DAMAGE CONTROL SURGERY IN NON TRAUMATIC EMERGENCIES

Carlos Mesquita

Coimbra Portugal

Session: EMERGENCY SURGERY 1 Thursday, April 28, 2011 Session times: 08:30 - 10:00 Duration of lecture: 15 m

“The modern surgeon must make the patient safe for the modern operation”

Lord Moynihan (1865-1936)

“The Barber Surgeon”

Jacobus de Cessolis (séc. XV) Harvard University

CM 2011

Thursday 2011-04-28 Session: EMERGENCY SURGERY 1

Session times: : 90 m (08:30 - 10:00)

Duration of lecture: 15 m Duration of presentations: 7 m

Keynote lecture:

DAMAGE CONTROL SURGERY IN NON TRAUMATIC EMERGENCIES

• Damage control strategy for trauma:

Widely and defined

Hypothermia, acidosis and coagulopathy understood as a vicious

cycle leading to patient's death - “LETHAL TRIAD"

Correction of metabolic failure rather than anatomic perfection

mandatory for immediate survival

1. Rapid control of bleeding and contamination

2. Abbreviated emergency laparotomy / temporary abdominal closure

3. ICU care, with correction of coagulopathy, acidosis, and hypothermia

4. Delayed definitive surgery

CM 2011

• Similar philosophy in non-trauma setting:

Not well detailed but applied

• Damage control surgery may be appealing and appropriate in non-trauma patients

• Metabolic disturbances (acidosis), peritonitis and peritoneal fecal load, as well as

hemodynamic instability, commonly encountered

hemodynamic instability defined as a SBP < 100 mmHg and HR > 100

open abdomen defined as non-approximation of the fascia and skin

• Abbreviated surgery in non-trauma setting rarely discussed in the

literature

• Little Level I evidence to support it

Thursday 2011-04-28 Session: EMERGENCY SURGERY 1

Session times: : 90 m (08:30 - 10:00)

Duration of lecture: 15 m Duration of presentations: 7 m

Keynote lecture:

DAMAGE CONTROL SURGERY IN NON TRAUMATIC EMERGENCIES

CM 2011

Thursday 2011-04-28 Session: EMERGENCY SURGERY 1

Session times: : 90 m (08:30 - 10:00)

Duration of lecture: 15 m Duration of presentations: 7 m

Keynote lecture:

DAMAGE CONTROL SURGERY IN NON TRAUMATIC EMERGENCIES

Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, Graaf PW, Lamme B, Gerhards MF,

Steller EP, Till JWO, Borgie CJAM, Gouma DJ, Reitsma JB, Boermeester MA.

Comparison of On-Demand vs Planned Relaparotomy Strategy in Patients With Severe Peritonitis. A

Randomized Trial.

JAMA 2007; 298(8): 865-873

Stawicki SP, Brooks A, Bilski T, Scaff D, Gupta R, Schwab CW, Gracias VH.

The concept of damage control: extending the paradigm to emergency general surgery.

Injury 2008 Jan;39(1):93-101

Person B, Dorfman T, Bahouth H, Osman A, Assalia A, Kluger Y.

Abbreviated emergency laparotomy in the non-trauma setting.

World Journal of Emergency Surgery 2009; 4:41

Kritayakirana K, Maggio PM, Brundage S, Purtill MA, Staudenmayer K, Spain DA.

Outcomes and complications of open abdomen technique for managing non-trauma patients.

J Emerg Trauma Shock 2010 Apr–Jun; 3(2): 118–122

CM 2011

• Abbreviated surgery in non-trauma setting – most common

indications:

Elective: Abdominal Compartment Syndrome (ACS)

elevated intra-abdominal pressure (>25 mm Hg) with tense abdomen and increasing respiratory failure, renal failure, or both

Urgent:

Peritonitis / sepsis 48 %

Mesenteric ischemia 32 %

Bleeding 10 %

Intestinal obstruction 07 %

Others 03 %

o Multi-Organ Failure (MOF) due to irreversible septic shock as the most common cause of death

Thursday 2011-04-28 Session: EMERGENCY SURGERY 1

Session times: : 90 m (08:30 - 10:00)

Duration of lecture: 15 m Duration of presentations: 7 m

Keynote lecture:

DAMAGE CONTROL SURGERY IN NON TRAUMATIC EMERGENCIES

CM 2011

• Converting from an elective surgical mindset to one of

damage control can be very challenging

General surgeon's perspective preoperatively:

• No surgeon starts an elective operation planning to leave

the OR with the abdomen packed and left open

• Humbling experience / cause for some reluctance

to use the technique

Trauma surgeons enter into the procedure with a plan:

To terminate the operation once bleeding and contamination were controlled

Thursday 2011-04-28 Session: EMERGENCY SURGERY 1

Session times: : 90 m (08:30 - 10:00)

Duration of lecture: 15 m Duration of presentations: 7 m

Keynote lecture:

DAMAGE CONTROL SURGERY IN NON TRAUMATIC EMERGENCIES

CM 2011

Thursday 2011-04-28 Session: EMERGENCY SURGERY 1

Session times: : 90 m (08:30 - 10:00)

Duration of lecture: 15 m Duration of presentations: 7 m

Keynote lecture:

DAMAGE CONTROL SURGERY IN NON TRAUMATIC EMERGENCIES

• Delayed abdominal closure must: Prevent evisceration Control peritoneal fluids Prevent ACS Prevent contamination Be economical as possible Be fast to execute Be easy to maintain Be radiolucent Allow second look and definitive closure, a few hours or days later, with minimal prejudices to the wall

CM – EUROTRUMA 2009 ANTALYA

CM 2011

• In conclusion

Innovation and unorthodox surgical practice

• occasionally required for patient’s salvage in emergency abdominal catastrophes

Damage control strategies not well defined in acute non-trauma setting

• such philosophy proved to save lives among the injured

• applying similar principles to patients inflicted by abdominal surgical diseases with the same

physiological derangements may prove beneficial as well

Thursday 2011-04-28 Session: EMERGENCY SURGERY 1

Session times: : 90 m (08:30 - 10:00)

Duration of lecture: 15 m Duration of presentations: 7 m

Keynote lecture:

DAMAGE CONTROL SURGERY IN NON TRAUMATIC EMERGENCIES