Chapter 78 Damage Control: Abdominal Closures
INTRODUCTION
Massive hemorrhage ranks second only to central nervous system injuries as the leading cause of prehospital trauma-related mortality.1 Moreover, uncontrolled bleeding stands atop the list of early in-hospital mortality due to major trauma.2 Regarding penetrating trauma patients, increasing use of newer, more powerful automatic firearms, now common in the civilian population, have resulted in more frequent multiple penetrations (often multicavity) with more severe degrees of tissue destruction and bleeding.3 This is even more pronounced in injuries sustained from high-velocity military weaponry now being experienced all too frequently in the global theater of war and terrorism. Advances in prehospital care and trauma bay resuscitations since the mid 1980s has resulted in a greater number of these severely injured patients surviving to the point of necessitating operative intervention. Such patients usually present nearing physiologic exhaustion with profound acidosis, hypothermia, and coagulopathy, the so-called lethal triad of hemorrhage. The “traditional surgical approach” to such patients, in which surgeons would definitively repair all identified injuries at the initial operation, proved inadequate with extremely high mortality despite control of anatomic bleeding. During the peak of gun violence in the late 1980s into the early 1990s, urban American trauma centers gained extensive experience in treating these patients and the concept of “Damage Control” (DC) surgery was born. Borrowed from the Navy, the term “damage control” referred to any and all methods used to keep a badly damaged ship afloat to maintain mission integrity.4 For the trauma surgeon, DC describes the process of abbreviated laparotomy and expedient control of hemorrhage and contamination followed by intraabdominal packing and temporary coverage. From the operating room (OR), the patient is taken to the surgical intensive care unit (SICU) for physiologic resuscitation. Finally, the patient returns to the OR, after physiologic capture, for definitive repair of all injuries and, if possible, abdominal wall closure. To the uninformed observer, the increased morbidity associated with this multistep process might seem like surgical failure or abandonment of proper technique. Despite the associated high morbidity, the DC sequence has proved to be an aggressive and effective strategy to combat the lethal pattern of physiologic failure associated with severe blunt and penetrating injury.5–8
INDICATIONS
Because of the associated morbidity that accompanies the DC process, patient selection and proper timing are crucial. Although major liver injury and progressive coagulopathy remain the most frequent indications, the list continues to expand. In 1997, Rotundo and Zonies9 organized the “key” factors in patient selection for DC into three categories: conditions, complexes, and critical factors. In 1998, Moore and coworkers10 offered their six major indications for abbreviated laparotomy with consideration for institutional available resources and expertise. Ultimately, the decision to proceed with DC principles rests on the surgeon present and is based on the physiology of the patient.
THE DC SEQUENCE
DC 0
• Consequence
• Prevention
Positioning and Incision
Failure to Gain Access to Injured Body Cavities
• Consequence
• Repair
• Prevention
Division of the Falciform Ligament and Placement of a Large, Self-retaining Retractor
Iatrogenic Injury to the Abdominal Contents
• Consequence
• Prevention
Hypotension
• Consequence
• Repair
Sequential Removal of Packs; Abdominal Inspection
Retroperitoneal Hematoma
• Consequence
• Repair
Solid Organ Injury
• Repair
Any and all topical hemostatic agents can be applied as well including fibrin glue. A “liver tampon” made up of several sausage-sized pieces of absorbable gelatin sponge (Gelfoam) soaked in thrombin solution and wrapped loosely in a sheet of oxidized cellulose (Surgicel) is a recommended hemostatic modality. This device is then stuffed into the parenchymal defect followed by additional packing. This effectively tamponades bleeding and creates a hemostatic milieu.22 Tampons composed of other absorbable hemostatic materials available to the surgeon are also feasible.
• Prevention
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