DAMAGE CONTROL SURGERY
A form of surgery by trauma surgeons for critically traumatized
patience to stabilize injuries, targeted at prevention of a triad of death
(hypothermia,acidosis and coagulopathy ) rather than correction of
anatomical defect.
STAGES OF DAMAGE CONTROL SURGERY
I. Patient selection
II. Control of haemorrhage and contamination
III. Resuscitation continued in ICU
IV. Definitive surgery
V. Abdominal closure
DAMAGE CONTROL SURGERY
Protracted surgery in the physiologically unstable patient can itself prove fatal
Patients with the deadly triad ( hypothermia, acidosis, coagulopathy)- at highest risk
A concept that originated from naval ship building strategy
‘Minimal repairs to prevent it from sinking while definitive repairs waited till it reached the port.’
The minimum amount of surgery to stabilize the patients condition, until physiological derangement is corrected.
2 goals
Stopping any active bleeding.
Controlling any contamination.
Once these goals are achieved abdomen is temporarily closed
Resuscitaion continues in ICU.
Once physiology is corrected patient warmed, coagulopathy corrected and returned to OR for definitive surgery.
INDICATIONS FOR DCS
Anatomical
Inability to achieve hemostasis
Complex abdominal injury (eg liver, pancreas)
Combined vascular, solid and hollow organ injury
Inaccessible major venous injury(retrohepatic vena cava)
Demand for non operative control of other injuries like fracture pelvis
Physiological
Temperature < 34 deg C
pH < 7.2
Serum lactate > 5 mmol/L (normal <2.5 mmol/L)
PT > 16 sec
APTT > 60 s
> 10 units blood transfused
Systolic BP <90 mm Hg for > 60 min
Environmental
Operating time > 60 min ( core temperature loss – 2 degree/hour)
Inability to approximate the abdominal incision
Desire to reassess the abdominal contents (relook)
DCS
Rapid life saving and limb saving procedures
Haemorrhage control- simple ligation of vessels, shunting of major arteries and veins, pressure, packing,
decompression of cavities- craniotomy.
Pringle manouvre- hepatoduodenal ligament clamped with a hemostat, umbilical tape or hand. Limits blood
inflow through hepatic artery and portal vein- controls bleeding from liver. (10-20 min cycles with 5 min flow in
between).
Contamination limitation- thorough wash, foreign body removed, faeces removed, lavage, drainage, stoma,
temporary stapling of bowels.
Temporary closure –’Vacpac’ or ‘opsite sandwich’; sheet of plastic (opsite) over the bowel, intermediate pack to
allow suction, superficial adherent plastic drape to the skin-water and air tight seal.
Definitive surgery: anastomosis, vascular reconstruction, closure of body cavity within 24-72 hours of injury
Individualised to the patient- response to resuscitation, progression of injury
Abdomen closed as soon as possible considering risk of abdominal compartment syndrome.
Aggressive offloading of fluid, hemofiltration may be needed
Best closure – closure of abd fascia.
If not possible- skin closure alone
Occassionally mesh closure, SSG and subsequent reconstruction
SUMMARY- PHASES OF DCS
Phase1- recognition of injury severity and need for DCR/DCS. Rapid sequence induction of anaesthesia and
intubation, early rewarming and prompt movement to OR.
Phase 2-immediate laparotomy with rapid control of bleeding and contamination, abdominal packing and
temporary wound closure
Phase 3-movement to ICU- ongoing resuscitation to normalise biochemical and physiological parameters.
Phase 4- Re-exploration in OR- definitive repair of all injuries– multiple settings may be needed.
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