Keywords

7.1 Background

Damage control surgery for trauma utilizes techniques that rapidly temporize injuries, stop bleeding, and stabilize patients in extremis. This philosophy focuses on streamlining early interventions with definitive management delayed until the patient is physiologically stable. The rapid and targeted operative phase allows early transfer of the patient to the intensive care unit (ICU), where resuscitation, rewarming, and reversal of coagulopathy can occur. The patient may then return to the operating room in a semi-elective fashion for definitive management. Temporizing techniques have been described in various forms throughout the past century, and in more recent decades, damage control surgery and the philosophy of delayed definitive management have gained popularity in the military setting, and lessons learned from the battlefield have been applied and adapted to civilian trauma.

Historically, operative trauma has been managed with hemorrhage control and definitive management of the traumatic injuries at the index operation. These techniques can be highly effective in the setting of physiologic stability and specific injury patterns. In cases of complex, destructive, or major arterial injury with instability, hypothermia, or coagulopathy, however, definitive management may contribute to ongoing physiologic demise. Reports of damage control techniques in the early 1900s progressed to small series publications in the latter half of the century that began to describe positive results using temporizing measures with a planned “second-look” operation [1, 2]. In the early 1980s, Stone et al. [3] published a series of 31 patients undergoing laparotomy for trauma in which the final 17 patients were managed with a staged method, rapid temporizing of the injuries, intra-abdominal packing, and delayed return to the operating room for definitive management. Patients treated with these damage control techniques had significantly lower transfusion requirements and improved mortality when compared to patients with standard management. By 1993, the stages of damage control were clearly defined [4] as first, hemorrhage and contamination control with temporary abdominal closure; second, ICU resuscitation; and third, re-exploration with definitive surgical management. The modern concept of damage control surgery includes not only the temporizing operative techniques but also the concepts of damage control resuscitation with clear transfusion, physiologic, and hemodynamic goals.

Although clear indication criteria for damage control surgery continue to evolve, as many as 10% of trauma patients undergoing operation may benefit from these techniques, and a clear mortality advantage has been shown with this staged approach, especially when coupled with the principles of damage control resuscitation (Fig. 7.1) [4,5,6,7].

Fig. 7.1
figure 1

Damage control operation in a young male who developed hypotension after being admitted with a grade 5 liver injury after blunt abdominal trauma. CT scan imaging obtained on arrival shows a grade 5 liver injury with active contrast extravasation (a). The patient underwent damage control laparotomy during which the liver hemorrhage was contained with multiple packs, and the patient was taken to the hybrid operating room for angio-embolization (b). The patient was then resuscitated and stabilized in the ICU and returned to the operating room 24 h later for a liver resection and pack removal (c)

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7.2 Indications for Damage Control

Damage control techniques are most commonly applied during massive exsanguination or in patients in poor physiological condition; however, they may also be applied in austere environments or in the treatment of complex injuries where further exploration or definitive management is outside the clinical expertise of the operating surgeon.

Damage control should be considered in patients in extremis, with severe metabolic or physiologic derangements. These physiologic abnormalities contribute to an overall shock state in which patients remain coagulopathic with ongoing hemorrhage despite maximal operative intervention. Ongoing hypotension, shock, tissue hypoperfusion, and acute coagulopathy after trauma have all been shown to significantly worsen outcomes [8,9,10]. It is in these patients that damage control procedures are most commonly recommended [6].

The classic premorbid parameters described after severe trauma include the “lethal triad” of hypothermia, coagulopathy, and acidosis. Hemodilution and consumptive coagulopathy combined with metabolic acidosis and increased fibrinolysis in the setting of hypothermia have all been clearly shown to contribute to ongoing bleeding and a patients’ inability to tolerate prolonged operative interventions [11,12,13,14].

Hypothermia is a common problem in the trauma population that can exacerbate the effects of acidosis and worsen ongoing coagulopathy. Prehospital environmental causes are propagated by difficulties in rewarming during operative intervention, cool resuscitative fluids, and ongoing heat loss due to open cavities and wounds. Hypothermia alone is not an indication for damage control; however, hypothermia can exacerbate coagulopathy causing altered platelet function and abnormalities in the coagulation cascade [12, 15, 16], and it is associated with increased mortality after trauma [17]. In the hypothermic trauma patient, cold and wet clothing should be removed and skin covered with warm blankets. Intravenous fluid warmers and warm air convection devices are commonly used [18, 19]. Despite early reports supporting the correlation between ambient operating room and patient core temperature [20], modern analyses have failed to reproduce these benefits [21]. In the setting of persistent hypothermia during operative intervention, the most effective maneuver to rewarm the patient is with copious warm saline cavity irrigation. Establishing normothermia is a key component of coagulopathy reversal during damage control resuscitation.

Complex injuries such as severe liver injuries, bleeding from pelvic fractures, pancreaticoduodenal injuries, and many vascular injuries may benefit from damage control procedures. In an acute setting, these complex injuries can be difficult to expose, coagulopathy can exacerbate blood loss, and definitive management can be futile, increasing the risk of intraoperative mortality. Even the most experienced surgeon may choose to proceed with temporary control of the injury using packing or shunts with the definitive treatment delayed until the patient may physiologically tolerate the procedure. Additionally, suboptimal environments such as those with limited resources, inadequate blood product resources, austere environments, or lack availability of surgeons experienced in the needed procedure can all be indications for damage control interventions.

7.3 Stages of Damage Control

7.3.1 Stage 1

The first stage of damage control involves temporary control of bleeding and contamination. An initial surveillance assessment of the injuries should be performed with temporizing measures such as packing to allow a rapid cataloging of injuries. This is immediately followed by bleeding control with ligation, simple repairs, and solid organ removal, using tight packing as an adjunct when standard surgical techniques are insufficient. After these initial steps, the surgeon, in consultation with the anesthesia team, has sufficient information and control to determine if a damage control operation is necessary or if definitive management can safely progress. Consideration to temperature, acidosis, coagulopathy, injury burden, underlying medical conditions, and surgeon experience as described above will factor into this decision. A common mistake is to delay the decision to proceed with damage control until the patient has further deteriorated. This can be a fatal mistake. Damage control should be considered early and not be reserved as a procedure of last resort. If the surgeon decides to proceed with damage control, a rapid but thorough exploration of the abdomen should be performed prior to temporary abdominal closure. Injuries are commonly missed in the setting of significant trauma, and delayed management of ongoing bleeding or contamination can increase morbidity and mortality.

Hollow viscus injuries should be addressed with contamination control. Small or minimally destructive injuries can be primarily repaired, while extensive or devascularizing injuries should be resected. Although bowel ligation and discontinuity are described in the damage control setting, there is concern that this practice will increase bowel ischemia and ultimately worsen outcome [22]. In a multicenter study including 167 patients with damage control operations for hollow viscus injury, those managed with discontinuity were significantly more likely to have ischemia on repeat operation. For hollow viscus injury in damage control operations, injury identification, contamination containment, and restoration of continuity are the key elements to minimize morbidity and mortality [22, 23].

Vascular injuries need to be addressed at the index operation with definitive hemorrhage control. In the setting of complex injuries or physiologic derangements, a variety of temporary techniques have been described that can safely be used to delay definitive injury management. In the right setting, primary vessel repair is the first-line management option; however, in damage control settings, ligation, balloon occlusion, packing, and temporary shunts are all acceptable means to address vascular injuries. Nearly all complex venous injuries including the infrarenal IVC and iliac veins can be ligated with minimal long-term effect, and ligation should be considered as a damage control strategy if the vessel cannot be repaired without a complex reconstruction or significant stenosis. The exception to this rule is the superior vena cava, which should never be ligated. Ligation of the suprarenal vena cava carries significant morbidity with renal failure, and although not universally fatal, ligation of the portal vein and superior mesenteric vein should be avoided whenever possible due to the significant risk of bowel edema and necrosis that results. Intravascular shunts are most commonly used in extremity arterial trauma either during damage control operations or as part of a staged repair with orthopedics in treating a mangled extremity (Fig. 7.2); however, they may also be used in damage control operations on the carotid artery and/or abdominal arterial injury [24]. The use of intravascular shunts is well tolerated and has likely improved outcomes and limb salvage after damage control operation [24,25,26,27]. Definitive repair of arterial injuries treated with intravascular shunts should be prioritized, as the ideal dwell time remains uncertain.

Fig. 7.2
figure 2

Intravascular shunt placement in the right brachial artery of a mangled extremity during a damage control procedure. The patient returned to the operating room 24 h later and underwent graft placement and tissue coverage

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In the stable patient with pelvic fracture-associated hemorrhage, angio-embolization is an ideal management algorithm. Pelvic hemorrhage in the setting of hemodynamic instability, however, can provide a more complex challenge. In this scenario, pre-peritoneal packing and, more recently, inflation of a REBOA catheter are damage control treatment options that can transiently stabilize a patient and potentially facilitate transfer to an angiography or hybrid suite [28,29,30,31,32]. Angiography may be used to address the pelvic bleeding; however, over 15% of all patients with pelvic fracture and almost one third of patients with severe pelvic fractures have associated intra-abdominal injuries [33]. For this reason, in patients with severe pelvic fractures, especially those with associated hemodynamic instability, open exploration should be strongly considered. During exploration, bilateral internal iliac artery ligation is a well-described damage control technique to address retroperitoneal pelvic bleeding [34]. This maneuver addresses distal pelvic fracture-associated arterial bleeding, decreases the arterial pressure head in the pelvis for venous bleeding, can be performed concurrently with an open abdominal exploration, and is generally well tolerated.

Topical hemostatic agents have gained in popularity and are useful adjuncts during this first stage of damage control. Hemostatic agents currently available include scaffold materials with impregnated matrices and topical clotting factors and materials that stimulate the coagulation cascade. These are available as powders, gels, foams, granules, impregnated sponges, or combined with expandable foams. In the civilian setting, these agents are not a substitute for surgical control of bleeding, but they have been used effectively as adjuncts, especially in the setting of trauma-induced coagulopathy.

Once the intra-abdominal bleeding has been controlled and injuries temporized, temporary abdominal closure is performed using either a sterilized plastic sheet or one of the many commercially available temporary closure devices. The skin should never be closed after a damage control operation due to the high risk of abdominal compartment syndrome during the resuscitative phase. The patient is then transitioned to the intensive care unit, a hybrid operating room, or to the angiography suite depending on the injury profile. Despite efforts to minimize the time spent in the operating room during this first stage of damage control, the patient must not leave the operating room with ongoing exsanguination. If the patient has transitioned to the ICU and persistent bleeding is identified, the patient must be returned immediately to the operating room for hemorrhage control.

7.3.2 Stage 2

The second stage of damage control is the resuscitative phase and most frequently occurs in the ICU. The overall goal of this phase is to physiologically normalize the patient through rewarming, product administration, fluid resuscitation, and reversal of metabolic derangements. This stage typically lasts 24–48 h and is designed to reverse the progression of coagulopathy by addressing the “lethal triad” through patient rewarming, correction of acidosis, clearance of lactate, correction of base deficit, and blood product administration. Although “damage control resuscitation” begins in the operating room, stabilization of the patient in the ICU requires a keen understanding of both the patient’s resuscitative needs and the physiologic response to damage control interventions.

Contemporary resuscitation strategies focus on early blood product transfusion including component therapy in lieu of the traditional large volume crystalloid resuscitation that was previously recommended. The dilutional effects of crystalloid resuscitation with the resultant coagulopathy and acidosis have been largely replaced with aggressive and early implementation of balanced blood product administration [35,36,37,38]. Early administration of plasma in addition to PRBC transfusion in a ratio approximating 1:1 has been shown to improve outcomes after trauma [39,40,41,42,43].

In the setting of severe liver injury or complex pelvic fractures, this second stage may require continued resuscitation in the radiology suite with postoperative angio-embolization for additional hemorrhage control. During this resuscitative phase, patients often remain critically unstable, and any interventions undertaken outside of the ICU setting require close monitoring and observation. In these cases, the ICU team and equipment including physicians and nurses must be transferred with the patient to the radiology suite to facilitate ongoing monitoring and resuscitation despite the need for off-site intervention.

7.3.3 Stage 3

The third stage of damage control involves the semi-elective return to the operating room for pack removal and definitive management of the identified injuries. Although adequate resuscitation is paramount prior to reoperation, packing material should be removed expeditiously to minimize infection risk. Once intra-abdominal injuries have been definitively addressed and packing material removed, abdominal fascia closure is a top priority. Delayed fascial closure can incur significant morbidity and mortality with increased risk of infection, fistula formation, anastomotic dehiscence, and hernia formation [44, 45].

Conclusions

Damage control surgery is a three-stage intervention strategy that focuses on rapid treatment of surgical injuries and high prioritization of patient resuscitation, followed by semi-elective definitive operative interventions. During the initial operation, hemorrhage and contamination control are achieved followed by transition to the ICU or angiography suite. Once resuscitated, the patient can return to the operating room for definitive injury management including pack removal or vascular reconstruction. These techniques are designed to perform only necessary operative interventions when the patient is most physiologically vulnerable and integrate damage control resuscitation strategies into the operative planning. The decision to proceed with damage control surgery should be made expeditiously and not be delayed until the patient has deteriorated significantly. Appropriate application of this staged approach has demonstrated improved outcome and survival.