Damage Control Surgery

Principles

Dr. Josip Jankovi

Dr. Boris Hrekovski
Department of surgery
General hospital Slavonski Brod

The modern operation is safe for the

patient. The modern surgeon must make
the patient safe for the modern operation
Lord Moynihan

Standard surgical practice (early total care):

the best operation for a patient is one,
definitive procedure
the first chance of any surgical
intervention is the best chance for any
definitive repair or reconstruction

ERORICU

BUT!!!

Multiple trauma patients (ISS 35) are more

likely to die from their intra-operative metabolic
failure that from a failure to complete operative
repairs

The death triad:

- Hypothermia
- Acidosis
- Coagulopathy

One of the major advances in surgical

technique in the past 20 years.
The most technically demanding and
challenging surgery a trauma surgeon can
perform.

approach

method

ERORICUORICU

Hypothermia:
Clinically important if less than 37*C for
more than 4 h
Can lead to cardiac arrhythmias,
decreased cardiac output, increassed
systemic vascular resistance
Can induce and exacerbate coagulopathy
by inhibition of clotting cascade reaction

Acidosis:
Uncorrected haemorrhagic shock leads
into inadequate cellular perfusion,
anaerobic metabolism and the production
of lactatic acid
Interferes with blood clotting mechanisms
and promotes coagulopathy and blood
loss

Coagulopathy:
Hypothermia, acidosis and the
consequences of massive blood
transfusion all lead to the development of
a coagulopathy
Platelet dysfunction at low temperature
Activation of the fibrinolytic system
Haemodilution following massive
resuscitation

Parameters as a guideline for instituting damage control:

pH less then or equal to 7.2

serum bicarbonate level less than or equal to

15 mEq/L

core temperature less than or equal to 34*C

transfusion volume of packed RBCs more than

or equal to 4000 ml

total blood replacement more than or equal to

5000 ml

total fluid replacement more than or equal to

12 000 ml

If all - death
If one - DCS

The principles of damage control surgery

are:
Control haemorrhage

Prevention contamination

Avoid further injury

Prehospital and emergency department times

should be minimized
BTLS
NO unnecessary and superfluous investigations
Rapid transport to the operating room without
repeated attempts to restrore cisculating
volume- they require operative control of
haemorrhage and simultaneous vigorous
resuscitation

Stage 1 DCS (abdomen)

initial laparotomy
identify the main source of bleeding
perihepatic packing (superior and inferior)
small gastotomies and enterotomies can be
rapidly closed
resect non-viable bowel and close the ends
minor pancreatic injuries not involving duct- no
treatment
distal injury including the panceratic duct- distal
pancreatectomy
NO pancreaticoduodenectomy (drainage)
abdominal closure is rapid and temporary- if
there is any doubt about abdominal
compartment syndrome, left it open (silo-bag,
vacuum-pack technique)

Stage 1 DCS (skeletal)

Stable patient osteosynthesis

Polytrauma patient- FE
Do not insist on anatomical reposition, but
on fracture stabilisation
Open fracture-debridman
Timing is individual considering clinical
state
Secundary brain damage?

Stage 2 DCS

Begins in ICU
The next 24 to 48 hours are crucial
Correction of metabolic disorder
Core rewarming
Correction of coagulopathy
Complete ventilatory support
Correction of acidosis
Identification of occult injury

Stage 3 DCS planned reoperation

Window of opportunity is 24-48 hours after the traumabetween the correction of metabolic disorder and the
onset of SIRS and MOF
Removal of the abdominal packs (48-72 h)
Primary repair with end-to-end anastomosis undertaken
Copious washout should be performed and the abdomen
closed
The patient sometimes needs early unplanned
reoperation-ongoing haemorrhage, abdominal
compartment syndrome or peritontis
Window of opportunity for definitive osteosynthesis is 510 days after trauma

Complications of DCS

Abdominal compartment syndrome

General copmlications:
wound sepsis
wound dehiscence
fistula formation
ICU-related infections
skin complications

DCS is a treathement method

DCS is one of the major advances in surgical
technique in the past 20 years
DCS is recognized all over the world for
treathing polytraumatized patients (ISS35)
DCS is used in our hospital in the last 10 years
Patients who had death rate according to
ISS90%, survived
How much surgery polytrauma patient can
tolerate?