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SURGICAL DAMAGE CONTROL. Bradley W. Thomas, MD LCDR MC USN Constanta Trauma Symposium 12 JUNE 2013. OUTLINE. 1. Definition/description 2. Who needs it 3. Operative techniques 4. ICU techniques 5. Reoperation techniques 6. Expected outcome. Navy Definition. “ the capacity of a ship to - PowerPoint PPT Presentation
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SURGICAL DAMAGECONTROL
Bradley W. Thomas, MDLCDR MC USN
Constanta Trauma Symposium12 JUNE 2013
OUTLINE1. Definition/description2. Who needs it3. Operative techniques4. ICU techniques5. Reoperation techniques6. Expected outcome
Navy Definition“the capacity of a ship
toabsorb damage andmaintain mission
integrity”Naval War Publication 3-20.31,Dept Defense, 1996(c/o Paul Possenti, PA-C,Bridgeport Hospital)
Stage 1: DC1 Control hemorrhage Limit peritoneal contamination Temporary abdominal closureStage 2: DC2 Hypothermia prevention/treatment Correction of coagulopathy Correction of acidosisStage 3: DC3 Definitive surgery May require multiple surgeries Creation of ostomies, feeding access, fascial
closure No longer than 72 hours from Stage 1 Data from Rotondo MF, Schwab CW, McGonigal MD, et al. ‘Damage control’: an
approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35(3):375.
Initial Damage Control Stages
“Despite the lethality of injuries, if a wounded solider survives the rapid transport to a military medical facility with surgical capability, the likelihood of survival is now higher than any previous recorded conflict.”
Eastridge BJ, Jenkins D, Flaherty S, et al. Trauma system development ina theater of war: experiences from Operation Iraqi Freedom and Operation
Enduring Freedom. J Trauma 2006;61(6):1366.
Lethal Triad
WHO NEEDS DAMAGECONTROL?
Intraoperative Sequelae of Shock
Initial or persistent hypothermia Initial or persistent metabolic Acidosis Nonmechanical bleeding* * * * * “metabolic failure”
WHO NEEDS DAMAGE CONTROL? DISTINGUISH
BETWEEN GROUPS
May StabilizeTemp 35 CpH > 7.2BD > -10
Near-ExsanguinatedTemp < 34 CpH < 7.1BD -15 -20HR/SBP>0.9
Stop hemorrhage
Near-exsanguinated↓
May stabilize↓
↓Consider def.
operation
↓Damage control
WHO NEEDS DAMAGECONTROL?
Distinguish Between Groups
Stop hemorrhage
2. Liver3. Pancreas
DAMAGE CONTROLControl Visceral Hemorrhage
4. Kidney
1. Spleen
Immunitypreserved
Immunitysuppressed
DAMAGE CONTROLSpleen
Grade I-II Grade III-IV
Repair→10-15min←Resect
Repair→15-30min
SPLENECTOMY IS HARMFUL
1. Lose splenic filter
2. Lose production of
3. Lose immunosuppression
IgMTuftsinOpsoninProperdin
SutureVicryl mesh tamponade
DAMAGE CONTROLSpleen
Surgicel/Avitene/Fibrin glue
Perisplenic packing
1500 ml/minTherefore, a poorly chosen
damage control technique
DAMAGE CONTROLLiver
Has a blood supply of
is likely to fail in thecoagulopathic patient
Raw surface
DAMAGE CONTROLLiver
Balloon catheter tamponade → Track
Absorbable mesh tamponade → Fx
Compression
Perihepatic packsSubc. hematoma
More selective, but time-consuming
Resectional debridement with S.V.L.
DAMAGE CONTROLLiver
Hepatotomy with S.V.L.
HEPATIC TRAUMAOMENTAL PACK
Control intrahepatic venous hemorrhageManage dead spaceBring mobile macrophages to site of injuryH.H. Stone, 1975; H.L. Pachter, 1979; T.C. Fabian, 1980
bleeders Suture
Control retropancreatic largebleeders Divide
DAMAGE CONTROLPancreas
Control peripancreatic small
Defer distal pancreatectomy toreoperation
Palpate normal sized kidneyon opposite side beforeperforming needed
DAMAGE CONTROLKidney
nephrectomy
Isolate holes Umbilical tapes
Resect holes Stapler
DAMAGE CONTROLControl GI Contamination
Close holes 1 layer, suture
Severe colon Colostomy at reop.
Nephrectomy
DAMAGE CONTROLControl Arterial Hemorrhage
Celiac a.Sup. mes. a.Renal a.Iliac a. Shunt or ligate,
fasciotomy, fem-fem
LigateShunt
DON’T IGNORE LIKELY SEQUELAE
X-clamp abd. aorta, CIA, EIA→
Bilateral or ipsilateral fasciotomy
DAMAGE CONTROLControl Arterial Hemorrhage
Retrohepatic vena cava Pack
DAMAGE CONTROLControl Venous Hemorrhage
Common or external, Ligate iliac, infrarenal, IVC SMV, Portal
Pelvic Veins
Clamps, Tacks, Omentum
Atriocaval Shunt
DON’T IGNORE LIKELY SEQUELAE
Ligate portal vein or SMVSilo/NPD and reoperation at 12hours
DAMAGE CONTROLVenous Hemorrhage
X-clamp or ligate infrarenal IVCBilateral fasciotomy
A simple but eloquent idea
Managing the Open Abdomen
J. Trauma 48:201-7, 2000
Avoid conductionAvoid evaporation
Keep bed dryKeep skin dry
DAMAGE CONTROLICU Phase
Treatment of Hypothermia
Standard Warming maneuversRoom, Head, Lung, Trunk, IVs
TREATMENT OF ACIDOSISAcidosis uncouples B-adrenergic
receptors at cellular level
DAMAGE CONTROLICU Phase
Test dose 50-200 mEq HC03 if pH<7.2 and patient failing
*Check for missed injuriesComplete GI resections, repairs,
reconstruction or diversion
Removal of packs/Evaluate hemostasis
Passage of nasojejunal feeding tube/Formal jejunostomy
Fascial closure vs. VAC
DAMAGE CONTROLReoperation
1. Components/modified2. Biologic Mesh3. Absorbable mesh, delayed
DAMAGE CONTROLClosure/Coverage Options
STSG, leave a big hernia
1. Ventral Hernia2. EC Fistula3. Intraabdominal Abscess
DAMAGE CONTROLComplications
Initial opsICU/LOS
ABDOMINAL DAMAGE CONTROLOutcome
56 consecutive patients with damage
Sutton E: JT 61: 831, 2006
control laparotomy:
MortalityReadmissionsLate mortality
4.4 ± 2.217/3027%76%0%
2. Limited OR time using techniques3. Surgeons control ICU phase
1. Choose based on criteria
4. Don’t miss injuries at reoperationalways pass feeding tube
5. Expect 50-75% survival
DAMAGE CONTROLSummary
DAMAGE CONTROLSummary
“….. Advances in surgery are measured by events, and damage control surgery has been
one of the greatest advances in trauma surgery in the last 20 years …..”
Hiram C. Polk, M.D.