The Concept of Damage Control Surgery Dr. Derek TL Fung Department of Surgery Queen Elizabeth Hospital
Damage Control Surgery (DCS) • Multiple abdominal trauma • Thoracic injury • Vascular surgery • Orthopaedics • Abdominal sepsis
Damage Control • Originated in the US Navy, refers to the capacity of a ship to absorb damage and maintain mission integrity
In 1970s & 1980s, surgeons tended to perform complex and lengthy operation in multiple trauma case • Extensive resection • Extensive reconstruction • Aggressive resuscitation • Extracorporeal support
History • Idea originated from liver trauma • Pringle published a case series of packing liver injuries in 1908 Pringle JH. V. Notes on the Arrest of Hepatic Hemorrhage Due to Trauma. Ann Surg. 1908 Oct;48(4):541-9. • Calnein 1979 published a series of liver trauma patients whose abdomens were packed prior to transfer and definitive surgery at another centre CalneRY, McMaster P, Pentlow BD. The treatment of major liver trauma by primary packing with transfer of the patient for definitive treatment. Br J Surg. 1979 May;66(5):338-9.
Stone et al. • Coagulopathy in trauma patient leads to exsanguination and mortality • In his series, 31 patients with major bleeding tendency • 11 out of 17 patient who was managed with packing and staged re-laparotomy survived. • 1 out of 14 patients with standard treatment survived Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983 May;197(5):532-5.
Rotondo et al. • Rotondo and co-workers published a further series and coined the phrase ‘damage control surgery’ in 1993 • 7-fold of improvement in survival in a subgroup of patient with major vascular injury and 2 or more visceral injuries if they were managed with damage control approach • 10/13 (77%) survived with damage control surgery • 1/9 (11%) with traditional definitive laparotomy Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, Latenser BA, Angood PA. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993 Sep;35(3):375-82; discussion 382-3
Lethal Triad Acidosis Hypothermia Coagulopathy
Hypothermia • Central thermoregulation lost • Metabolic activity • Cold IV fluid • Platelet dysfunction • Clotting factors kinetics disturbance • Cardiac dysfunction • Vasoconstriction • Hypoperfusion
Acidosis • Cardiac contractility • Dysrhythmias • Synergizewith hypothermia in its detrimental effect on the coagulation cascade
Coagulopathy • Platelet dysfunction • Clotting cascade disturbed • Haemodilution Uncontrolled bleeding from all cut surfaces
Principles of DCS • Quickly abort the vicious cycle by haemorrhage and contamination control • Minimize further trauma created by Surgeon • Restore normal physiology before definitive surgery in reoperation
Stages of Damage Control Surgery • 1. Patient selection • 2. Intraoperative stage • 3. Critical care stage • 4. Return to the operating theatre • 5. Formal closure Moore EE. Thomas G. Orr Memorial Lecture. Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am J Surg. 1996 Nov;172(5):405-10.
Stage 1: Patient Selection WHO? WHO?
Rotondo M, Zonies D. The damage control sequence and underlying logic. Surg Clin N Am 1997; 77: 761-777.
No Definite Selection Criteria • Too Liberal Unnecessary staged operation • Too Strict Adverse physiological outcome established Too late to salvage • Experience, rapid surgical assessment and liaison with anesthetist are the keys in decision making
Stage 2: Intraoperative • Aim: • Controlling Haemorrhage • Limiting contamination
Risk of abdominal compartment Syndrome • Ineffective Drainage
Negative Pressure Therapy • Evacuation of abdominal fluid • Minimize risk of Intra-abdominal hypertension • Low fistula rates • Good early closure rates
Stage 3: Critical Care Stage • Active rewarming • Correction of Acidosis • Correction of Coagulopathy • Monitor the need for early return to theatre • Ongoing surgical bleeding • Abdominal compartment syndrome
Stage 4: Return to the Theatre Timing: • 24-48hrs later when • Base deficit < 4 mmol/L • Lactate of < 2.5 mmol/L • Core temperature > 35 C • INR < 1.25
Stage 4: Return to the Theatre • Definitive surgery • Removal of packs • Anastomoses or stomas • Vascular repairs • Solid organ debridement • Placement of feeding tube
Stage 5: Formal Closure • May not be feasible due to significant bowel edema or risk of abdominal compartment syndrome • 30 - 80% closure rate in the 1st reoperation Hirshberg A, Wall MJ, Mattox KL. Planned reoperation for trauma: a two-year experience with 124 consecutive patients. J Trauma 1994;37(3):365– 9. Hatch QM, Osterhout LM, Ashraf A, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Current use of damage-control laparotomy, closure rates, and predictors of early fascial closure at the first take-back. J Trauma. 2011 Jun;70(6):1429-36. • The highest closure rates are achieved during the first 7–10 days Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg. 2012 Mar;36(3):497-510.
DCS Vs Immediate and definitive repair (in patients with major abdominal trauma) • A total of 1523 studies were identified • A total of 1521 studies were excluded because they were not relevant to the review topic • Targets were not suffering from major abdominal trauma/ narrow spectrum • Not directly comparing DCS Vs definitive repair • Two studies were excluded because they were case-control studies. (Rotondo 1993, Stone 1983) Cirocchi R, Abraha I, Montedori A. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007438.
Evidence • No RCT, systemic review could not be done • Most of the studies were case series • Different patient groups • Different methodology • Conclusion: Evidence is LIMITED. Cirocchi R, Abraha I, Montedori A. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007438.
Complication • Surgical site infection & intraabdominal abscess: up to 83% of cases • Enterocutaneous fistula: 5-19% • Chronic Ventral Hernia 13-80% Smith BP, Adams RC, Doraiswamy VA. Review of abdominal damage control and open abdomens: focus on gastrointestinal complications. J Gastrointestin Liver Dis. 2010 Dec;19(4):425-35. Review.
Overuse of DCS • Complications • Long intensive care unit stays • Increased use of blood products • Multiple operations • Higher hospital cost Higa G, Friese R, O'Keeffe T, Wynne J, Bowlby P, Ziemba M, Latifi R, Kulvatunyou N, Rhee P. Damage control laparotomy: a vital tool once overused. J Trauma. 2010 Jul;69(1):53-9. Hatch QM, Osterhout LM, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma. 2011 Dec;71(6):1503-11.
Damage Control Resuscitation • Proactive early treatment to address the lethal triad (by rapid reversal of acidosis, prevention of hypothermia and coagulopathy) on admission to combat hospital. • Assumption that coagulopathy is actually present very early after injury Holcomb J, Jenkins D, Rhee P et al. Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma. J Trauma 2007; 62: 307-310.
Damage Control Resuscitation • Permissive Hypotension • Satisfied with MAP = 50-60mmHg • Minimize dilution effect and hypothermia secondary to overzealous fluid replacement • Early use of blood product over isotonic fluid for volume replacement • Early correction of coagulopathy with components, ie. Massive transfusion protocol • PRBCs: FFP: Platelet = 1:1:1
Midwinter MJ. Damage control surgery in the era of damage control resuscitation. J R Army Med Corps. 2009 Dec;155(4):323-6.
Conclusion • Damage control surgery was an useful tool in handling patients with multiple injury, though high level of evidence is lacking • DCS is not without risk and complication, over-utilization may lead to more harm than benefit • With DCR integrating into DCS, the need of DCS may reduce as coagulopathy is corrected earlier