DAMAGE CONTROL SURGERY FOR NON-TRAUMA CASES

Definitive Surgery for Trauma and Acute Care Surgery

The College of Surgeons of Indonesia
First Edition, 2019

1
Dr. dr. Ibrahim Labeda SpB-KBD, FCSI
(President of College of Surgeons of Indonesia)

EDUCATION
S3 Doktoral of Medicine Program on Universitas Hasanuddin

ACTIVITIES
Lecture of Universitas Hasanuddin
Doctor on Wahidin Sudirohusodo Hospital
Book Author “Surgeon plus One”

+62 8124215593 ibrlabeda@yahoo.com +62 8124215593

 INTRODUCTION
1940 : Ogilvie
Management of OA
HISTORY 1993 : Introduced
English literature DCS for Trauma

1983 : Surgeons Belgium 1940-2011 (70 th) :

Search Term
“Planned relaparotomi vs “Open abdomen”
Open damaged” ”Management”“DCS”
Penninckx : WJS “TAC”“Septic Abdomen”

1995 : Brock
1984 : Di Columbia Introduced
1st Used : Vacuum Pack Technique
THE BOGOTA BAG
Kreis BE. Open Abdomen Management, Med Sci Monit, 2013
Adapted by Labeda I, 2019
INTROD
Concept of Damage Control

UCTION
The term "damage-control"
originates from US Navy referring
to the ability of a ship to absorb
damage while maintaining
mission integrity

Beuran M, Iordache FM.”Damage-Control Surgery”. Journal of Clinical Medicine 2012 Jan; 7(1): 92–93.
 Etymology
Stone, et al. : Technique of ‘truncated laparotomy’ in 1983.

Rotondo et al. : restoring as fast as possible normal physiology postponing

definitive surgical treatment.

Rotondo MF, Schwab CW, McGonigal MD, et al. "Damage control": An approach for improved survival in exsanguinating penetrating abdominal injury.  J Trauma. 1993;35:375–383.
Beuran M, Iordache FM.”Damage-Control Surgery”. Journal of Clinical Medicine 2012 Jan; 7(1): 92–93.
5
Definition DCS
Damage Control Surgery
(DCS) is a concept of
abbreviated laparotomy,
designed to prioritized
short-term physiological
recovery over anatomical
reconstruction in the
seriously injured and
compromised patient.
 Lethal Triad
Coagulopathy

Acidosis Hypotermia
As general surgery patients with severe intraperitoneal sepsis or bleeding are just as suspectible to
detrimental effects of acidosis, hypothermia, and coagulopathy, acute care and emergency general
surgeons have gradually applied the principle of DCS to severely ill surgical patients in the non trauma setting
ec
To
H
n
h
o
id
rs
sp
d
ti
sat
tga
l
ae
g:F
&
e
o
:u
DCS Stages
H
A
r
o
Ib
t
sh
b
C
rp
U
eis
rvtt
eiaa
salg
te
u
sep
:
h
cd
iaD
tlse
aef
tp
i
ia(n
rsi
o
et
o
n
tli
ev
o
ce
m
yt
is
o
u
n
r
 DCS in Non-  Abdominal Sepsis
trauma Cases 

Peritonitis
mesenteric ischemia
 NEC
 Pancreatitis
 Gangrenous proctitis
 Haemorrhagic
 Post splenectomy bleeding
 Duodenal bleeding
 Gastric ulcer
 Bleeding during pancreatic surgery
 ACS (Intraabdominal pressure >20 mmHg)
 Indication of DCS on Non-Trauma Case

Arterial systolic blood pressure <

70 mmHg

Hypothermia <35oC

Serum pH <7,25

INR  1.7

Transfusion exceeding five PRC.

Girard E, et al. ‘ Damage Control Surgery fot Non-Traumatic Abdominal Emeergencies’. Worl J Surg 2017, Springer. 12
Goals of DCS
Rapid control of bleeding

Rapid control of septic contamination

Rapid control of abdominal hypertension

13
 Hemorrhage Control
Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

Bleeding from large

vessels was
suture
controlled and
packing was
liberally employed
for diffuse bleeding

14
Bleeding Duodenal/Gastric Ulcer
Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

01 Endoscopic control of bleeding ulcers can be

considered to minimize the role of laparotomy

02
The aim at this initial operation is to stop the bleeding: by
direct suture, by resection, or even by direct packing on
the luminal surface.

03
An extensive surgical reconstruction should not be
attempted, but instead deferred until after a period of
resuscitation

15
Bleeding Duodenal/Gastric Ulcer
Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

04
The abdomen may be left open temporarily to avoid
abdominal compartment syndrome, and facilitate re-
exploration, if required

05
The definitive anatomical restoration and abdominal
closure may then be performed when the patient’s
physiology has normalized, usually not later than 48h after
initial surgery

06
Combination of manouvers including peritoneal lavage,
limited resection of diseased bowel segments leaving behind
blind ending stumps and external diversion of digestive
and/or biliary contents by intubation of digestive perforation
with flexible drains
 Gastrointestinal Perforation With Generalized Peritonitis
• Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

Prompt diagnosis of gastrointestinal perforation

usually allows definitive surgery, aimed at
primary repair or resection of the pathology
and final closure of the abdominal wall

However, in the most severe instances, when

generalized peritonitis and septic shock
dominate the clinical phenotype, the patient’s
compromised physiology may preclude a safe
primary definitive surgical strategy
Acute mesenteric ischaemia
Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

Among the abdominal surgical

catastrophes, acute mesen-
teric ischemia has one of the
highest rates of misdiagnosis
owing to its often non-specific
clinical presentation and
frequently inconclusive
investigation findings

18
Acute Mesenteric Ischaemia
Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

The treatment involves resection of infarcted bowel and

revascularization
The possible delays in diagnosis compound the
already severe physiological insult associated with the
primary pathology.
Because of the deranged physiology, a long procedure with
vascular repair and immediate bowel resection is not advisable;
a staged procedure adhering to damage control principles
is recommended.
At the first laparotomy, gangrenous bowel is resected, with the
ends stapled off, and the abdomen closed with a temporary closure. A
diagnostic angiogram is then performed, with the intention of
endovascular reperfusion.
Following a period of resuscitation, the peritoneal cavity is re-explored,
with a view to re-establishing bowel continuity and definitive closure
of the abdominal wall
 Toxic megacolon
Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

01
Standard surgical resection of a toxic
megacolon is normally limited to a subtotal
colectomy, with the remaining distal
sigmoid colon and rectum left in situ

02
This approach evolved as significantly
increased mortality was observed if total
proctocolectomy was carried out during the
acute phase of illness.

03
The remaining colon/rectum may then be
dealt with after recovery from the acute illness,
as may the possible enteric anastomosis
 Acute Cholecystitis
Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

The current standard of emergency cholecystectomy for acute cholecystitis is

based largely on experiences from physiologically normal patients

A percutaneous cholecystostomy offers an alternative treatment, which

in its widest use of the definition can be termed a damage control strategy before
definitive repair.

However, in the subset of patients with acute cholecystitis + physiological

compromise, an operative approach is less considered due to the
additional stress associated with the procedure

This bedside drainage procedure, performed under local anaesthetic,

removes the septic source with minimal physiological stress to the patient

21
 Abdominal Hypertension Management
• Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

01 The sources of increased intra-abdominal

pressure include gut edema, ascites, bleeding,
and packs.

02 Open abdomen using a vacuum suction

device is performed if skin closure only
(CSO) is impossible or in the presence of
massive contamination or ACS

22
Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118
23
 Factors to Consider for Damage
Control Strategy
Weber DG, Bendinelli C, Balogh ZJ. ’Damage Control Surgery for Abdominal Emergencies’. BJS 2014; 101: e109–e118

24
CONCLUSION
1. Damage control surgery is employed in a wide
range of abdominal emergencies and is an increasingly
recognized life-saving tactic in emergency surgery
performed on physiologically deranged patients.
2. When correctly applied, rapid source control laparotomy
may help to improve survival in decompensated
Emergency General Surgery patients.
3. Basic principles include arresting hemorrhage; restoring
blood volume; and correcting coagulopathy, acidosis
and hypothermia.

25
?
26
Wassalamu Alaikum W.W.

SEKIAN DAN TERIMA KASIH

27
28
29
30
31
 OBJECTIVES

To discuss:

32
SUMMARY

33
THANK YOU

34
35
36
37
38
39
40
41
42
43
44
45