Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_663_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

30.08.2026

Размер:

58 Мб

Скачать

☆

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 3738 / 5038 39 40 41 42 43 44 45 46 47 48 49 50 > Следующая >>>

Damage Control Surgery

https://t.me/medicina_free

RiaanPretorius, FrankPlani,KennethD.Board, and VickyJennings

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 identied early, and physiological restoration is prioritised above denitive 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 denitive 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 denitive surgery intraoperatively, as this might lead to adverse outcomes, due to underestimation of the initial physiological insult.

387

388

https://t.me/medicina_free

R. Pretorius et al.

47.1.1 Hypothermia

A temperature of less than 35°C is dened 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

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.

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 (<90mmHg) 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-

47 Damage Control Surgery

https://t.me/medicina_free

Fig. 47.1 Application of massive transfusion protocol

nal compartment syndrome, severe inammation, 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 100mmHg or a mean arterial blood pressure (MAP) of 70mmHg should be adequate.

Permissive hypotension should only be practised for 90–120min 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 dened 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 signicant 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 24h. 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 inammation.

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

390

https://t.me/medicina_free

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 denitive 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

Inammation 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 inammation

Development of the optimal oxygen carrier

Target genetic factors Early treatment

47.3 Stages ofDamage 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: Denitive surgery – Stage 5: Closure of the abdomen

47.3.1 Stage 1: Indication/Patient Selection ofDamage 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 denitive sur-

gery was initially planned, and during the operation, the patient’s haemodynamic physiology has deteriorated, and the denitive 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

<70mmHg (b) Temp <35 ° C (c) pH<7.2 (d) Lactate >5mmol/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 denitive 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.

47 Damage Control Surgery

https://t.me/medicina_free

47.3.2 Stage 2: Operative Control ofHaemorrhage andContamination

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 denitive 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 identied.

391

Fig. 47.2 Application of Vac Pack

47.3.2.2 Thoracic Damage Control

In the chest, damage control often ends up as denitive 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 denitively 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-

392

https://t.me/medicina_free

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 signicant 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 debrillators 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)

47 Damage Control Surgery

https://t.me/medicina_free

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 ination 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). Denitive 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 monolament 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 24h), 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 1200mL/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:

394

https://t.me/medicina_free

– “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 denitive procedures.

– “Pringle”—The purpose of the Pringle manoeuvre is to

control the haemorrhage inow 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 identied 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-

47 Damage Control Surgery

https://t.me/medicina_free

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 benet 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 sufcient. 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 efuent. 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 denitive 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 signicant 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 identied 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 sufces. 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 andUrinary 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

396

https://t.me/medicina_free

R. Pretorius et al.

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 inICU

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

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 3738 / 5038 39 40 41 42 43 44 45 46 47 48 49 50 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
30.08.202659 Мб0Книга_655_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202659 Мб0Книга_657_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202659 Мб0Книга_659_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202659 Мб0Книга_660_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202659 Мб0Книга_661_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202658 Мб0Книга_663_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202658 Мб0Книга_664_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202658 Мб0Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202658 Мб0Книга_666_Библиотеки_им_академика_М_И_Перельмана.djvu
#
30.08.202658 Мб0Книга_667_Библиотеки_им_академика_М_И_Перельмана.pdf
#
30.08.202658 Мб0Книга_670_Библиотеки_им_академика_М_И_Перельмана.pdf