The Concept of Damage Control SurgeryDr. Derek TL FungDepartment of SurgeryQueen Elizabeth Hospital

Damage Control Surgery (DCS)

Multiple abdominal trauma

Thoracic injury

Vascular surgery

Orthopaedics

Abdominal sepsis

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

Damage Control

In 1970s & 1980s, surgeons tended to perform complex and lengthy operation in multiple trauma case

Extensive resection

Extensive reconstruction

Aggressive resuscitation

Extracorporeal support

HistoryIdea originated from liver trauma

Pringle published a case series of packing liver injuries in 1908

Pringle JH. V. Notes on the Arrest of Hepatic Hemorrhage Due to Trauma. Ann Surg. 1908 Oct;48(4):541-9.

Calne in 1979 published a series of liver trauma patients whose abdomens were packed prior to transfer and definitive surgery at another centre

Calne RY, McMaster P, Pentlow BD. The treatment of major liver trauma by primary packing with transfer of the patient for definitive treatment. Br J Surg. 1979 May;66(5):338-9.

Stone et al.

Coagulopathy in trauma patient leads to exsanguination and mortality

In his series, 31 patients with major bleeding tendency

11 out of 17 patient who was managed with packing and staged re-laparotomy survived. 1 out of 14 patients with standard treatment survived

Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983 May;197(5):532-5.

Rotondo et al.Rotondo and co-workers published a further series and coined the phrase ‘damage control surgery’ in 1993

7-fold of improvement in survival in a subgroup of patient with major vascular injury and 2 or more visceral injuries if they were managed with damage control approach

10/13 (77%) survived with damage control surgery1/9 (11%) with traditional definitive laparotomy

Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, Latenser BA, Angood PA. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993 Sep;35(3):375-82; discussion 382-3

Lethal Triad

Acidosis

Hypothermia

Coagulopathy

Hypothermia

Central thermoregulation lost

Metabolic activity

Cold IV fluid

Platelet dysfunction

Clotting factors kinetics disturbance

Cardiac dysfunction

Vasoconstriction

Hypoperfusion

Acidosis

Cardiac contractility

Dysrhythmias

Synergize with hypothermia in its detrimental effect on the coagulation cascade

Coagulopathy

Platelet dysfunction

Clotting cascade disturbed

Haemodilution

Uncontrolled bleeding from all cut surfaces

Principles of DCS

Quickly abort the vicious cycle by haemorrhage and contamination control

Minimize further trauma created by Surgeon

Restore normal physiology before definitive surgery in reoperation

Stages of Damage Control Surgery

1. Patient selection

2. Intraoperative stage

3. Critical care stage

4. Return to the operating theatre

5. Formal closure

Moore EE. Thomas G. Orr Memorial Lecture. Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am J Surg. 1996 Nov;172(5):405-10.

Stage 1: Patient Selection

Rotondo M, Zonies D. The damage control sequence and underlying logic. Surg Clin N Am 1997; 77: 761-777.

No Definite Selection Criteria

Too Liberal Unnecessary staged operation

Too Strict Adverse physiological outcome established Too late to salvage

Experience, rapid surgical assessment and liaison with anesthetist are the keys in decision making

Stage 2: Intraoperative

Aim: Controlling Haemorrhage

Limiting contamination

Temporary Closure

- Risk of abdominal compartment Syndrome

- Ineffective Drainage

Negative Pressure Therapy System, eg. VAC

Negative Pressure Therapy

Evacuation of abdominal fluid

Minimize risk of Intra-abdominal hypertension

Low fistula rates

Good early closure rates

Stage 3: Critical Care Stage

Active rewarming

Correction of Acidosis

Correction of Coagulopathy

Monitor the need for early return to theatre

Ongoing surgical bleedingAbdominal compartment syndrome

Stage 4: Return to the Theatre

Timing:

24-48hrs later whenBase deficit < 4 mmol/LLactate of < 2.5 mmol/LCore temperature > 35 C INR < 1.25

Stage 4: Return to the Theatre

Definitive surgeryRemoval of packsAnastomoses or stomasVascular repairsSolid organ debridementPlacement of feeding tube

Stage 5: Formal ClosureMay not be feasible due to significant bowel edema or risk of abdominal compartment syndrome

30 - 80% closure rate in the 1st reoperationHirshberg A, Wall MJ, Mattox KL. Planned reoperation for trauma: a two-year

experience with 124 consecutive patients. J Trauma 1994;37(3):365– 9.

Hatch QM, Osterhout LM, Ashraf A, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Current use of damage-control laparotomy, closure rates, and predictors of early fascial closure at the first take-back. J Trauma. 2011 Jun;70(6):1429-36.

The highest closure rates are achieved during the first 7–10 days

Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg. 2012 Mar;36(3):497-510.

Evidence

˜

DCS Vs Immediate and definitive repair (in patients with major abdominal trauma)

A total of 1523 studies were identified

A total of 1521 studies were excluded because they were not relevant to the review topic

Targets were not suffering from major abdominal trauma/ narrow spectrum

Not directly comparing DCS Vs definitive repair

Two studies were excluded because they were case-control studies. (Rotondo 1993, Stone 1983)

Cirocchi R, Abraha I, Montedori A. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007438.

Evidence

No RCT, systemic review could not be done

Most of the studies were case series Different patient groups

Different methodology

Conclusion: Evidence is LIMITED.

Cirocchi R, Abraha I, Montedori A. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007438.

Complication

Surgical site infection & intraabdominal abscess: up to 83% of cases

Enterocutaneous fistula: 5-19%

Chronic Ventral Hernia 13-80%

Smith BP, Adams RC, Doraiswamy VA. Review of abdominal damage control and open abdomens: focus on gastrointestinal complications. J Gastrointestin Liver Dis. 2010 Dec;19(4):425-35. Review.

Overuse of DCS

Complications

Long intensive care unit stays

Increased use of blood products

Multiple operations

Higher hospital cost

Higa G, Friese R, O'Keeffe T, Wynne J, Bowlby P, Ziemba M, Latifi R, Kulvatunyou N, Rhee P. Damage control laparotomy: a vital tool once overused. J Trauma. 2010 Jul;69(1):53-9.

Hatch QM, Osterhout LM, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma. 2011 Dec;71(6):1503-11.

Damage Control Resuscitation

Damage Control Resuscitation

Proactive early treatment to address the lethal triad (by rapid reversal of acidosis, prevention of hypothermia and coagulopathy) on admission to combat hospital.

Assumption that coagulopathy is actually present very early after injury

Holcomb J, Jenkins D, Rhee P et al. Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma. J Trauma 2007; 62: 307-310.

Damage Control Resuscitation

Permissive HypotensionSatisfied with MAP = 50-60mmHg

Minimize dilution effect and hypothermia secondary to overzealous fluid replacement

Early use of blood product over isotonic fluid for volume replacement

Early correction of coagulopathy with components, ie. Massive transfusion protocol

PRBCs: FFP: Platelet = 1:1:1

Midwinter MJ. Damage control surgery in the era of damage control resuscitation. J R Army Med Corps. 2009 Dec;155(4):323-6.

Conclusion

Damage control surgery was an useful tool in handling patients with multiple injury, though high level of evidence is lacking

DCS is not without risk and complication, over-utilization may lead to more harm than benefit

With DCR integrating into DCS, the need of DCS may reduce as coagulopathy is corrected earlier

Thank You!