analysis. Plast Reconstr Surg. 2016;137(5):1602–13.
13. Creagh TA, Dixon L, Frizelle FA. Reconstruction with Vertical Rectus Abdominus Myocutaneous flap in advanced pelvic malignancy. J Plast Reconstr Aesthet Surg. 2012;65(6):791–7.
14. Fletcher JA, Drami I, West MA, Burns EM, Ross D, Northover J, Jenkins JT. Inferior gluteal
artery perforator flap reconstruction of the perineum: A Video Vignette. Colorectal Dis.
2022;24(9):1098.
15. Galbraith NJ, McCollum C, Di Mascio L, Lowrie J, Hinckley M, Lo S, Watson S, Telfer JRC,
Roxburgh CS, Horgan PG, Chong PS, Quinn M, Steele CW. Effect of differing flap reconstruction strategies in perineal closure following advanced pelvic oncological resection: A
retrospective cohort study. Int J Surg. 2023.
16. Stein MJ, Karir A, Hanson MN, Cavale N, Almoudaris AM, Voineskos S. Pelvic Reconstruction following abdominoperineal resection and pelvic exenteration: Management practices
among plastic and colorectal surgeons. J Reconstr Microsurg. 2022;38(2):89–95.
218 M. Quinn and C. W. Steele
https://t.me/med1917
17. Miyamoto Y, Akiyama T, Sakamoto Y, Tokunaga R, Ohuchi M, Shigaki H, Kurashige J, Iwatsuki M, Baba Y, Yoshida N, Baba H. Omental flap after pelvic exenteration for pelvic cancer.
Surg Today. 2016;46(12):1471–5.
18. Khaw CW, Ebrahimi N, Lee P, McCarthy ASE, Solomon M. Long-term results of mesh pelvic
floor reconstruction to address the empty pelvis syndrome. Colorectal Dis. 2022;24(10):1211–
5.
19. Lee P, Tan WJ, Brown KGM, Solomon MJ. Addressing the empty pelvic syndrome following
total pelvic exenteration: Does mesh reconstruction help? Colorectal Dis. 2019;21(3):365–9.
20. Blok RD, Sharabiany S, Stoker J, Laan ETM, Bosker RJI, Burger JWA, Chaudhri S, van Duijvendijk P, van Etten B, van Geloven AAW, de Graaf EJR, Hoff C, Hompes R, Leijtens JWA,
Rothbarth J, Rutten HJT, Singh B, Vuylsteke R, de Wilt JHW, Dijkgraaf MGW, Bemelman
WA, Musters GD, Tanis PJ. Cumulative 5-year results of a randomized controlled trial comparing biological mesh with primary perineal wound closure after extralevator abdominoperineal
resection (BIOPEX-study). Ann Surg. 2022;275(1):e37–44.
21. Carboni F, Federici O, Giofre M, Zazza S, Valle M. Empty pelvis syndrome: the use of breast
prosthesis in the prevention of complications. Colorectal Dis. 2019;21(11):1321–5.
22. Guimaraes GC, Baiocchi G, Rossi BM, Ferreira FO, Aguiar S, Nakagawa WT, Lopes A. The
use of silicone expander and cecal transposition after pelvic exenteration. Eur J Surg Oncol.
2007;33(5):586–9.
23. Kazi M, Desouza A, Bankar S, Jajoo B, Dohale S, Vadodaria D, Ghadi A, Ghandade N,
Vasudevan L, Nashikkar C, Saklani A. The use of an obstetric balloon as a pelvic spacer in preventing empty pelvis syndrome after total pelvic exenteration in rectal cancers - A prospective
safety and efficacy study for the Bakri balloon. Colorectal Dis. 2023;25(4):616–23.
24. Bankar S, Desouza A, Paliwal V, Pandey D, Gori J, Sukumar V, Rohila J, Saklani A. Novel use
of the Bakri balloon to minimize empty pelvis syndrome following laparoscopic total pelvic
exenteration. Colorectal Dis. 2020;22(12):2322–5.
25. Jacombs AS, Rome P, Harrison JD, Solomon MJ. Assessment of the selection process for
myocutaneous flap repair and surgical complications in pelvic exenteration surgery. Br J Surg.
2013;100(4):561–7.
26. Tao Y, Han JG, Wang ZJ. Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic
review and meta-analysis. Int J Colorectal Dis. 2021;36(5):893–902.
27. Funder JA, Tolstrup R, Jepsen BN, Iversen LH. Postoperative paralytic ileus remains a problem
following surgery for advanced pelvic cancers. J Surg Res. 2017;218:167–73.
28. Peacock O, Waters PS, Kong JC, Warrier SK, Wakeman C, Eglinton T, Murphy DG, Heriot
AG, Frizelle FA, McCormick JJ. Complications and 5-year survival after radical resections
which include urological organs for locally advanced and recurrent pelvic malignancies: analysis of 646 consecutive cases. Tech Coloproctol. 2020;24(2):181–90.
29. Llaguna OH, Calvo BF, Stitzenberg KB, Deal AM, Burke CT, Dixon RG, Stavas JM, Meyers
MO. Utilization of interventional radiology in the postoperative management of patients after
surgery for locally advanced and recurrent rectal cancer. Am Surg. 2011;77(8):1086–90.
30. Brown KG, Koh CE, Vasilaras A, Eisinger D, Solomon MJ. Clinical algorithms for the diagnosis and management of urological leaks following pelvic exenteration. Eur J Surg Oncol.
2014;40(6):775–81.
31. Hamilton JM, Larach TJ, Heriot AG, Warrier SK, McCormick JJ. Delayed Haemorrhage Following Pelvic Side Wall Excision With Internal Iliac Vessel R esection in Locally Recurrent
Rectal Cancer. ANZ J Surg. 2020;90(10):2125–7.
32. Rottoli M, Sabharwal T, Schizas AM, George ML. Bleeding pseudoaneurysm of the internal iliac artery after extended resection for advanced rectal cancer: report of two cases. Int J
Colorectal Dis. 2014;29(12):1585–6.
33. Lohsiriwat V. Persistent perineal sinus: incidence, pathogenesis, risk factors, and management.
Surg Today. 2009;39(3):189–93.
34. Lubbers EJ. Healing of the perineal wound after proctectomy for nonmalignant conditions. Dis
Colon Rectum. 1982;25(4):351–7.
8 Empty Pelvis Syndrome Complication Management Following Pelvic … 219
https://t.me/med1917
35. Christian CK, Kwaan MR, Betensky RA, Breen EM, Zinner MJ, Bleday R. Risk factors
for perineal wound complications following abdominoperineal resection. Dis Colon Rectum.
2005;48(1):43–8.
36. McSorley ST, Anderson JH, Whittle T, Roxburgh CS, Horgan PG, McMillan DC, Steele CW.
The impact of preoperative systemic inflammation on the efficacy of intravenous iron infusion
to correct anaemia prior to surgery for colorectal cancer. Perioper Med (Lond). 2020;9:17.
37. Dinaux AM, Amri R, Berger DL. Prone positioning reduces perineal infections when performing the miles procedure. Am J Surg. 2017;214(2):217–21.
38. Romeo A, Gonzalez MI, Jaunarena J, Zubieta ME, Favre G, Tejerizo JC. Pelvic exenteration
for gynecologic malignancies: Postoperative complications and oncologic outcomes. Actas
Urol Esp (Engl Ed). 2018;42(2):121–5.
39. Turrini O, Guiramand J, Moutardier V, Viret F, Mokart D, Madroszyk A, Lelong B, Bege T,
Blache JL, Houvenaeghel G, Delpero JR. Perineal small bowel fistula after pelvic exenteration
for cancer: technical guidelines for perineal fistula. Ann Surg Oncol. 2006;13(12):1622–6.
40. Loge L, Florescu C, Alves A, Menahem B. Radiation enteritis: Diagnostic and therapeutic
issues. J Visc Surg. 2020;157(6):475–85.
41. Samad S, Anele C, Akhtar M, Doughan S. Implementing a Pro-forma for multidisciplinary management of an enter cutaneous fistula: A case study. Ostomy Wound Manage.
2015;61(6):46–52.
42. Sutton PA, Brown KGM, Ebrahimi N, Solomon MJ, Austin KKS, Lee PJ. Long-term surgical complications following pelvic exenteration: Operative management of the empty pelvis
syndrome. Colorectal Dis. 2022;24(12):1491–7.
43. Mojadeddi ZM, Harmankaya S, Oberg S, Rosenberg J. Surgical technique for primary perineal
hernia repair: a systematic scoping review. Hernia. 2023;27(4):751–63.
Contemporary Management
https://t.me/med1917
of the Open Abdomen
Dominic Alexander James Slade
Abstract
The open abdomen (OA) is a challenging surgical scenario necessitating meticulous management to mitigate complications and improve outcomes. This chapter
provides a concise overview of contemporary strategies for OA management,
encompassing indications, techniques, and complications. Emphasis is placed
on evolving approaches such as negative pressure wound therapy, dynamic
closure systems, and progressive closure techniques. Additionally, the author
highlights the importance of multidisciplinary collaboration and adherence to
evidence-based practices in optimizing outcomes for patients with an open
abdomen.
Keywords
Open abdomen•Abdominal compartment syndrome•Surgical management
Negative pressure wound therapy•Dynamic closure systems•Progressive
•
closure techniques
Evidence-based practice•Surgical outcomes
Complications•Multidisciplinary collaboration
•
9
•
Key Points
•
Leaving the abdomen open after an emergency laparotomy is a recognised lifesaving technique, but its use should be carefully considered.
•
It may be used in the management of the abdominal catastrophe or to prevent
abdominal compartment syndrome.
D. A. J. Slade (B)
Consultant Colorectal, Intestinal Failure and General Surgeon, Salford Royal Hospitals NHS
Foundation Trust, Salford Royal Hospital, Stott Lane, Salford M6 8HD, UK
e-mail: Dom.slade@btinternet.com
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
M. Evans e t al. (eds.), Coloproctology, https://doi.org/10.1007/978-3-031-59630-8_9
221
222 D. A. J. Slade
https://t.me/med1917
•
Early and aggressive management of the open abdomen increases the chance
of closure and decreases complication rates.
•
Negative pressure wound therapy and mesh-mediated fascial traction offer the
highest rate of fascial closure with the lowest risk of enteric fistulation.
9.1 Introduction
Leaving the abdomen is a recognised life-saving manoeuvre in critically ill
patients. It was popularised in trauma as part of damage control surgery but had
already been employed in the management of the abdominal catastrophe, abdominal compartment syndrome and severe intra-abdominal sepsis (IAS) [22, 80]. The
evidence for benefit in all these settings is mainly retrospective or observational
and current thinking suggests its indications and use could be rationalized [26].
When employed, it should be considered a temporary measure rather than a definitive therapy, with the onus on the surgical team to close the abdomen at the earliest
juncture. Whatever its duration, an open abdomen requires immediate and often
prolonged input from both surgical and intensive care teams. It is associated with
significant long-term morbidity, most notably gastrointestinal fistulation, and ventral hernia. Contemporary management of the open abdomen includes active steps
to reduce the significant nursing burden of the open wound and to achieve fascial closure at the earliest opportunity, which in turn reduces the risk of fistulation
and hernia [82]. The mainstay of treatment is negative pressure wound therapy
(NPWT) with protection of the exposed intestines using a visceral protection layer
and active traction to achieve delayed fascial closure.
Subsequent reconstruction and restitution of normal anatomy when the
abdomen cannot be closed and has been left to heal by secondary intention can be
exceedingly challenging and requires multidisciplinary input [69].
9.2 Indications for an Open Abdomen
The abdomen may be left open as part of a damage control laparotomy in
trauma whilst physiological instability is reversed, to prevent or treat impending
abdominal compartment syndrome (ACS), when closure is impossible due to visceral oedema or to allow for re-exploration in cases of intra-abdominal sepsis or
mesenteric ischaemia (Table 9.1).
An open abdomen comes at a considerable cost to the patient and can be complex and time-consuming to nurse [34]. The correct choice of temporary abdominal
closure dressing (TAC, see later section) has a significant impact on reducing the
complexity of nursing care. It is why negative pressure wound therapy (NPWT)
has gained such a following and is recommended by both the World Society of
the Abdominal Compartment Syndrome and the World Society for Emergency
Surgery (WSACS and WSES- Grade 2B-weak recommendation, moderate quality
evidence [19]).
9 Contemporary Management of the Open Abdomen 223
https://t.me/med1917
Tab le 9.1 World Society for Emergency Surgery (WSES) guidelines on open abdomen in trauma
and non-trauma patients (adapted [19])
Condition Indicators Recommended action
Trauma • Persistent hypotension
Abdominal compartment
syndrome (ACS)
Intra-abdominal sepsis • Abbreviated laparotomy with
Mesenteric ischaemia Planned second look Leave abdomen open
Pancreatitis Unresponsive severe acute
•pH<7.2
•Temp<34°C
• Coagulopathy
Risk of abdominal compartment
syndrome (ACS):
• Damage control laparotomy
• Haemorrhage control with
packing and planned
re-operation
• Severe visceral oedema
•Obesity
• Abdominal wall tissue loss
• Aggressive fluid resuscitation
• Unable to control contamination
• Need to reassess bowel
perfusion
Repeated intra-abdominal
pressure > 20 mmHg
AND presence of organ
dysfunction eg oliguria
DESPITE optimal medical
therapy
unstable patient
• Deferral of intestinal
anastomosis
• Failure of source control
• Persistent visceral oedema
pancreatitis with evidence of ACS
Damage control laparotomy
Decompressive laparotomy
Leave abdomen open
Decompressive laparotomy
Leave abdomen open
Decompressive laparotomy
Irrespective of the dressing chosen, a patient with an open abdomen is at risk of
bleeding, secondary infection, gastrointestinal fistulation, damage to skin integrity,
hypothermia from insensible heat loss, hypotension due to excessive fluid losses,
whilst also maintaining a hypercatabolic state requiring immediate and adequate
nutritional support. Hypermetabolism in the critically ill is characterised by skeletal muscle breakdown and inhibition of protein synthesis which is further amplified
in the presence of sepsis. The goal of early feeding maintains lean body mass
and abrogates these deleterious effects. Enteral nutrition is quite safe in cases of
an intact and functioning intestinal tract but where there is a high output fistula,
discontinuity (e.g. stapled-off bowel ends), suspicion of internal fistulation and
224 D. A. J. Slade
https://t.me/med1917
associated abscess then parenteral nutrition via the safest route should be instituted
[14].
Patients who cannot achieve delayed primary fascial closure are at increased
risk of intra-abdominal infection and gastrointestinal fistulation whilst the presence of these complications along with fluid volume overload, prolonged duration
of an open abdomen and increased number of relook laparotomies predicts failure of abdominal closure [16]. When exposed loops of bowel do fistulate they
create an entero-atmospheric fistula, literally a communication between the bowel
and the abdominal wall defect, discharging their content into the open abdomen.
It is considered the worst possible complication as it is associated with increased
mortality, and morbidity, the management is complex and the prospect of spontaneous closure with conservative management lies between 20–60% [81]. Timing
of further surgery has a direct effect on the likelihood of delayed primary fascial
closure. A multicentre prospective study of 499 patients who underwent damage
control laparotomy (DCL-see next section) showed that patients had the highest
chance of closure if first take back was within 24 h and certainly no greater than
48 h [50]. For every hour delay after 24 h there was an associated 1.1% (26.4%
per day) decrease in achieving delayed fascial closure. It is imperative therefore to
achieve closure of the abdominal fascia at the earliest opportunity.
9.2.1 Trauma and the Damage Control Laparotomy
The primary goal of a damage control laparotomy (DCL) in trauma is to stop lifethreatening haemorrhage and gross enteric contamination in patients with severe
physiological derangements at the expense of immediate restoration of normal
anatomy [62].
DCL was born through the recognition that trauma patients died from uncontrolled haemorrhage, which developed intra-operatively, and was related to the
“triad of death”; a description of the deranged physiology that creates lifethreatening coagulopathy following injury [22]. The coagulation cascade, dependent on multiple enzymatic factors to ensure formation of a stable clot, requires
optimum pH and temperature. Acidosis and hypothermia, which are common in
trauma, worsen with extended surgery and perpetuate coagulopathy, which is further aggravated by dilution of clotting factors through crystalloid resuscitation,
creating a vicious triad that leads to death from refractory haemorrhage.
Stone described a series of 31 trauma patients who developed major coagulopathy during their trauma laparotomy [73]. He showed that by “aborting” the
laparotomy using purse-string sutures to control holes in bowel and ties on bleeding vessels, packing, and then closing the abdomen under tension, the survival rate
could be dramatically improved (7% standard laparotomy vs 64% aborted laparotomy). The term “damage control” was first coined by Rotondo and Schwab who
described its use in 22 patients managed by a staged approach to life-threatening
injuries with improved survival [59]. It comprises three phases starting with an
Соседние файлы в папке @xirurgi_2025