38
Trauma Damage Control
-DPLH-&ROHPDQō%ULDQ/%UHZHUō'DYLG9)HOLFLDQR
The technique of initial abortion of laparotomy, establish-
ment of intra-abdominal pack tamponade, and then comple-
tion of the surgical procedure once coagulation has returned
to an acceptable level has proven to be lifesaving in the previ-
ously non-salvageable situations.
(Stone et al, 1983)1
Although abdominal packing and abbreviated laparotomy
had been described prior to this landmark manuscript, this
sentence written by H. Harlan Stone in 1983 initiated a major
paradigm shift in the operative management of patients with
hemorrhagic shock after trauma. Previously, injured patients
with or without shock underwent similar operations. All
definitive procedures were completed at a first operation or
the patient died in the process. A number of papers describ-
ing the coagulopathy associated with hypothermia and meta-
bolic acidosis in injured patients with hemorrhage were then
published over the next decade.1–8 Simultaneously, several
centers began to practice the concept of Stone’s abbreviated
laparotomy and assess the results.9–12 In 1993, Rotondo et al
from the University of Pennsylvania labeled these abbrevi-
ated procedures as “damage control” surgery; also, they
documented that the strategy substantially improved survival
(11% vs 77%) in patients with combined abdominal visceral
and vascular injuries.13 Originally implemented for injured
patients with “metabolic failure” or “physiologic exhaustion”
(hypothermia, metabolic acidosis, coagulopathy), damage
control surgery quickly became a technique used by multiple
surgical specialties including the following: general surgery,
thoracic surgery, vascular surgery, orthopedic surgery, gyne-
cologic surgery, etc.14–27
This chapter reviews the definition, indications, and tech-
niques of “damage control” surgery on injured patients.
Emerging concepts including damage control resuscitation,
thromboelastography directed infusions of blood components,
and resuscitative endovascular balloon occlusion of the aorta
(REBOA—see Chapter 34) will be discussed, as well.
Moore_Ch38_p0741-0764.indd 741
DAMAGE CONTROL OPERATIONS:
DEFINITION AND STAGES
Definition
The abbreviated laparotomy in “damage control” surgery
controls bleeding and limits further contamination from the
gastrointestinal tract before the patient is transferred to the
intensive care unit (ICU). Although early papers described
a three step process, this has been expanded to include pre-
hospital management and closure of the abdominal incision.
Stages
PREHOSPITAL (“GROUND ZERO”)
The initial evaluation by prehospital personnel often initiates
the damage control process. Early notification of the trauma
center about the level of hemodynamic instability and magni-
tude of injuries can prompt mobilization of operative and/or
interventional teams. Permissive hypotension will be appro-
priate in patients without traumatic brain injuries, and blood
transfusion during transport is available in some prehospital
systems.
ABBREVIATED INITIAL OPERATION
As noted above there are certain subsets of patients who can
be identified in the prehospital phase as likely to need damage
control operations. Most decisions to initiate damage control
operations, however, are based on the intraoperative physiology
of the patient, the operative findings and amount of transfu-
sion (Table 38-1).28 Common historic indications have been
for abdominal (56.5%) or vascular injuries (12.7%), especially
in patients with unresolved metabolic failure despite control
of hemorrhage in combination with damage control resuscita-
tion.6,28–44 The major recent evolution in the decision for dam-
age control has been in recognizing patients at risk and early
741
06/02/17 1:11 PM
 742 Section III Management of Specific Injuries
TABLE 38-1: Intraoperative Indications to
Perform Damage Control Operations
Factor Level
1. Initial body temperature <35°C (95.0°F)
2. Initial acid-base status

t
"SUFSJBM
Q) <7.2

t
#BTF
EFëDJU < –15 mmol/L in patient <55 years

t
4FSVN
MBDUBUF >5 mmol/L
3. Onset of coagulopathy INR and/or partial thromboplastin
time >50% of normal
implementation of the strategies described herein, rather than
waiting till traditional approaches have failed.28
In addition to the control of hemorrhage and contamination
in the abdomen described above, the concept of damage control
now includes the following operative procedures in a number
of locations in the body: packing of oozing spaces and organs
including the pleural cavity, liver, spleen, retroperitoneum,
abdominal cavity; temporary intravascular shunting rather than
ligation of named arteries or veins in the abdomen and proximal
extremities; and temporary closure (skin staples, skin sutures,
towel clips only) or coverage (silo, vacuum-assisted device) of
incisions in the neck, chest, abdomen, or an extremity.
RESUSCITATION IN THE ICU
Any postoperative hypothermia, metabolic acidosis, and/or a
coagulopathy (metabolic failure or physiologic exhaustion) is
treated during the IUC phase. Newer concepts such as “dam-
age control resuscitation” (whole blood or high ratio blood
components and limited infusion of crystalloid solutions)
and goal-directed resuscitation may decrease the incidence
of known complications such as the adult respiratory distress
syndrome and the primary or secondary abdominal compart-
ment syndrome.
REOPERATION
Once the patient’s metabolic failure has been corrected and there
are limited numbers of major organ failures, reoperation is per-
formed from 12 to 72 hours after the original damage control
operation. In a patient with a prior damage control laparotomy,
the goals at reoperation are as follows: removal of packs, compre-
hensive examination to find missed injuries, reestablish intestinal
continuity, create stomas, and insertion of drains and feeding
access (nasojejunal feeding tube, feeding jejunostomy).
CLOSURE OF ABDOMINAL WALL45
Factors influencing the decision on whether to formally close
the midline incision versus cover the open abdomen at the
end of the reoperation include the following: the patient’s
cardiovascular, respiratory, and renal status; the continuing
need to complete organ repairs or gastrointestinal reconstruc-
tion; distension of the midgut; and the distance separating
Moore_Ch38_p0741-0764.indd 742
the two sides of the linea alba. Also, it is recognized that an
inappropriately timed midline aponeurotic closure may cause
an abdominal compartment syndrome that negates all the
advantages of the damage control process.46–48
ABBREVIATED INITIAL OPERATION
Operative Techniques in Thoracic
Trauma
HEART (SEE CHAPTER 26)
Surgical access to the heart is attained by a left anterolateral
thoracotomy (the most rapid approach), bilateral anterolateral
thoracotomy with transverse sternotomy, or a median sternot-
omy. Once the pericardium is opened, a number of techniques
are available to obtain temporary or permanent control of
hemorrhage from the heart by a general surgeon. Digital com-
pression is one of the quickest ways, but may be inadequate
for blunt ruptures or multiple penetrating injuries. Skin staples
(6 mm) have been shown to be quick and effective for tem-
porary or permanent control of hemorrhage from penetrating
wounds.49–52 Formal cardiac repair in the operating room with
a nonabsorbable monofilament suture and Teflon pledgets can
then be performed in between or overlying the staples, which
can be sequentially removed if so desired by the surgeon.
Larger wounds or ruptures may be temporarily controlled
by the insertion of a Foley balloon catheter directly into the
injury.53,54 Once the balloon is within the heart, it is inflated
and traction gently applied to plug the hole. Teflon-pledgeted
sutures are then passed through the atrium or ventricle over
the balloon, recognizing that the balloon can be easily punc-
tured. One technique to avoid this complication is to remove
the traction on the balloon and push the catheter slightly
into the cardiac chamber while the suture is being placed,
although this results in significant blood loss.
If the above measures are insufficient, such as with a longi-
tudinal perforation or significant rupture of a ventricle, inflow
occlusion is a time-honored technique that is useful in avoiding
cardiopulmonary bypass.55 Inflow occlusion involves placing
curved aortic or angled vascular clamps on the superior and
inferior vena cavae. As the heart slows, horizontal sutures are
inserted rapidly on either side of the defect and then crossed to
control hemorrhage. A continuous suture or staples are placed
to close the defect and, before completion, air is vented out of
the elevated ventricle by releasing the clamps on the cavae.
Although cardiopulmonary bypass is rarely required (2%
of the time acutely) in penetrating cardiac injuries, it is appro-
priate for larger wounds not amenable to simple suture repair
or for wounds in which repair has failed.55–58
LUNG (SEE CHAPTER 25)
In the rare patient who arrives with signs of life after sustain-
ing an injury to the pulmonary hilum just at the border of
the pericardium, intrapericardial control of the pulmonary
artery may be necessary. The previously performed ipsilat-
eral thoracotomy should be extended across the sternum and
into the contralateral thorax to allow for wide exposure of the
06/02/17 1:11 PM

pericardial contents. The intrapericardial right pulmonary
artery is exposed by retracting the superior vena cava to the
right and the ascending thoracic aorta to the left. The right pul-
monary artery passes transversely and posterior to these struc-
tures and can be clamped between them. The intrapericardial
left pulmonary artery passes transversely, inferior and posterior
to the transverse aortic arch and is exposed by retracting the
ascending thoracic aorta to the right and superiorly.
Exsanguinating hemorrhage more laterally from the hilum
or from the pulmonary parenchyma is controlled by cross-
clamping or temporary hand control of the hilum, the hilar
twist, or application of a hilar snare. Cross-clamping is the
application of a DeBakey aortic clamp from superior to infe-
rior if the inferior pulmonary ligament has not been divided.59
If there is time to divide the inferior pulmonary ligament, the
cross-clamp can be placed in an anterior-to-posterior direction.
Hand control of the pulmonary hilum has been described, as
well. Left hand control of the right pulmonary hilum by the
surgeon will allow for the assistant to evacuate blood from
the pleural cavity, divide the inferior pulmonary ligament,
and replace the surgeon’s manual control with his or her own
hand. The surgeon then applies an aortic cross-clamp across
the hilum in the most appropriate direction.60 The surgeon’s
right hand is used for manual control of the left pulmonary
hilum. The “hilar twist” as described by the group at Ben Taub
General Hospital includes division of the inferior pulmonary
ligament and then rotating or twisting the lung 180° to control
exsanguinating parenchymal hemorrhage.61,62 The hilar snare is
an experimental technique in which an umbilical tape is passed
around the pulmonary hilum and pulled tight through a 36
French plastic tube acting as a Rumel tourniquet.63
A definitive technique to expose the source of bleeding from
deep parenchymal stab wounds or missile tracks is pulmonotomy
or pulmonary “tractotomy.”64,65 The pulmonary parenchyma
overlying the area of bleeding is divided between noncrushing
vascular clamps or a linear stapler. This exposes injured paren-
chymal vessels, which can be selectively ligated. The pulmon-
otomy can then be closed used a continuous 0 or 2-0 absorbable
suture or left open if the injured lung is too edematous.
It is now commonly accepted that “lung-sparing” operative
techniques have improved outcomes in patients undergoing
either urgent or damage control procedures on parenchymal
injuries.66
THORACIC DAMAGE CONTROL
Packing with or without closure of the incision is now used
in patients with an intraoperative coagulopathy and oozing
from the lung or pleural cavity.67,68 Garcia et al have recently
reviewed damage-control techniques in the management of
severe trauma to the lung, while Phelan et al had previously
summarized multiple techniques used in injuries to the heart,
great vessels, and lungs (Table 38-2).69,70
ESOPHAGUS (SEE CHAPTER 25)
Primary closure without an overlying buttress is appropri-
ate management of the perforated esophagus in a damage
Moore_Ch38_p0741-0764.indd 743
Chapter 38 Trauma Damage Control 743
TABLE 38-2: Damage Control Techniques for
Thoracic Trauma
Heart
Sauerbruch maneuver to control hemorrhage
Inflow occlusion to control hemorrhage
Restore rhythm before suture repair
Leave pericardial sac open/leave incision open
Great vessels
Foley balloon catheter tamponade
Claviculectomy for injury to subclavian vessels
Insertion of temporary intraluminal shunt
Ligation of major injured veins
Lungs
Hilar twist to control hemorrhage
Pulmonotomy (pulmonary tractotomy) for through-and-through or
deep lobar injuries
Simultaneously stapled pneumonectomy
Pack pleural cavity/leave incision open
Adapted from Phelan HA, Patterson SG, Hassan MO, et al: Thoracic damage-
control operation: principles, techniques, and definitive repair. J Am Coll Surg.
2006;203:933–941.
control situation.71–73 At a reoperation, reinforcement of the
repair is appropriate with one of the following: (1) cervical
esophagus—sternal head (detached) of the sternocleidomas-
toid muscle; (2) thoracic esophagus—rhomboid muscle,
intercostal muscle, three-sided pleural flap; (3) abdominal
esophagus—fundoplication or 3-sided diaphragmatic flap.
If primary repair is not possible because of a large defect in
the cervical esophagus, creation of a lateral loop esophagos-
tomy at this site over a Robinson catheter as a rod is appropri-
ate.74 With a similar large defect in the thoracic esophagus,
insertion of a surgeon-created large T-tube (Abbott-Mansour
tube) into the defect is a time-honored technique.75,76
Operative Techniques in Abdominal
Trauma
GASTROINTESTINAL TRACT (SEE CHAPTERS 32, 33)
Most duodenal injuries are caused by penetrating trauma and are
commonly associated with injuries to the pancreas and/or upper
abdominal vessels. A Kocher maneuver should be performed to
allow for complete visualization of an injury to D1, D2, or D3.
In patients who are hemodynamically unstable, the perforation
should be quickly oversewn in a transverse direction, if possible,
with a continuous full-thickness suture of 3-0 or 4-0 polypro-
pylene or side stapled with a TA-stapler. A No. 10 Jackson-Pratt
drain is then placed inferior to the repair. At an early reoperation,
the suture or staple line is inspected and repaired or replaced,
if necessary. Techniques that have been used to protect a nar-
rowed, complex, or tenuous repair of the duodenum are duode-
nal “diverticulization,” triple tube drainage or pyloric exclusion
with antecolic gastrojejunostomy. Duodenal diverticulization is
mentioned for historical interest only. The sacrifice of a normal
gastric antrum and need to insert a T-tube into a normal-sized
06/02/17 1:11 PM
 744 Section III Management of Specific Injuries
common bile duct have always limited enthusiasm for this proce-
dure.77 The triple-tube approach (gastrostomy, transjejunal retro-
grade duodenostomy, antegrade jejunostomy) described in 1978
is an effective decompressive procedure, but has the disadvantage
of making three new holes in the upper gastrointestinal tract to
insert the tubes.78 Pyloric exclusion and antecolic gastrojeju-
nostomy were used extensively at Ben Taub General Hospital/
Baylor College of Medicine in the 1970s and 1980s.79,80 Many
urban centers, however, have abandoned the technique over the
past 20 years or more as no improvements in the rate of post-
operative sepsis and mortality could be demonstrated with this
adjunctive procedure.81–85
Rapid control of contamination from the small bowel and
colon is one of the main goals of damage control laparotomy
as previously noted. Noncircumferential injuries are closed
with a 3-0 suture in a transverse direction similar to duo-
denal perforations. Multiple or large perforations within a
short segment of small bowel or colon are best treated with
segmental resection, utilizing large metal clips to control
mesenteric bleeders and linear staplers to divide the bowel.
Reestablishing intestinal continuity with an anastomosis or
forming an ostomy is not performed until the reoperation in
12–72 hours. While there is still controversy, most authors
currently favor performing an anastomosis of the colon at
a reoperation when resection was performed at the dam-
age control procedure.86,87 In one recent article favoring this
approach, contraindications to a delayed colon anastomosis
included “severe acidosis, bowel wall edema, and/or persistent
intra-abdominal infections.”87
LIVER (SEE CHAPTER 29)
As the liver receives 1500 mL of blood per minute, rapid
control of hemorrhage is the primary goal. Hemostasis for
American Association for the Surgery of Trauma (AAST)
Organ Injury Scale (OIS) grade I or II injuries is by tempo-
rary compression with laparotomy pad packs, electrocautery
and/or topical hemostatic agents.
With grade III to V injuries and the need for a damage
control procedure, bimanual compression to close a deep
laceration or to compress a stab or missile tract followed by
the insertion of perihepatic packing with dry laparotomy
pads will control the hemorrhage in many patients.9,10 Any
raw hepatic surface should be covered with a plastic drape
prior to insertion of the laparotomy pads to decrease the risk
of rebleeding when the packs are removed at a reoperation
(Fig. 38-1). Also, it should be noted that there have been
refinements in the operative placement of perihepatic packs
in recent years.88,89 The acute disadvantages of tight perihe-
patic packing are now well known and include compression
of the retrohepatic vena cava with secondary oliguria and
contributing to the development of an abdominal compart-
ment syndrome. And, the surgeon should be mindful of the
possible need for postoperative hepatic arteriography with
therapeutic embolization as an adjunct to laparotomy. If the
radiopaque markers of the laparotomy pads are not cut off,
they may obscure the visualization of bleeding intrahepatic
arteries during the subsequent arteriogram.
Moore_Ch38_p0741-0764.indd 744
FIGURE 38-1 Perihepatic packing over a plastic sheet is indicated
in patients with AAST Organ Injury Scale Grade III–V hepatic inju-
ries, associated abdominal injuries, and an intraoperative coagulopa-
thy. (Reproduced with permission from Feliciano DV. Abdominal
trauma. In: Schwartz SI, Ellis H, eds. Maingot’s Abdominal Operations.
9th ed. East Norwalk, CT: Appleton & Lange; 1989:457–512.)
If perihepatic packing successfully tamponades hepatic
hemorrhage, the perihepatic packs are left in place and a skin
closure only of the upper one-third of the midline incision with
towel clips is performed to maintain perihepatic tamponade
with the packs. A temporary silo or vacuum-assisted coverage is
used over the remaining two-thirds of the open abdomen until
the reoperation for removal of the packs is performed.
If perihepatic packing is not successful in controlling
hemorrhage, a Pringle maneuver is performed. Although the
exact length of time that this maneuver can be applied in the
hypothermic patient is unknown, one hour in the absence of
cirrhosis is acceptable to most senior surgeons with experi-
ence in operative hepatic trauma.90,91 If the Pringle maneu-
ver controls hepatic hemorrhage, the falciform ligament and
the triangular and coronary ligaments of the injured lobe are
divided to allow for its mobilization into the midline.
Advanced indirect methods of control for hepatic hemorrhage
in damage control situations include balloon catheter tampon-
ade, absorbable mesh tamponade, and extensive compressive suture
hepatorrhaphy.54,92 Balloon catheter tamponade can be used in
long transhepatic stab or missile tracks. A Foley catheter, Fogarty
catheter, or Penrose drain over red rubber catheter (tied down at
either end) is sequentially advanced into the track, and the bal-
loon is inflated. Successful control of hemorrhage mandates con-
tinued inflation until a reoperation. Absorbable mesh tamponade
is a time-honored technique for control of hemorrhage from any
disrupted solid organ in the abdomen. Either a disrupted lobe
with viable fragments attached to the hilum is encircled with a
large piece of mesh with the edges sutured together or a piece of
mesh is used to replace a disrupted Glisson’s capsule after rup-
ture of a subcapsular hematoma. Extensive hepatorrhaphy with
zero absorbable continuous or interrupted sutures (figure of 8)
is a historical technique that is still useful in damage control
06/02/17 1:11 PM
 Chapter 38 Trauma Damage Control 745

operations on the liver. This technique can lead to significant

hepatic necrosis when the “Pringle time” is prolonged and the
sutures are tied tight enough to compress intraparenchymal
injured vessels.92
Advanced direct methods of control for hepatic hemor-
rhage include hepatotomy with selective vascular ligation and
resectional debridement. A rapid hepatotomy or entrance
into the liver is performed using the electrocautery or finger
fracture in damage control situations and allows for exposure
of injured vessels and bile ducts in deep lacerations or in stab
or missile tracks. Either clips or ties can be used on these
structures when they are small. On occasion, a laceration in a
large intrahepatic vein can be repaired with a 5-0 polypropyl-
ene suture. Resectional debridement is indicated for partial FIGURE 38-2 Rapid two-suture splenorrhaphy and application of
avulsions of hepatic segments II/III or VI/VII. With a Pringle a topical hemostatic agent are faster than splenectomy for an AAST
maneuver in place, the electrocautery is used to mark a line Organ Injury Scale Grade I–II splenic injury.
on the uninjured hepatic capsule medial to the frayed and
partially avulsed segments. A combination of the electrocau- AAST OIS grade I or II injury be present, splenorrhaphy after
tery and multiple metal clips placed on uninjured vessels and rapid mobilization may be faster than splenectomy and will
ducts in the line of resection will allow for rapid resection avoid leaving a denuded retroperitoneal bed in the coagulopathic
of all injured parenchyma, vessels, and ducts laterally. In a patient (Fig. 38-2). Options for rapid splenorrhaphy with grade I
patient with an intraoperative coagulopathy, deep horizon- or II injuries include application of topical hemostatic agents or
tal mattress sutures placed circumferentially around the raw repair with a 3-0 chromic or polypropylene suture.103 On occa-
edge of the remaining injured liver may help control hemor- sion, after application of topical hemostatic agents or absorbable
rhage. Approximating the anterior and posterior edges of the mesh to replace part of the splenic capsule, perisplenic packing
remaining uninjured liver with large compressive horizontal with laparotomy pads may ensure hemostasis.
mattress sutures is another option.93
Other advanced damage control techniques of hepatic PANCREAS (SEE CHAPTER 32)
hemostasis used in the past have been abandoned (selec- Parenchymal defects not involving the duct and ductal inju-
tive hepatic artery ligation) or are used in less than 2–4% of ries are treated with closed suction drainage once hemor-
patients (formal hepatic resection). rhage from the gland or underlying mesenteric-portal vessels
If hepatic hemorrhage is not temporarily controlled by is controlled at the damage control operation (Fig. 38-3).
packing or by applying a Pringle maneuver, an injury to
the retrohepatic vena cava or a hepatic vein should be sus-
pected. Mobilization and elevation of the overlying injured
hepatic lobe after warning the anesthesiologist about the
increased blood loss will allow for visualization of the area
of venous injury. Another attempt at perihepatic pack-
ing of the overlying lobe is worthwhile as this is venous
hemorrhage, but failure of packing to control hemorrhage
will lead to a significant mortality regardless of subsequent
operative management.94 Operative and endovascular
options include the following: (1) direct temporary control
of the laceration in the vein with Judd-Allis clamps fol-
lowed by suture repair,95 (2) direct transhepatic approach,96
(3) total hepatic vascular occlusion (clamping of the por-
tal triad and suprahepatic and infrahepatic inferior vena
cavae),97 (4) insertion of a No. 36 French thoracostomy
tube or a No. 8 endotracheal tube as an atriocaval shunt
after loop control of the suprarenal and intrapericardial
inferior vena cava,98 (5) venovenous bypass (from the com-
mon femoral to axillary or internal jugular vein),99 and (6)
use of an endovascular stent.100–102
FIGURE 38-3 Stab wound of the head of the pancreas was drained
SPLEEN (SEE CHAPTER 30) only at the damage control operation. (Reproduced with permission
from Feliciano DV. Abdominal trauma. In: Schwartz SI, Ellis H, eds.
Under damage control conditions splenectomy is the safest Maingot’s Abdominal Operations. 9th ed. East Norwalk, CT: Appleton
choice for an AAST OIS grade III, IV, or V injury. Should an & Lange; 1989:457–512.)

Moore_Ch38_p0741-0764.indd 745 06/02/17 1:11 PM

 746 Section III Management of Specific Injuries
At reoperation, parenchymal defects are filled with a viable
omental plug, while ductal transections to the left of the mes-
enteric vessels are treated with a distal pancreatectomy and
splenectomy in adults.104,105 Ductal defects in the head of
the pancreas or an AAST OIS grade V injury of the pancreas
(“massive disruption of pancreatic head”) mandate pancreato-
duodenectomy at the reoperation. Depending on the patient’s
condition the Whipple resection and subsequent reconstruction
may have to be performed at two separate reoperations.106,107
ABDOMINAL ARTERIES (SEE CHAPTER 34)
Major named abdominal arteries are managed with repair,
insertion of a temporary intravascular shunt, or, on rare
occasions, ligation at the damage control laparotomy. With
segmental loss or need for resection of the suprarenal or infra-
renal abdominal aorta, a large intraluminal shunt (thoracos-
tomy tube) may be used if the surgeon is uncomfortable in
inserting an interposition graft (12-, 14-, or 16-mm-woven
Dacron, albumin-coated Dacron, or PTTE). A significant
injury to the celiac axis or one of its branches is treated
with ligation, though the hepatic artery proper or common
hepatic artery may be amenable to repair, on occasion. An
extensive injury to a renal artery is treated with ligation and
ipsilateral nephrectomy at the reoperation in the presence of
a palpably normal contralateral kidney. The superior mesen-
teric, common iliac and external iliac arteries are never ligated
by experienced trauma surgeons. A better choice is insertion
of an intraluminal Argyle (Sherwood Medical Co., St. Louis
MO.), Javid (C.R. Bard, Inc., Murray Hill, NJ), or Pruitt-
Inahara (LeMaitre Vascular, Inc., Burlington, MA) shunt to
maintain arterial inflow to the midgut or lower extremity
(Fig. 38-4).108–111 If the surgeon lacks the experience to insert
a shunt into the superior mesenteric artery and chooses liga-
tion, an early reoperation for vascular reconstruction is man-
datory to avoid loss of the midgut. In similar fashion, ligation
instead of shunting of the common or external iliac artery
mandates performing a four compartment fasciotomy of the
ipsilateral leg at the damage control operation.112
FIGURE 38-4 Intraluminal shunt in proximal superior mesenteric
artery in patient with gunshot wound of the abdomen.
Moore_Ch38_p0741-0764.indd 746
ABDOMINAL VEINS (SEE CHAPTER 34)
Ligation is the treatment of choice in a damage control situa-
tion if there are multiple abdominal injuries and a significant
injury to one of the following veins: infrarenal inferior vena
cava; superior mesenteric vein; renal vein; common, exter-
nal, or internal iliac vein; or portal vein.112 Ligation of the
infrarenal inferior vena cava in a patient with hemorrhagic
shock and the need for massive transfusion mandates measur-
ing a compartment pressure in the bilateral below knee ante-
rior muscle compartments at the damage control operation.
A pressure of 30–35 mm Hg mandates immediate bilateral
below knee two-skin incision four-compartment fascioto-
mies. In addition, serial monitoring of the pressures in the
anterior compartments of the thighs should be performed
in the ICU postoperatively. Significant infusion of crystal-
loid solutions will be necessary in the postoperative period,
as well.
Lateral repair or ligation is the treatment for an injury to
the renal vein. Ligation of the right renal vein mandates a
right nephrectomy at a reoperation. If the left renal vein is
ligated medial to the entrance of the left adrenal and gonadal
veins, nephrectomy may not be necessary. Long-term follow-
up of left renal function is necessary in such a patient.
Ligation of the superior mesenteric or portal vein causes
splanchnic hypervolemia as described by Stone et al in
1982.113 The associated systemic hypovolemia that results
will, once again, be treated with significant infusions of crys-
talloid solutions.
PELVIC TRAUMA (SEE CHAPTER 35)
Closure of an “open book” (anterior-posterior compression)
closed pelvic fracture with a compressive sheet wrap or binder
or external fixation by the orthopedic service will control
hemorrhage in 90–92% in-patients. Patients who remain
hypotensive while waiting for angiography with emboliza-
tion may benefit from the interim placement of extraperito-
neal pelvic packing.114-117 After an 8-cm longitudinal incision
from the umbilicus to the pubis is made, the extraperitoneal
paravesical spaces are packed with three laparotomy pads on
either side. In order not to obscure extravasation on subse-
quent pelvic arteriography, the tails of the laparotomy pads
should be removed before insertion into the pelvis. When a
laparotomy has been performed for other abdominal inju-
ries and a pelvic hematoma is noted to be expanding without
pulsations, intrapelvic packing with laparotomy pads without
tails is performed.
Selective embolization of branches of the internal iliac
artery for hemorrhage after pelvic fractures has been avail-
able since 1971.118 Many centers continue to perform bilat-
eral embolization of the main internal iliac arteries when
exsanguinating hemorrhage is occurring, though there con-
tinue to be reports of buttock necrosis when a crush injury
has occurred.119–122 For these reasons, surgical ligation of the
internal iliac arteries for pelvic hemorrhage has fallen into dis-
favor until recently. In 2010, DuBose et al demonstrated that
temporary or permanent occlusion of the bilateral internal
06/02/17 1:11 PM

iliac arteries at surgery was worthwhile in a small subset of
patients in a damage control situation who would “not sur-
vive to reach angiography.”123
Transpelvic gunshot wounds can cause exsanguinating
hemorrhage from the presacral veins. Ligation of injured
presacral veins is very difficult as they are intimately adher-
ent to the periosteum of the sacrum. One option for con-
trol during a damage control procedure is the insertion
of (preferably) sterile tacks into or around the defect in
a vein with an orthopedic hammer. Another option is to
sew a free piece of omentum into the venous defect with
sutures into the periosteum of the sacrum. Failure of either
option to control venous hemorrhage should be followed
by the insertion of intrapelvic laparotomy pad packs with-
out tails.
RESUSCITATIVE THORACOTOMY VERSUS
RETROGRADE ENDOVASCULAR BALLOON
OCCLUSION OF THE AORTA (SEE CHAPTER 34)
Resuscitative thoracotomy and retrograde endovascular bal-
loon occlusion of the aorta (REBOA) are two damage con-
trol techniques used in the management of patients with
noncompressible bleeding in the chest, abdomen, or pel-
vis. Resuscitative thoracotomy has been used in the United
States since the late 1800s, but did not become widespread
until the 1960s and 1970s.124 Since that time, numerous
studies have examined this technique, the timing of its
application, and its use in a variety of thoracic and abdomi-
nal injuries, both from blunt and penetrating trauma.125–127
Concerns have been raised about the increased exposure risk
to health care providers, the revival of patients with residual
severe anoxic encephalopathy, and an overall low survival
rate.128,129 From the numerous writings on the subject, cer-
tain patient factors have been shown to impact the success
of this technique, including the following: mechanism of
injury, initial vital signs, cardiac rhythm, and presence or
absence of signs of life on presentation.129,130 For patients
arriving in shock, current data reflect a 15% survival for
patients presenting after penetrating trauma (primarily
patients with stab wounds of the heart) and 2% for patients
after blunt trauma.127
First described during the Korean War, balloon occlu-
sion of the aorta has recently been the subject of renewed
interest and research.131–136 There are no current studies
comparing this technique to that of resuscitative thora-
cotomy in humans, and the role of REBOA has not been
clearly defined. The American Association for the Surgery
of Trauma, however, is collecting data on all approaches to
aortic occlusion (resuscitative thoracotomy, REBOA, and
laparotomy).135 Limitations of REBOA include complica-
tions such as paraplegia and femoral artery thrombosis, the
need for radiologic guidance, and, formerly, a large deploy-
ment device requiring a closure of the arteriotomy.135–138
The size of the deployment device has decreased, but fur-
ther study and testing of FDA approved devices are needed
before widespread use.
Moore_Ch38_p0741-0764.indd 747
Chapter 38 Trauma Damage Control 747
INTRA-ABDOMINAL PACKING
Diffuse intra-abdominal packing as described by Stone in
1983 is rarely indicated in the modern era of damage control
resuscitation and massive transfusion protocols.1 The current
indications are oozing in the retroperitoneum (splenic bed,
renal bed, bed of pancreas, paraspinal or spinal area) or pelvis
secondary to an intraoperative coagulopathy. As with perihe-
patic packing, dry folded laparotomy pads are preferred as is
a temporary closure of the abdominal wall (skin closure with
towel clips or sutures). Reoperation for removal of the packs
should be performed as soon as the patient is hemodynami-
cally stable and the coagulopathy is resolved (see below). Part
of the reason for this is the known contamination that occurs
with the presence of intra-abdominal packs.139,140
Operative Techniques for Temporary
Closure of the Abdominal Wall or
Coverage of the Open Abdomen
GENERAL
Damage control operations often end with a temporary clo-
sure of the abdominal wall or with a temporary cover of an
open abdomen. The three main reasons have been consistent
over the past 30 years and include the following: (1) unable
to close the midline incision over an enlarged midgut (avoid
abdominal compartment syndrome—to be described);
(2) need to perform an early reoperation as a damage control
operation has been performed; and (3) loss of or severe injury
to abdominal wall (Table 38-3).
Management of the open abdomen can be divided into
two phases. The first phase in the acute setting is to provide
temporary closure or coverage. The temporary closure or
cover should not add significant time to the initial damage
TABLE 38-3: Indications for Temporary Skin
Closure Only of the Abdominal Incision or
Application of a Temporary Cover Over the
Open Abdomen
Unable to close incision/avoid creating abdominal compartment
syndrome
t
$SZTUBMMPJE
SFTVTDJUBUJPO
t
'BJMVSF
PG
/B+ pump in cell membrane
t
*OUFSTUJUJBM
FEFNB
PG
HVU
t
3FQFSGVTJPO
JOKVSZ
t
*MFVT
Need for early reoperation/avoid creating abdominal compartment
syndrome
t
1FSJIFQBUJD
QBDLT
t
%JêVTF
JOUSBBCEPNJOBM
QBDLT
t
"OZ
iEBNBHF
DPOUSPMw
PQFSBUJPO
Loss of abdominal wall
t
4IPUHVO
XPVOE
t
5SBOTFDUJPO
PG
TVCDVUBOFPVT
UJTTVF
BOE
SFDUVT
NVTDMFT
CZ
MBQ

seatbelt
06/02/17 1:11 PM
 748 Section III Management of Specific Injuries
control operation and will allow the patient to be taken from
the operating room to the intensive care unit for additional
resuscitation and stabilization. Once the patient’s physiology
has normalized, the patient then enters the second phase, that
is, managing the open abdomen. The goal of this phase is
not only continued protection of intra-abdominal contents,
but also progression towards definitive closure. Closure of the
abdomen within 8 days is preferred to reduce complications
from the open abdominal wound.45,141–145
TOWEL CLIP OR CONTINUOUS SUTURE CLOSURE
OF THE SKIN ONLY OF THE INCISION
The towel clip or continuous suture closure of the skin only
is a simple and rapid technique used for temporary closure
of cervical, thoracic, abdominal, or extremity incisions. The
towel clips or suture bites are placed at approximately 1.5 cm
intervals to prevent evisceration of underlying viscera.
With the towel clip closure, 25–30 will usually be applied
to close a midline abdominal incision in 2 minutes. Suture clo-
sure is performed with a 2-0 nylon or thicker suture. To prevent
manipulation of either closure, decrease cross-contamination,
and decrease fluid leakage from the underlying body cavity, a
plastic adhesive drape is applied over the clips of sutures.
With ongoing concerns about contributing to a postop-
erative abdominal compartment syndrome, these temporary
skin closures are rarely performed in the modern era.
TEMPORARY SILOS
The technique of using a large piece of nonadherent mate-
rial over the open abdomen was first described in Bogota,
Colombia by Dr Oswaldo Borraez G. at the San Juan de Dios
Hospital in 1984. Therefore, the silo is commonly referred
to as a “Bogota bag.” As the technique of complete silo cov-
erage has evolved, a variety of materials and methods have
been used, including the following: large sterile intravenous
or irrigation bags, Silastic sheeting, parachute silk, polytet-
rafluoroethylene patch, and x-ray cassette covers.141,142,145,146
When a small- or moderate-sized silo is needed, an adherent
plastic wound drape (Steri-Drape, 3M Healthcare, St. Paul,
Minnesota) is applied to the skin around the open abdomen.
In patients with significant distention of the intra-abdominal
contents, a stronger silo can be made with a sterile x-ray cas-
sette cover, Silastic sheeting (DowCorning Corp, Midland,
Michigan) or a sterile 2.5 L genitourinary irrigation bag size
by cutting three seams of the bag open. The silos are sewn to
the skin edges of the abdominal wound with 2-0 nylon or
polypropylene suture. Advantages of this technique include
its low cost, nonadherence of the silo to the bowel, ease of
removal, and low incidence of postoperative abdominal com-
partment syndrome. In addition, some materials allow for
visual inspection of the bowel at the bedside for patients in
whom bowel ischemia is suspected. The disadvantages, how-
ever, are that this technique does not allow for effective fluid
removal from the abdomen or prevent retraction of fascial
edges. Although temporary silos are still used as the first cover
Moore_Ch38_p0741-0764.indd 748
of the open abdomen after a damage control operation by
some senior surgeons, they are usually replaced by a negative
pressure device at the first reoperation.
ZIPPERS, SLIDE FASTENERS, VELCRO ANALOGUE
Originally described by Leguit in 1982, the zipper closure
of the abdominal wall was popularized by Stone et al in the
United States in their open treatment of patients with pancre-
atic abscesses.147,148 Either a conventional zipper is sutured to
the skin or fascia with a continuous suture of 0 or 2-0 nylon
or polypropylene, or a commercial zipper with adhesive side-
pieces is applied to the skin edges. The major advantage of
using the skin is that it preserves the fascia for formal wound
closure at an appropriate time.
Another commercial device is the Wittmann Patch (Star-
surgical, Burlington, Wisconsin). It is a device that consists of
two adherent Velcro sheets, one consisting of loops, the other
of hooks. The sheets are cut to the length of the incision and
sewn to the fascia. The sheets are then pulled from either side
allowing them to overlap and be pressed together. This pro-
vides continuous fascial tension along the length of the inci-
sion in an effort to prevent loss of abdominal domain. This
process is then repeated with serial trimming of the sheets,
thereby gradually pulling the fascial edges closer together
until closure of the midline incision can be safely performed.
The major advantages of this system are the ease of access for
reoperations and the tension on the aponeurotic edges that
prevents the usual lateral retraction. Good success in achiev-
ing definitive closure has been documented in the literature
with this device. Tieu et al reported an 82% closure rate
using the Wittmann Patch in a mixed population of trauma
and critically ill surgical patients.149 In a study by Weinberg
et al, delayed primary fascial closure was achieved in 78% of
trauma patients treated with the Wittmann Patch.150 A “mod-
ified Wittmann” technique has been described with good
closure rates, as well. Fantus et al described placing a non-
adherent layer, such as the previously mentioned sterile x-ray
cassette cover, under the abdominal wall and over the viscera
to decrease the formation of adhesions between the two that
would make delayed fascial closure more difficult.151 Despite
the high closure rate, this system is not without its disadvan-
tages. This device is contraindicated in patients with intra-
abdominal sepsis because it does not allow for an efficient
egress of fluid. In addition, the serial tightening can result
in damaged and ischemic fascia which could make primary
abdominal closure more difficult. Despite these concerns, the
abdominal complication rates associated with the use of the
Wittmann Patch are comparable to other temporary abdomi-
nal serial tightening techniques.152
VISCERAL PACKING
This older technique placing nylon cloth material over the
midgut has been used at Detroit Receiving Hospital for
almost 40 years.153,154 The cloth is covered with “generous”
gauze packs, and several widely spaced retention sutures are
placed through the abdominal wall above the packs. Every
06/02/17 1:11 PM

effort is made to keep the midgut below the fascial edges to
lessen dilation and thinning of the wall.
As midgut edema resolves, the retention sutures are gradu-
ally tightened at each reoperation until the linea alba can be
reapproximated and definitive primary closure achieved. In
the report by Bender et al, 15 or 17 patients surviving longer
than 24 hours had successful closure of the midline incision
using the technique described.153 There were no enterocuta-
neous fistulas nor incisional hernias in the 14 long-term sur-
vivors. One significant advantage of this technique is that it
serves not only as a temporary closure, but also as a method
to achieve primary closure by placing progressive amounts of
tension on the abdominal wall.
VACUUM-ASSISTED WOUND CLOSURE
Schein et al first reported the negative pressure dressing as a tem-
porary abdominal wound closure in 1986.155 The dressing they
described consisted of Marlex mesh applied directly on top of
the bowel with suction drains overlying the mesh. An Op-Site
adhesive drape was then placed over both the mesh and drains.
Over the past 19 years, this technique has been modified
by several groups, but typically consists of a nonadherent per-
forated subfascial drape with blue towel, laparotomy pad, or
sponge with or without sutures to provide constant fascial ten-
sion.156-162 At the present time, a commercially available nega-
tive pressure dressing, the AbThera (Kinetic Concepts, Inc.,
San Antonio, TX) is most commonly used. Approved by the
United States Food and Drug Administration in 2009, it con-
sists of two layers. The innermost layer is made of nonadherent
fenestrated plastic with six pieces of foam arranged in a radial
pattern. It is placed directly on top of the viscera and extends
widely into the paracolic gutters and pelvis. The second layer
is a foam sponge cut to accommodate the abdominal wound
and is placed directly on top of the first layer. An adhesive
drape is then applied over this polyurethane foam to keep the
dressing in place and provide an airtight seal to the system. A
small section of the adhesive drape and foam underneath are
removed, allowing for the suction tubing system to be applied.
Another commercially available device is the ABRA Abdomi-
nal Wall Closure System (Canica, Ontario, Canada). This
product integrates a silicone traction component with a skin
fixation component. The combination is used to provide gentle
elastic traction on the tissues theoretically preventing loss of
abdominal domain and facilitating primary wound closure.
This device is less commonly used than the AbThera, and more
clinical data are still needed to determine its role.
There are many advantages to this type of closure. The
dressing can be used as a temporary abdominal closure and will
aid in completing primary fascial closure. On a cellular level,
studies have shown that the application of micromechanical
forces created by the negative suction promotes cell division,
angiogenesis, the growth of granulation tissue, and the local
elaboration of growth factors—all without increasing apop-
tosis.163,164 Practically speaking, applying suction to the open
wound over the midgut allows for the rapid removal of peri-
toneal fluid and collapses space between the viscera. As both
of these results will make the contents of the abdominal cavity
Moore_Ch38_p0741-0764.indd 749
Chapter 38 Trauma Damage Control 749
smaller, there is a greater chance of definitive aponeurotic clo-
sure of the midline incision. In fact, primary fascial closure
rates with this technique over the years have approached or
been 100% and with few complications.156,158,165,166
COMBINATION CLOSURE
In patients with significant hepatic injuries requiring perihe-
patic packing, a combination of closures may be appropriate
and beneficial as previously noted. In such a patient, it is some-
times desirable to have a “tight” closure of the upper abdomen
to maintain pack tamponade of the injured liver. Partial fascial
closure limited to the upper abdomen or partial towel clip clo-
sure of the same area may be used in conjunction with a silo
or vacuum-assisted dressing placed over the lower abdomen.
This arrangement maintains a tamponade effect on the injured
liver while allowing ample room for expansion of the midgut to
avert development of an abdominal compartment syndrome.
A number of similar approaches have been described in the
literature, as well.167,168
Operative Techniques in
Trauma to the Extremities (see
Chapters 39, 40, 41)
Damage control operations on an extremity are appropriate
under the following circumstances: (1) when exsanguination has
caused intraoperative metabolic failure; (2) when multisystem
injuries have occurred and an emergent craniotomy, thoracot-
omy, or laparotomy needs to be performed in addition to the
vascular repair of the extremity; or (3) when the instability of an
open fracture precludes formal repair of the associated vascular
injury such as with a mangled extremity (see Chapter 41).
Rapid control of hemorrhage is the first step and can usu-
ally be achieved using direct pressure or a proximal tourni-
quet for distal injuries with bleeding. Another technique is
the placement of a Foley balloon catheter into the missile
tract with inflation of the balloon to tamponade the bleed-
ing as previously described for hemorrhage from the liver.53,54
Lateral vascular repairs are used for partial transections of
vessels, much as in non-damage control situations. Segmental
injuries or transections of injured arteries or major veins in
the patient with metabolic failure and other injuries are man-
aged with insertion of a temporary intravascular shunt.108-110
As previously noted, Argyle, Javid, Pruitt-Inahara and other
shunts are available. While the Pruitt-Inahara shunt has the
smallest luminal size (9 French), it does have inflatable bal-
loons at either end to prevent bleeding from the ends of the
vessel during shunting. In addition, it has a T-port that allows
for the injection of heparin, papaverine, or radiologic dye in
the postoperative period.
Intraluminal shunts have a 70% limb salvage rate when
used in the axillary, brachial, common femoral, superficial
femoral, and popliteal arteries.109 As the major veins of the
extremities have a larger luminal size than the arteries, thora-
costomy tubes may be used instead of the shunts listed above
on occasion. The major complication of an intraluminal
06/02/17 1:11 PM
 750 Section III Management of Specific Injuries
shunt is thrombosis, which is often a reflection of distal arte-
rial occlusion from emboli or distal in situ thrombosis.
As segmental resection of injured arteries or veins is per-
formed prior to insertion of the shunt, the insertion of a graft
is necessary after removal of the shunt(s). If the original area of
injury has been packed open, it is considered to be contami-
nated. Therefore, the saphenous vein graft inserted into the
previously shunted artery and the externally supported PTTE
graft inserted into the previously shunted vein should, ideally,
be placed in an extra-anatomic position.169,170 Practically, this
would only be performed when there is any distance more than
10 cm between the two ends of the vessel being repaired.
Venous repair, even with a ringed prosthetic graft, is preferred
to ligation for injuries to the popliteal, femoral, and common
femoral veins in the lower extremity. Patent venous outflow after
damage control vascular management in a lower extremity has the
following advantages: (1) increased arterial inflow, (2) decreased
incidence of deep venous thrombosis in the injured extremity,
(3) decreased long-term edema in the same, and (4) decreased
oozing from any distal fasciotomy sites.169
RESUSCITATION IN THE ICU
Correction of Metabolic Failure
HYPOTHERMIA
Hypothermia continues to be a common problem in vic-
tims of major trauma, with several studies reporting an
incidence as high as 66% for patients admitted to the oper-
ating room from the emergency department.3,4,171,172 There
are several well-known causes of hypothermia in victims of
major trauma. Hypovolemic shock in the preoperative period
adversely affects oxygen delivery and leads to decreases in
oxygen consumption and, therefore, diminished produc-
tion of heat. Should the patient be intoxicated at the time
of injury, vasodilation will further compromise the ability to
retain heat.3-6,30,173,174 The multiple iatrogenic contributors
to hypothermia include the following: (1) failure to main-
tain a heated resuscitation room, (2) the need to “expose”
the severely injured patient for evaluation, resuscitation, and
operation, and (3) the failure to pass blood and crystalloid
infusions through warmers before infusion.
The impact of hypothermia is dramatic. Coagulation
factor activity is reduced by as much as 10–15% for each
1°C drop in temperature.175 Thromboelastography (TEG®;
Haemonetics Corp, Niles, IL, US) and rotational thrombo-
elastometry (ROTEM®; Tem International GmbH, Munich,
Germany) have recently become the standard for detecting
the effect of hypothermia on coagulation.176,177 Although
hyperfibrinolysis has been suggested as a potential mecha-
nism of hypothermia-mediated coagulopathy, it has not
been confirmed by viscoelastography.178 In addition, severe
hypothermia can reduce cardiac contractility and, ultimately,
cardiac output, and this can be exacerbated by arrhythmias
such as atrial fibrillation.179,180 The resuscitation team should
be observant for the presence of Osborn waves, which may
proceed ventricular fibrillation.179,180
Moore_Ch38_p0741-0764.indd 750
Rewarming maneuvers to be instituted in the resuscita-
tion and operating rooms and in the ICU are outlined in
Table 38-4. Although these rewarming maneuvers prevent
further loss of heat, they may not rewarm patients effec-
tively. For patients with refractory hypothermia, Gentilello
et al have described the use of a continuous arteriovenous
rewarming (CAVR) device that can transfer the equivalent
of 5–8 kcal of heat per liter.181
METABOLIC ACIDOSIS
A persistent metabolic acidosis is a manifestation of anaerobic
metabolism occurring during hypoperfusion and has adverse
effects on the patient.182 Acidemia desensitizes the adrenergic
receptors in the peripheral vessels to endogenous and exoge-
nous catecholamines, thereby disabling compensatory mech-
anisms in response to hemorrhagic shock.183 Other adverse
effects of severe acidemia include inhibition of platelet activa-
tion, diminished activity of coagulation factors, and acceler-
ated breakdown of fibrinogen. Failure to correct an acidosis
within the first 24 hours after injury leads to higher rates of
multiple system organ failure and death.
The most effective way to treat the metabolic acidosis
component of the “vicious cycle” is to stop bleeding that
causes hypoperfusion.184,185 During the acute phase of hemor-
rhage control, infusions of bicarbonate can be used to buffer
a severe acidosis, but may lower the intracellular pH, reduce
serum ionized calcium, and alter serum osmolality. Infusing
Tris(hydroxymethyl)aminomethane (THAM) may be more
effective in correcting a severe acidosis, but is used infre-
quently and may not be readily available.
COAGULOPATHY
Patients may continue to bleed during and after a damage
control operation from a coagulopathy.186 While much less
common in the modern era, hypothermia, acidosis, and dilu-
tion of clotting factors from overinfusion of crystalloid solu-
tions are contributing factors.
TABLE 38-4: Maneuvers to Prevent or
Reverse Hypothermia During Damage
Control Operations
Increase operating room temperature >85°F (29.4°C).
Infuse crystalloid solution and blood through a warming device
such as the level 1 fluid warmer.a
Cover patient’s head with a turban or warming device.
Cover body parts out of the operative field with a warming device
such as the Bair Huggerb or Life-Airc system.
Irrigate nasogastric and thoracostomy tubes with warm saline
during laparotomy.
Irrigate open pericardial cavity, pleural cavities, and peritoneal
cavity during simultaneous sternotomy or thoracotomy and
laparotomy.
External warming lights in intensive care unit.
a
Level 1 Technologies, Inc, Rockland, Massachusetts.
b
Augustine Medical, Inc.
c
Medical products Group, Marshal, Minnesota.
06/02/17 1:11 PM

Massive transfusion protocols or balanced transfusion
therapy has led to a marked decrease in intraoperative and
postoperative coagulopathies, improved survival for patients
with either blunt or penetrating trauma, and reduced the
incidence of infectious complications, multiorgan failure,
and the abdominal compartment syndrome.187–191
Pohlman et al have described in a more precise manner
the four main causes of trauma-associated coagulopathies as
follows: (1) qualitative platelet defect, (2) diffuse endothe-
lial injury, (3) depletion of factors and platelets secondary to
hemorrhage, and (4) consumption of platelets or coagulation
factors as seen with disseminated intravascular coagulation
(DIC) or hyperfibrinolysis.177 The best therapy for all these
problems in the injured patient with bleeding is “goal-directed
resuscitation.”
TEG and ROTEM are integral to goal-directed resuscita-
tion as they provide point-of-care information on the kinet-
ics of clot formation and lysis and the physical properties
of clot strength and elasticity.177,192–194 Measured parameters
include the following: R-value is related to the generation of
thrombin; alpha angle reflects fibrinogen activity; maximal
amplitude is a function of the contribution of platelets; and
LY 30 reflects the rate of fibrinolysis. This information directs
providers to transfuse blood products to correct specific defi-
ciencies, rather than transfuse in fixed ratios as done in the
past. Current data in injured patients suggest that TEG or
ROTEM reduces transfusion requirements, though contro-
versy on the value of either persists.
Goal-directed damage control resuscitation has a role in
helping select which newly available clotting factor concen-
trates should be used in patients with coagulopathies, also. In
addition to cryoprecipitate, fibrinogen concentrate/RiaSTAP
(CSL Behring, King of Prussia, PA), four-factor prothrombin
concentrate (Kcentra, CSL Behring, King of Prussia, PA),
recombinant activated factor VII (NovoSeven, Novo Nordisk
A/S, Bagsvaerd, Denmark), and tranexamic acid (Lysteda,
Ferring Pharmaceuticals Inc., Parsippany, NJ) are all cur-
rently available.195-198 Results with the recombinant activated
factor VII have, however been disappointing.198 In contrast,
use of tranexamic acid (loading dose 1 g over 10 minutes,
then infusion of 1 g over 8 hours) in adult trauma patients
with or at risk of significant bleeding in the CRASH-2 trial
reduced “all-cause mortality” (p = 0.0035).199
In addition, there has been a trend toward earlier adminis-
tration of fibrinogen in the form of cryoprecipitate or fibrino-
gen concentrate. Finally, TEG can identify the problem of
increased fibrinolysis in order to direct the administration of
commercially available antifibrinolytic agents.200,201
Abdominal Compartment Syndrome
RECOGNITION OF INTRA-ABDOMINAL
HYPERTENSION AND ITS EFFECTS
Early studies on the detrimental effects of increased intra-
abdominal pressure (IAP) in various animal models were
reviewed by H.C. Coombs in 1920.202 He noted that
Heinricius had documented in 1890 that significant increases
Moore_Ch38_p0741-0764.indd 751
Chapter 38 Trauma Damage Control 751
in intra-abdominal pressure (>27 cm H2O) led to deaths in
feline and porcine models.203 In 1911, Emerson described
adverse cardiovascular sequelae of increased IAP.204 Numer-
ous confirmatory studies occurred over the next 35 years until
the vivid clinical description of avoiding too much tension in
closure of the abdominal wall in patients with war wounds
by W.H. Ogilvie in 1940.205 Robert E. Gross of Boston sub-
sequently described adverse respiratory, cardiovascular, and
intestinal sequelae in neonates in whom primary closure of an
omphalocele was attempted.206 The classical modern clinical
descriptions of measuring IAP and opening the abdominal
wall to relieve organ failures from the abdominal compart-
ment syndrome are well known to all.207–209
DEFINITION
The updated consensus definitions from the World Society
of the Abdominal Compartment Syndrome (WSACS) are
listed in Table 38-5.210 With an intra-abdominal pressure of
5–7 mm Hg in critically ill adults, intra-abdominal hyper-
tension is defined as a “sustained or repeated pathological
elevation in IAP >12 mm Hg.”210 ACS is now defined as a
“sustained IAP >20 mm Hg [with or without an abdomi-
nal perfusion pressure (APP) <60 mm Hg] that is associ-
ated with new organ dysfunction/failure.”210 Patients with an
intra-abdominal pressure (IAP) more than 25 mm Hg (intra-
abdominal hypertension [IAH] grade IV) are at highest risk
to develop the ACS, and the most common manifestations
are in the respiratory system (increased peak airway pressure),
cardiovascular system (increased systemic vascular resistance,
and urinary system [oliguria]).
Measurement of Intra-Abdominal Pressure Direct mea-
surement of IAP continues to be best accomplished with the
transbladder technique. With the patient in the supine position
and with the transducer leveled at the midaxillary line, 25 mL of
saline is injected into an empty bladder. The bladder catheter is
attached to a pressure transducer or manometer, and the trans-
mitted IAP is measured at end expiration.
Abdominal Perfusion Pressure Abdominal perfusion
pressure (APP) is defined as mean arterial pressure (MAP)
minus IAP. In the paper by Cheatham et al in 2000, APP
was significantly superior to IAP, arterial pH, base deficit, and
arterial lactate.211 The recent WSACS guidelines made “no
recommendation” regarding use of APP.210
RISK FACTORS FOR ACS210,212
The WSACS lists risk factors for developing an ACS in five
categories as follows: (1) diminished abdominal wall compli-
ance (ie, abdominal surgery, trauma, burns); (2) increased
intraluminal contents (ie, gastric distension, ileus, pseudo-
obstruction); (3) increased intra-abdominal contents (ie,
hemoperitoneum; intra-abdominal infection or abscess);
(4) capillary leak/fluid resuscitation (eg, fluid resuscitation,
damage control); and (5) other/miscellaneous (ie, coagulopa-
thy, incisional hernia repair; PEEP >10).
06/02/17 1:11 PM
 752 Section III Management of Specific Injuries

TABLE 38-5: Consensus Definition of the World Society of the Abdominal Compartment
Syndrome—2013210

No. Definition
Retained definitions from the original 2006 consensus statements13
1. IAP is the steady-state pressure concealed within the abdominal cavity.
2. The reference standard for intermittent IAP measurements is via the bladder with a maximal instillation volume of 25 mL of sterile saline.
3. IAP should be expressed in mm Hg and measured at end-expiration in the supine position after ensuring that abdominal muscle
contractions are absent and with the transducer zeroed at the level of the midaxillary line.
4. IAP is approximately 5–7 mm Hg in critically ill adults.
5. IAH is defined by a sustained or repeated pathological elevation in IAP 2: 12 mm Hg.
6. ACS is defined as a sustained IAP >20 mm Hg (with or without an APP <60 mm Hg) that is associated with new organ dysfunction/failure.
7. IAH is graded as follows:
Grade I, IAP 12–15 mm Hg
Grade II, IAP 16–20 mm Hg
Grade III, IAP 21–25 mm Hg
Grade IV, IAP >25 mm Hg
8. Primary IAH or ACS is a condition associated with injury or disease in the abdominopelvic region that frequently requires early surgical or
interventional radiological intervention.
9. Secondary IAH or ACS refers to conditions that do not originate from the abdominopelvic region.
10. Recurrent IAH or ACS refers to the condition in which IAH or ACS redevelops following previous surgical or medical treatment of
primary or secondary IAH or ACS.
11. APP = MAP – IAP.
New definitions accepted by the 2013 consensus panel
12. A polycompartment syndrome is a condition where two or more anatomical compartments have elevated compartmental pressures.
13. Abdominal compliance is a measure of the ease of abdominal expansion, which is determined by the elasticity of the abdominal wall and
diaphragm. It should be expressed as the change in intra-abdominal volume per change in IAP.
14. The open abdomen is one that requires a temporary abdominal closure due to the skin and fascia not being closed after laparotomy.
15. Lateralization of the abdominal wall is the phenomenon where the musculature and fascia of the abdominal wall, most exemplified by the
rectus abdominus muscles and their enveloping fascia, move laterally away from the midline with time.
ACS, abdominal compartment syndrome; APP, abdominal perfusion pressure; IAH, intra-abdominal hypertension; MAP, mean arterial pressure; TAP, intra-abdominal pressure.
Reproduced with permission from Kirkpatrick AW, Roberts DJ, DeWaele J, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated con-
sensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 2013;39:1190.

In one recent literature review, “large volume crystalloid
resuscitation and markers of shock/hypotension and meta-
bolic derangement/organ failure were risk factors” for intra-
abdominal hypertension and ACS in trauma and surgical
patients.212
Clinical Manifestations of IAH and ACS It has long
been recognized that IAH and ACS have multisystem effects,
and these are summarized in Table 38-6.213
PREVENTION OF ACS
In patients thought to be at high risk for the development
of the abdominal compartment syndrome, closure of the
linea alba is contraindicated. To summarize the list of causes
presented under the “Risk Factors for ACS” section above,
injured patients at highest risk for the development of the
ACS are as follows: (1) enlargement of the midgut (fail-
ure of Na+ pump in the cell membrane, interstitial edema,
reperfusion injury, over-infusion of crystalloid solutions,
ileus, or some combination); (2) presence of perihepatic or
intra-abdominal packs; or (3) ongoing coagulopathy with
expectation of further intra-abdominal hemorrhage.
When enlargement of the midgut is present, but the sur-
geon has decided to close the linea alba, measuring peak infla-
tion pressure (PIP) sequentially during closure is helpful. PIP
is the maximum pressure generated following tidal volume
inhalation. A measurement of 40 cm H2O at the midpoint
of the midline closure documents that the IAP will be too
high with complete closure, and the partial closure should be
removed. One of the open abdomen techniques previously
discussed is then used.
SECONDARY ABDOMINAL COMPARTMENT
SYNDROME
As defined in the WSACS consensus definitions in 2013, sec-
ondary IAH or ACS occurs after injuries or disease processes
“that do not originate from the abdominopelvic region.”211
On the Acute Care Surgery service, patients who develop
this syndrome have sustained significant hemorrhage from
an injury in the neck, chest, or an extremity, a major burn

Moore_Ch38_p0741-0764.indd 752 06/02/17 1:11 PM


TABLE 38-6: Clinical and Laboratory
Manifestations of IAH and the ACS
Abdominal
Body wall
Decreased blood flow
Gastrointestinal tract
Decreased mucosal blood flow and intramucosal pH
Possible bacterial translocation
Hepatic
Decreased portal blood flow and hepatocyte mitochondrial
function
Renal
Increased renal vein pressure
Increased plasma renin and aldosterone
Decreased renal blood flow, glomerular filtration rate, and urine
output
Thoracic
Lung
Increased intrathoracic pressure, peak airway pressure, peak
inspiratory pressure, and intrapulmonary shunt
Decreased dynamic compliance
Heart/cardiovascular
Decreased venous return and cardiac output
“False” increase of central venous pressure and pulmonary artery
wedge pressure
Increased systemic and pulmonary vascular resistance
Central nervous system
Increased intracranial pressure secondary to decreased venous
return
Decreased cerebral perfusion pressure
(>41%), or have required resuscitation for severe sepsis.
The diagnosis was made from 3 hours to 9 days in the early
reports, and the mean mortality was 65.5%.214–216
Interesting approaches to avoid operative decompres-
sion in such patients in the past have included laparo-
scopic decompression or the insertion of an angiocatheter
or a peritoneal dialysis catheter to remove intraperitoneal
fluid.217,218
SECONDARY EXTREMITY COMPARTMENT
SYNDROME
The secondary extremity compartment syndrome (SESC) is
a related problem in patients undergoing massive resuscita-
tion and has had a mortality of 70%, 35%, and 67% in the
three largest reports.219–221 In any patient who appears to have
edema of the head, trunk, and extremities after massive resus-
citation (polycompartment syndrome), early measurements
of compartment pressure in selected compartments (below
knee anterior, thigh anterior, forearm superficial volar, arm
biceps) is appropriate.219–222 In addition, serial measurements
of creatine phosphokinase (CPK) levels in the blood and
urine myoglobin are valuable diagnostic adjuncts.
Moore_Ch38_p0741-0764.indd 753
Chapter 38 Trauma Damage Control 753
REOPERATION AFTER A DAMAGE
CONTROL OPERAITON
Emergency Indications
An early return (within hours) to the operating rooms after a
damage control operation is a difficult decision as metabolic
failure/physiologic exhaustion may still be present. In addi-
tion, respiratory failure (needs ventilator), cardiovascular fail-
ure (needs pressors), or acute kidney injury may be present.
It has long been recognized that a failure to attain the
desired end points of resuscitation during the ICU phase of
damage control may reflect ongoing hemorrhage.17,223 Based
on a combination of current results of TEG or ROTEM, the
rate of ongoing transfusion to maintain “normal” hemody-
namics, and output from drains or the vacuum-assisted clo-
sure system if one has been placed, the surgeon must decide
whether mechanical (surgical) hemorrhage or a continuing
coagulopathy is occurring. In patients with significantly
altered coagulation parameters, it is worthwhile to continue
“goal-directed resuscitation” and delay a decision on reopera-
tion for 1–2 hours.
Abdominal compartment syndrome as an indication for
an early return to the operating room is very uncommon in
the modern era. This is a reflection of damage control resusci-
tation that minimizes the use of crystalloid infusions. In addi-
tion, the application of a large silo or vacuum-assisted cover
over the open abdomen at completion of the original dam-
age control operation is a technique that decreases the risk of
the ACS developing. Should an ACS develop, sudden release
by reopening the midline, detaching a silo, or removing a
vacuum-assisted device has led to a cardiac arrest in a certain
number of patients over the years. The efficacy of the prere-
lease volume loading anti-reperfusion solution (2 L of 0.45%
normal saline, 50 g mannitol/L, 100 mEq bicarbonate/L) rec-
ommended by Morris et al in 1996 is unknown.223
Routine Reoperation
When postoperative bleeding is not a concern, a return to
the operating room is based on reversal of metabolic failure
and normalizing of cardiovascular, pulmonary, and coagula-
tion parameters. A patient who is normotensive without a
coagulopathy and is in the diuretic phase of recovery after
resuscitation from shock is an ideal candidate for reopera-
tion. While this usually takes place within 48–72 hours of
the damage control laparotomy, it may be delayed in patients
with massive distention of the midgut so that a further diure-
sis may occur.
After removal of perihepatic or other intra-abdominal
packs, the abdomen is irrigated with 2–3 L of a saline solu-
tion containing antibiotics (cephalosporins have excellent
transperitoneal absorption). If persistent hemorrhage is
noted from an area that had been packed previously, this
is managed immediately with electrocautery, application of
topical hemostatic agents, selective suture ligation, or, as a
last resort, reinsertion of packs. With hemorrhage controlled,
06/02/17 1:11 PM
 754 Section III Management of Specific Injuries
the entire abdomen is carefully inspected, including areas of
previous repairs and areas thought to be uninjured at the
damage control operation. In patients with blunt trauma,
this mandates an inspection of the entire abdomen, espe-
cially the hemidiaphragms, retroperitoneal duodenum, pan-
creas, and kidneys, and the mesentery of the small bowel.
After penetrating trauma, the entire abdomen is inspected,
as well. Special areas of focus include the hemidiaphragms,
contusions or repaired areas on the mesenteric side of the
midgut and hindgut, and retroperitoneal organs and ves-
sels in the track of the stab or missile wound. A narrowed
or leaking repair of the gastrointestinal tract may require a
re-resection or debridement, reclosure, and an omental but-
tress. Reanastomosis of the small bowel may be performed
with either sutures or staples when extensive dilatation,
edema, or contusions are absent.224 When any of these are
present, many senior surgeons prefer a handsewn anasto-
mosis. As previously noted in this chapter (in the subsec-
tion “Gastrointestinal Tract” under the section “Abbreviated
Initial Operation”), reanastomosis of the colon is favored at
the first reoperation after trauma.86,87 With continued expe-
rience, however, it has become known that there are certain
anatomic and physiologic findings that increase the leak rate
after a delayed colon anastomosis. These include the follow-
ing: (1) reanastomosis in the area of the splenic flexure225
or left colon226; (2) persistent metabolic acidosis and edema
of the bowel87; and (3) with fascial closure beyond day 5.226
When a reanastomosis of the colon is contraindicated based
on the reasons listed, a decision must be reached on whether
to delay creating a colostomy till a second reoperation. A
further decrease in edema of the bowel, mesentery and
abdominal wall may occur and decrease technical problems
in creating the colostomy.
A nasojejunal feeding tube is inserted via a simultaneous
upper gastrointestinal endoscopy in all patients at the first
reoperation. This avoids the risks of a standard Witzel jeju-
nostomy such as leaks and obstruction when placed in dis-
tended small bowel through an edematous abdominal wall.
Enteral feedings can be initiated in the recovery room in
patients who are hemodynamically stable and have been off
pressors for greater than 24 hours.227
Finally, drains are inserted in patients with AAST Organ
Injury Scale (OIS) grade III or greater injuries to the liver,
pancreas, and kidney.
Missiles that have passed through the colon and are embed-
ded in the anterior abdominal wall or muscles of the flank or
back are a potential source of postoperative sepsis, though not
all agree.228,229 It is the authors policy to remove retained mis-
siles at the reoperation after damage control unless the missile
is in proximity to the spine, spinal nerves or retroperitoneal
vessels. If attempted removal cannot be performed safely, irri-
gation of the missile track in muscles of the flank or back with
a saline solution containing antibiotics is performed.
After inspection of the abdominal cavity for residual gas-
trointestinal contents, missed injures, or retained laparotomy
pads, the abdominal cavity is irrigated with a saline solution
containing antibiotics.
Moore_Ch38_p0741-0764.indd 754
Continuing Management of the
Open Abdomen
Patients in whom closure of the linea alba is still precluded
by distension of the midgut or by the need for further intra-
abdominal repairs have coverage of the open abdomen with
a vacuum-assisted device, the Wittmann Patch; or visceral
packing. All experienced trauma surgeons are now aware that
gastrointestinal repairs or anastomoses are placed under the
body wall or omentum to avoid direct contact with the suc-
tion applied over the midgut with the vacuum-assisted device.
CLOSURE OF THE ABDOMINAL
INCISION VERSUS PLANNED
VENTRAL HERNIA
Sequential Approximation
of Rectus Muscles
The sequential techniques previously described aim to
achieve closure of the linea alba by differing mechanisms. The
vacuum-assisted cover removes edema from the abdominal
wall and exposed viscera and, as previously noted, eliminates
spaces between viscera. Combined with natural or stimulated
post-resuscitation diuresis, the rectus muscles tend to fall
back in proximity to one another. With the Wittmann Patch,
resolution of edema allows for progressive trimming of the
hook and loop sheets at each reoperation and prevents lat-
eral retraction of the rectus muscles.150 The retention sutures
placed over the rayon cloth and visceral gauze packing are tied
tighter at each reoperation when the visceral packing tech-
nique is used.153,154
As previously noted numerous reports over the past
20 years have documented 90–100% rates of closure of the
linea alba using the techniques described above, especially the
vacuum-assisted cover.157,230
The group at Denver Health Medical Center has described
a technique combining several of those listed above. The white
sponges of the vacuum-assisted device are placed over the
midgut followed by the placement of No. 1-polydioxanone
sutures through the two sides of the linea alba “under moder-
ate tension.” The black sponges are placed over the sutures,
and the usual suction is applied. As edema resolves, closure
of the linea alba is performed sequentially from the ends. In
their report from 2012, 29 patients with an open abdomen
after the first reoperation had 100% closure of the linea alba
using the protocol described. Only 55% of a similar group
of patients not treated with the protocol had closure of the
linea alba.156
Planned Ventral Hernia
In the modern era, the overuse of damage control lapa-
rotomies in some trauma centers (not Denver) has led to
increasing rates of closure of the linea alba simply using the
vacuum-assisted cover method. There is a group of injured
patients with near-exsanguination, profound shock, multiple
06/02/17 1:11 PM
 Chapter 38 Trauma Damage Control 755

abdominal injuries, the need for massive transfusions, and

early postoperative complications (ie, gastrointestinal leaks,
fistulas, abscesses), however, who cannot have closure of the
linea alba at the first admission. These patients represent
5–10% of patients undergoing damage control laparotomies
in high volume centers. While all experienced trauma sur-
geons recognize the protein and water losses, persistence of
the catabolic state and the risk of enteroatmospheric fistulas
with an open abdomen, they are still necessary on both the
trauma and emergency surgery services.
Opinions vary widely as the how long it is appropriate to
continue attempts to close the linea alba; however, 5–10 days
is a reasonable limit in the era of vacuum-assisted cover-
age. In the patients with the gastrointestinal complications
mentioned above, leaks or fistulas are unlikely to heal with FIGURE 38-5 Multiple enteroatmospheric fistulas in patient with
negative pressure applied continuously. These patients may prior shotgun wound of the abdomen.
benefit from an earlier decision for a planned ventral hernia
as described below.
The open abdomen is covered with two layers of absorb- Also, both Bruhin et al and Di Saverio et al have noted that
able polyglycolic mesh with a 2- to 3-cm extension beyond there is a higher incidence of EAF in the septic open abdo-
the borders of the abdominal wall.231,232 Visceral packing to men as compared to the nonseptic.234,236
keep the midgut below the level of the fascia or a vacuum- Even with the significant decrease in the number of open
assisted device is placed over the absorbable gauze sheets in abdomens on trauma services worldwide, the continuing
most centers. The advantages of the vacuum-assisted device occurrence of EAF over the past 30 years has prompted many
when an open abdomen approach has been selected, however, innovative approaches to their management (Fig. 38-6). These
remain unclear. The visceral packing can be removed, a super- approaches were comprehensively described by Di Saverio
ficial washout performed, and new visceral packing inserted et al in 2015 (Table 38-7).236
in the patient’s room on a daily basis. When there is signifi- Once drainage from the fistula is controlled, management
cant overgrowth of the absorbable mesh with Pseudomonas of sepsis (percutaneous drainage, appropriate antibiotics) and
sp., a return to the operating room for a vigorous washout nutritional repletion (total parenteral nutrition, enteral ele-
may prevent premature removal. The absence of septic com- mental diet, dietary supplements) are necessary as previously
plications in the ICU coupled with appropriate enteral nutri- noted. The granulated open abdomen is then covered with a
tional support and daily wound care results in granulation split-thickness skin graft in the usual fashion. On occasion,
tissue appearing through the mesh in 2–4 weeks.232 At a reop- the authors have sewn the rolled up edge of a male condom
eration, excess or loose mesh is cautiously debrided, and a catheter to the edges of the fistula to keep effluent off the
meshed split-thickness skin graft from the thigh is applied. new graft (see Fig. 38-6). This catheter drainage system will
The edges of the graft are fixated to visible normal abdominal often last for 3 days and can be replaced at that time. When
wall with skin staples or multiple sutures of 3-0 absorbable
material. The standard compressive dressing is applied and
can be wet down daily with Sulfamylon slurry to minimize
infection of the graft during the first 5 postoperative days. As
an alternate approach, many plastic surgeons choose to cover
split-thickness skin grafts with a vacuum-assisted cover in the
modern era.233

Enteroatmospheric Fistula in a Planned

Ventral Hernia
One of the disadvantages of the open abdomen with a vacuum-
assisted cover is the 8–12% incidence of enteroatmospheric
fistulas that results (Fig. 38-5).232,234 All surgeons recognize the
risk of repeated manipulations of the exposed midgut, while
the risk of exposure of fresh suture lines to a vacuum-assisted
cover is unclear.234 In the review by Bradley et al in 2013,
statistically significant predictors of an enteroatmospheric fis-
tula (EAF) were large volume resuscitation, resection of the FIGURE 38-6 Male condom catheter sewn to edges of enteroat-
large bowel, and an increased number of reexplorations.235,236 mospheric fistula to allow new split-thickness skin graft time to heal.

Moore_Ch38_p0741-0764.indd 755 06/02/17 1:11 PM

 756 Section III Management of Specific Injuries

TABLE 38-7: List of EAF Management

Techniques237

Male condom catheter sewn to edge of fistula q 3 days

Baby bottle nipple diversion (nipple pasted to fistula; Foley or
Malecot catheter through nipple; vacuum-assisted cover)
Floating stoma (silo bag hole sutured to edge of fistula; covered
with stoma bag)
Tube VAC (Malecot intubation of fistula through VAC sponge)
Fistula VAC (VAC sponge hole to fistula)
VAC chimney (VAC white sponge as chimney supported by tube)
Seal small fistula with suture, biologic dressing, or fibrin glue
Pedicle flap
Fistula plug (silicone plug in fistula fixated to overlying foam-
covered aluminum)
Fistula patch (gel lamellar circle in bowel fixated to drain tube
outside the bowel)
FIGURE 38-7 Time-honored “pinch test” of split-thickness skin
Fistula suspension (convert fistula to stoma by sewing edges to
graft over planned ventral hernia documents that reconstruction of
adjacent dermis) the abdominal wall can be considered.
Used with permission from DiSaverio S, Tarasconi A, Inaba K, et al. Open
abdomen with concomitant enteroatmospheric fistula: attempt to rationalize the
approach to a surgical nightmare and proposal of a clinical algorithm. J Am Coll Factors in the choice of operation for reconstruction are
Surg. 2015;220:e23.
listed in Table 38-8.
Reconstruction of the abdominal wall is accompanied by
the skin graft is fully healed, a stoma bag is placed around the removal of the healed skin graft. Therefore, the surgeon must
fistula which then resembles an enterostomy or colostomy. determine if adequate skin lateral to the skin graft will be
Closure of the enteroatmospheric fistula is performed available to cover a tissue repair or a prosthetic patch. If it
3 months after the patient has been discharged. Long expe- appears that skin will be lacking, a plastic surgeon is con-
rience has demonstrated that this procedure should not be sulted to consider implanting lateral tissue expanders for 2–3
performed at the same time as reconstruction of the abdomi- months prior to undertaking reconstruction of the abdomi-
nal wall. The technique of closure of the EAF was originated nal wall. Should scarring of the abdominal wall or the pres-
by David Livingston, MD, New Jersey Medical School— ence of a colostomy or former colostomy site prevent the use
Rutgers, Newark, NJ, and is outlined as follows: (1) sepa- of a tissue expander on one side of the abdominal wall, a
rate edge of skin graft from abdominal wall for 30–50% of tensor fascia lata myocutaneous flap may have to be elevated
circumference as needed for exposure; (2) do not divide off the ipsilateral thigh. This flap is then tacked back in place
adhesed bowel or omentum from underside of old skin graft several weeks before reconstruction of the abdominal wall.
except as needed for exposure; (3) expose loops with fistu- Operative techniques for closure of the previous planned
las only, mobilize, and perform limited resection; (4) two- ventral hernia are divided into the following: (1) primary
layer handsewn anastomosis; (5) reattach edge of separated closure without tissue release, (2) primary closure with tis-
old skin graft to skin of abdominal wall; if too much edema sue release, (3) bridging prosthetic patch, and (4) retrorec-
of bowel, sew in absorbable mesh patch to cover all viscera; tus prosthetic patch (abdominal wall reconstruction). In
and (6) new split-thickness graft to cover absorbable mesh selected patients, the narrow midline defect that remains
patch when granulated. Another interesting technique that
has been described to close a deeply placed duodenal fistula
has been the use of a contralateral rectus abdominis myofas-
cial transposition flap.237 TABLE 38-8: Factors in the Choice of
Operation for Late Closure of a Previous
“Planned Ventral Hernia”
LATE CLOSURE OF A PLANNED
VENTRAL HERNIA Width of defect between rectus muscles
A patient who requests closure of a planned ventral hernia Whether loss of domain (apposition of anterior abdominal wall
covered with a healed skin graft is evaluated 3–6 months after and posterior abdomen laterally) of intra-abdominal viscera has
closure of an EAF or completion of any other intra-abdominal occurred
Presence of stoma or prior stoma on one or both sides of the
repair. The time-honored pinch test of the loose healed skin
abdominal wall
graft simply demonstrates healing, but does not predict the
Willingness of patient to undergo insertion of unilateral or bilateral
extent of adhesions to be encountered during reconstruction
tissue expanders
of the abdominal wall (Fig. 38-7).

Moore_Ch38_p0741-0764.indd 756 06/02/17 1:11 PM


after excision of the skin graft over the midgut can be read-
ily closed with a continuous or interrupted suture technique
using No. 1 polypropylene material.238 When it is not pos-
sible to close secondary to excessive tension on the linea alba,
the components separation technique of closure is used. The
skin and fat are elevated off the underlying fascia through
the midline incision or using a lateral laparoscopic approach
until the flaps extend to several centimeters lateral to the rec-
tus sheath. The external oblique aponeurosis is then divided
lateral to the rectus muscle bilaterally from the lower tho-
racic wall to just above the inguinal ligament. Each relaxing
incision usually creates an additional 4–5 cm of width to the
abdominal wall and often allows for closure of the midline.
This is, actually, the “second step” of the components separa-
tion technique first described by Ramirez et al (Fig. 38-8).239
If this does not allow the linea alba to be reapproximated, the
posterior rectus sheath is divided to complete the standard
components separation. When there is extensive scarring of
the remnant edge of the linea alba on either side of the mid-
line, excision of the scar back to viable rectus muscle is neces-
sary. When a greater release is needed, the modified technique
described by Fabian et al can be used.232,240–242 After the rec-
tus abdominis muscle is separated from the posterior rectus
FIGURE 38-8 Bilateral anterior myofascial components release
technique of midline aponeurotic closure.239 (Reproduced with per-
mission from Lowe JB III, Lowe JB, Baty JD, Garza JR. Risks associ-
ated with “components separation” for closure of complex abdominal
wall defects. Plast Reconstr Surg. 2003;111:1276.)
Moore_Ch38_p0741-0764.indd 757
Chapter 38 Trauma Damage Control 757
sheath, the internal oblique component of the anterior rectus
sheath is divided from the epigastrium to the arcuate line.
The final stage involves suturing the anterior rectus sheaths
in the midline, as well as approximating the medial border
of the posterior rectus sheath to the lateral border of the pre-
viously divided anterior rectus sheath (Fig. 38-9). With any
primary closure, components release, and modified compo-
nents release, another layer of a bioprosthetic material can be
used as a buttress over the tissue repair below. This additional
layer has been reported to lower hernia recurrence rates to
5% or less.243,244
Historically, permanent prosthetic patches have been
used to bridge large (>10–15 cm) defects between the rectus
muscles. The operative technique involves extensive lysis of
adhesions and debridement of the attenuated remnants of the
linea alba bilaterally with exposure of both rectus abdominis
muscles. The choice of prosthetic will depend on the presence
of omentum to cover the midgut. When sufficient omentum
is available, a relatively cheap knitted mesh (Marlex, C.R.
Bard, Inc., Murray Hill, NJ) should be chosen. In the absence
of omentum to separate the mesh from the underlying mid-
gut, a more expensive smooth polytetrafluoroethylene patch
or a composite (two surface) patch should be chosen. The
patch is fixated in an intraperitoneal location with a 3- to
4-cm overlap of the medial edge of the exposed rectus muscle
using multiple vertical mattress sutures of No. 1 polypropyl-
ene suture. On occasion, the tension absorbed by a newly
inserted small patch will allow a separate closure of the ante-
rior rectus sheaths in the midline. The disadvantages of per-
manent prostheses are numerous—secondary infection with
breakdown or infection of the skin incision, postoperative
seromas over the patch, and, most importantly, an unaccept-
ably high recurrence rate on long-term follow-up.245
Bioprosthetic patches have been suggested as an alter-
native, but “incorporation” cannot occur when the rectus
muscles are widely separated. The most appropriate role for
a bioprosthesis is when infection of a permanent patch man-
dates removal, and the surgeon desires to place a cover over
the midgut and delay the appearance of the inevitable recur-
rent incisional hernia.246–248
Insertion of a retrorectus permanent prosthesis (biopros-
thesis to be considered in the presence of prior mesh infec-
tion) by the Rives-Stoppa-Wantz technique has the lowest
recurrence rates when repairing complex and or large planned
ventral hernias.249 The operation can be difficult in patients
with previous lateral drain sites or colostomies or with prior
failed mesh repairs. Basically, bilateral transverse abdominis
releases (posterior releases) are performed after dissection of
the retrorectus spaces. The posterior rectus sheaths/perito-
neum are closed in the midline (absorbable mesh may be used
to fill in any defect) followed by insertion of the prosthetic
patch from Cooper’s ligament inferiorly to the retroxiphoid
space superiorly (Fig. 38-10). The anterior rectus sheaths are
usually able to be closed once the patch has been fixated in
place. Adding an anterior myofascial components release to
complete this closure, however, is contraindicated as it “desta-
bilizes” the abdominal wall.250
06/02/17 1:11 PM
 758 Section III Management of Specific Injuries

B´ A A´ B´
External oblique

B B Internal oblique
Transversus
abdominis

B´ A A´ B´

B B

B´ A A´ B´

B B

B´ A A´ B´
B B

FIGURE 38-9 Modified components separation technique of midline aponeurotic closure.232 (Reproduced with permission from Fabian TC.
Damage control in trauma: laparotomy wound management acute to chronic. Surg Clin North Am. 2007;87:73-93. Copyright © Elsevier.)

SUMMARY patients with complex injuries or patterns of injuries in the

“Damage control” surgery has evolved from a novel con-
cept to one of the most overused operative approaches in
all fields of trauma. Its use should be restricted to patients
with metabolic failure/physiologic exhaustion in whom mul-
tiple sources of hemorrhage are present. It is not indicated in
absence of metabolic failure. A decision to perform a “dam-
age control” procedure based on the early stages of metabolic
failure should be reversed if a solitary source of hemorrhage is
rapidly controlled at operation. Finally, the need to leave an
abdominal incision open may, on occasion, follow a “routine”
rather than a “damage control” operation. Examples would

Bilateral released edges of

transversus abdominis muscle

Mesh as sublay
in retromuscular space

FIGURE 38-10 Retrorectus permanent mesh reconstruction of planned ventral hernia with lateral retraction of rectus muscles. (Reproduced with
permission from Novitsky YW. Open retromuscular ventral hernia repair. In: Rosen MJ, ed. Atlas of Abdominal Wall Reconstruction. Philadelphia,
PA: Elsevier Saunders; 2012:74–95. Copyright © Elsevier.)

Moore_Ch38_p0741-0764.indd 758 06/02/17 1:11 PM


be when the patient has developed significant edema of the
midgut, has secondary or tertiary peritonitis, or when the sur-
geon is unable to complete an appropriate repair of an organ
or vessel based on lack of experience or adequate assistance.
In appropriately selected patients, survival after damage con-
trol laparotomy will be 90% in the modern era.251,252 Patients
will require at least four operations at the original admission,
and 75% will require readmissions for complications such as
infection or fistulas or for reconstruction of the gastrointes-
tinal tract or abdominal wall.252 In the 2006 review from the
Shock Trauma Center at the University of Maryland, there
was a 0% mortality for patients who survived the original
hospitalization.252
REFERENCES
1. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopa-
thy with onset during laparotomy. Ann Surgery. 1983;197:532.
2. Svoboda JA, Peter ET, Dang CV, et al. Severe liver trauma in the face
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