SURGICAL DAMAGECONTROL

Bradley W. Thomas, MDLCDR MC USN

Constanta Trauma Symposium12 JUNE 2013

OUTLINE1. Definition/description2. Who needs it3. Operative techniques4. ICU techniques5. Reoperation techniques6. Expected outcome

Navy Definition“the capacity of a ship

toabsorb damage andmaintain mission

integrity”Naval War Publication 3-20.31,Dept Defense, 1996(c/o Paul Possenti, PA-C,Bridgeport Hospital)

Stage 1: DC1 Control hemorrhage Limit peritoneal contamination Temporary abdominal closureStage 2: DC2 Hypothermia prevention/treatment Correction of coagulopathy Correction of acidosisStage 3: DC3 Definitive surgery May require multiple surgeries Creation of ostomies, feeding access, fascial

closure No longer than 72 hours from Stage 1 Data from Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’: an

approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35(3):375.

Initial Damage Control Stages

“Despite the lethality of injuries, if a wounded solider survives the rapid transport to a military medical facility with surgical capability, the likelihood of survival is now higher than any previous recorded conflict.”

Eastridge BJ, Jenkins D, Flaherty S, et al. Trauma system development ina theater of war: experiences from Operation Iraqi Freedom and Operation

Enduring Freedom. J Trauma 2006;61(6):1366.

Lethal Triad

WHO NEEDS DAMAGECONTROL?

Intraoperative Sequelae of Shock

Initial or persistent hypothermia Initial or persistent metabolic Acidosis Nonmechanical bleeding* * * * * “metabolic failure”

WHO NEEDS DAMAGE CONTROL? DISTINGUISH

BETWEEN GROUPS

May StabilizeTemp 35 CpH > 7.2BD > -10

Near-ExsanguinatedTemp < 34 CpH < 7.1BD -15 -20HR/SBP>0.9

Stop hemorrhage

Near-exsanguinated↓

May stabilize↓

↓Consider def.

operation

↓Damage control

WHO NEEDS DAMAGECONTROL?

Distinguish Between Groups

Stop hemorrhage

2.  Liver3.  Pancreas

DAMAGE CONTROLControl Visceral Hemorrhage

 

4.  Kidney

1. Spleen

Immunitypreserved

Immunitysuppressed

DAMAGE CONTROLSpleen

Grade I-II Grade III-IV

Repair→10-15min←Resect

Repair→15-30min

SPLENECTOMY IS HARMFUL

1. Lose splenic filter

2. Lose production of

3. Lose immunosuppression

IgMTuftsinOpsoninProperdin

SutureVicryl mesh tamponade

DAMAGE CONTROLSpleen

Surgicel/Avitene/Fibrin glue

Perisplenic packing

1500 ml/minTherefore, a poorly chosen

damage control technique

DAMAGE CONTROLLiver

Has a blood supply of

is likely to fail in thecoagulopathic patient

Raw surface

DAMAGE CONTROLLiver

Balloon catheter tamponade → Track

Absorbable mesh tamponade → Fx

Compression

Perihepatic packsSubc. hematoma

More selective, but time-consuming

Resectional debridement with S.V.L.

DAMAGE CONTROLLiver

Hepatotomy with S.V.L.

HEPATIC TRAUMAOMENTAL PACK

Control intrahepatic venous hemorrhageManage dead spaceBring mobile macrophages to site of injuryH.H. Stone, 1975; H.L. Pachter, 1979; T.C. Fabian, 1980

bleeders Suture

Control retropancreatic largebleeders Divide

DAMAGE CONTROLPancreas

Control peripancreatic small

Defer distal pancreatectomy toreoperation

Palpate normal sized kidneyon opposite side beforeperforming needed

DAMAGE CONTROLKidney

nephrectomy

Isolate holes Umbilical tapes

Resect holes Stapler

DAMAGE CONTROLControl GI Contamination

Close holes 1 layer, suture

Severe colon Colostomy at reop.

Nephrectomy

DAMAGE CONTROLControl Arterial Hemorrhage

Celiac a.Sup. mes. a.Renal a.Iliac a. Shunt or ligate,

fasciotomy, fem-fem

LigateShunt

DON’T IGNORE LIKELY SEQUELAE

X-clamp abd. aorta, CIA, EIA→

Bilateral or ipsilateral fasciotomy

DAMAGE CONTROLControl Arterial Hemorrhage

Retrohepatic vena cava Pack

DAMAGE CONTROLControl Venous Hemorrhage

Common or external, Ligate iliac, infrarenal, IVC SMV, Portal

Pelvic Veins

Clamps, Tacks, Omentum

Atriocaval Shunt

DON’T IGNORE LIKELY SEQUELAE

Ligate portal vein or SMVSilo/NPD and reoperation at 12hours

DAMAGE CONTROLVenous Hemorrhage

X-clamp or ligate infrarenal IVCBilateral fasciotomy

A simple but eloquent idea

Managing the Open Abdomen

J. Trauma 48:201-7, 2000

Avoid conductionAvoid evaporation

Keep bed dryKeep skin dry

DAMAGE CONTROLICU Phase

Treatment of Hypothermia

Standard Warming maneuversRoom, Head, Lung, Trunk, IVs

TREATMENT OF ACIDOSISAcidosis uncouples B-adrenergic

receptors at cellular level

DAMAGE CONTROLICU Phase

Test dose 50-200 mEq HC03 if pH<7.2 and patient failing

*Check for missed injuriesComplete GI resections, repairs,

reconstruction or diversion

Removal of packs/Evaluate hemostasis

Passage of nasojejunal feeding tube/Formal jejunostomy

Fascial closure vs. VAC

DAMAGE CONTROLReoperation

1.  Components/modified2. Biologic Mesh3. Absorbable mesh, delayed

DAMAGE CONTROLClosure/Coverage Options

STSG, leave a big hernia

1.  Ventral Hernia2. EC Fistula3. Intraabdominal Abscess

DAMAGE CONTROLComplications

Initial opsICU/LOS

ABDOMINAL DAMAGE CONTROLOutcome

56 consecutive patients with damage

Sutton E: JT 61: 831, 2006

control laparotomy:

MortalityReadmissionsLate mortality

4.4 ± 2.217/3027%76%0%

2.  Limited OR time using techniques3.  Surgeons control ICU phase

1.  Choose based on criteria

4.  Don’t miss injuries at reoperationalways pass feeding tube

5.  Expect 50-75% survival

DAMAGE CONTROLSummary

DAMAGE CONTROLSummary

“….. Advances in surgery are measured by events, and damage control surgery has been

one of the greatest advances in trauma surgery in the last 20 years …..”

Hiram C. Polk, M.D.