Damage control laparotomy

A procedure in which the initial, abbreviated laparotomty focuses on stopping hemorrhage and controlling contamination.

A temporary dressing is placed over the intestines and the abdominal wall is left open.

The patient is subsequently taking to the ICU for resuscitation and correction of any physiological insult, such as coagulopathy.

After resuscitation, usually within 24 hours, the patient is returned to the operating room for definitive repairs of all injuries and abdominal closure.

It is a surgical technique used to care for critically ill patients.

The leading cause of death among trauma patients remains uncontrolled hemorrhage and accounts for approximately 30–40% of trauma related deaths.

This surgery of damage control surgery is meant to be used as a measure that saves lives.

Its application has resulted in a significant decrease in the morbidity and mortality of critically ill patients,

It is a procedure that is generally indicated when a person sustains a severe injury that impairs the ability to maintain homeostasis due to severe hemorrhage leading to metabolic acidosis, hypothermia, and increased coagulopathy.

It provides a limited surgical intervention in order to control both hemorrhage and contamination.

It subsequently allow for clinicians to focus on reversing the physiologic insult prior to completing a definitive repair.

Damage control surgery is divided into the following three phases: Initial laparotomy, resuscitation, and definitive reconstruction.

Laparotomy goal is to control hemorrhage followed by contamination control, abdominal packing, and placement of a temporary closure device.

Laparotomy minimizes the length of time spent in controlling hemorrhage followed by contamination control, abdominal packing, and placement of a temporary closure device.

Eviscerating the intra-abdominal small bowel and packing all four abdominal quadrants usually will allow surgeons to establish hemorrhagic control.

The procedure can control hemorrhage, resect solid organ damage, stop hepatic bleeding, and control intra-abdominal contamination.

Anastomosis should not be attempted in the damage control setting.

Following the initial phase of damage control reversing the physiologic insults is undertaken including acidosis, coagulopathy, and hypothermia.

The optimization of the pathophysiological factors will typically take 24–48 hours.

The resuscitation period allows for any physiologic derangements to be reversed in order to give the best outcome for patient care.

Typical resuscitation strategies have used include aggressive crystalloid and/or blood product resuscitation to restore blood volume.

Permissive hypotension refers to maintaining a low blood pressure in order to mitigate hemorrhage; however, continue providing adequate end-organ perfusion.

Studies show use of a permissive hypotentsion resuscitation strategy resulted in better outcomes, increased 30-day survival, in those undergoing damage control laparotomy.

The third step is closure of the abdomen, which occurs only when the patient is improving.

Prior to returning to the operating room it is paramount that the resolution of acidosis, hypothermia, and coagulopathy has occurred.

Initially, all abdominal packs are removed, and the abdomen is to re-explore the abdomen allowing for the identification of potentially missed injuries during the initial laparotomy and re-evaluating the prior injuries.

Attention is then turned to performing the necessary bowel anastomosis or other definitive repairs.

An attempt should be made to close the abdominal fascia at the first take back in order to prevent complications that can result from having an open abdomen.

The longer the abdomen is left open from initial laparotomy the higher the rate of complications.

If the abdomen is not able to be closed, after about one week, consideration of placing a Vicryl mesh to cover the abdominal contents is given.

A mesh cover allows granulation to occur over a few weeks with the subsequent ability to place a split-thickness skin graft on top for coverage.

Instead of replacing blood volume with high volumes of crystalloid and packed red blood cells with the sporadic use of fresh frozen plasma and platelets, maintaining a transfusion ratio of 1:1:1 of plasma to red blood cells to platelets in patients requiring massive transfusion results in improved outcomes.

In patients with substantial hepatic trauma, hepatic packing increased survival by 90%.

There are four main complications of damage control surgery:

The development of an intra-abdominal abscess, reported as high as 83%.

Development of an entero-cutaneous fistula, which ranges from 2 to 25%.

The development of an abdominal compartment syndrome that has been reported anywhere from 10 to 40% of the time.

Fascial dehiscence has been show to result in 9–25% of patients that have undergone damage control surgery.

The procedure is associated with high likelihood of postoperative complications such as incisional hernia, enterocutaneous fistula, and organ/space surgical site infections.

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