DAMAGE CONTROL SURGERY: TEAMWORK IS THE KEY

A surgeon partly becomes an anesthetist in managing such cases with lots of decision making in short time.

1. DAMAGE CONTROL SURGERY Dr Reshma Chandrasekaran DNB General Surgery Resident

2. OVERVIEW DEFINITION INDICATIONS PHASES OF DCR OPERATIVE TECHNIQUE- DCS PRINCIPLES MODIFICATIONS SUMMARY

3. DAMAGE CONTROL

4. CONCEPT

5. HISTORY Stone and colleagues: Technique of ‘ truncated laparotomy ’ in 1983. Rotondo and colleagues: coined term DCS as a 3 phase technique in 1993. Johnson and schwab: 4 phase technique ( pre-theatre phase ). Rotondo MF, Schwab CW, McGonigal MD, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993; 35: p. 375-82; discussion 382-3. Stone HH, Strom PR, Mullins RJ (May 1983). "Management of the major coagulopathy with onset during laparotomy" Annals of Surgery. 197(5): 532-5. doi:10.1097/00000658-198305000-00005. PMC 1353025 . PMID 6847272

6. TRAUMA TRIAD OF DEATH

7. DEFINITION Damage control surgery(DCS) is a concept of abbreviated laparotomy, designed to prioritize short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. Damage control resuscitation (DCR) : A systematic approach to major trauma combining the ABC to definitive treatment in order to minimize blood loss and maximize tissue oxygenation. To keep hemoglobin, Ph, lactate and clotting factors within normal range.

8. DAMAGE CONTROL RESUSCITATION Damage control resuscitation aims to limit blood loss and prevent coagulopathy by combining hypotensive resuscitation, early airway control, balanced use of blood products and other hemostatic agents. DCR is to address the lethal triad of coagulopathy, acidosis, and hypothermia.

9. DCS GOALS: Stopping any active surgical bleeding Controlling any contamination Restoring normal physiology

10. BAILEY AND LOVE 28 th edition THE STAGES OF DAMAGE CONTROL SURGERY STAGE INTERVENTION Patient selection Control of hemorrhage and control of contamination Resuscitation continued in the intensive care unit Definitive surgery Abdominal closure

11. INDICATIONS OF DCR ANATOMICAL: Inability to achieve haemostasis Complex abdominal injury, e.g. liver and pancreas Combined vascular, solid and hollow organ injury, e.g. aortic or caval injury Inaccessible major venous injury, e.g. retrohepatic vena cava Demand for non-operative control of other injuries, e.g. fractured pelvis Anticipated need for a time-consuming procedure

12. PHYSIOLOGICAL (decline of physiological reserve) Temperature <34°C pH <7.2 Serum lactate >5 mmol/L (normal: <2.5 mmol/L) Prothrombin time >16 s Partial thromboplastin time >60 s >10 units blood transfused Systolic blood pressure <90 mmHg for >60 min

13. ENVIRONMENTAL Operating time >60 min (core temperature loss is usually 2°C/h) Inability to approximate the abdominal incision Desire to reassess the intra-abdominal contents (directed relook)

14. PHASES OF DCR

15. PHASE 1- GROUND ZERO Prehospital care & Initial resuscitation: Built on fundamentals of ATLS guidelines. Rapid Transport to definitive care. Rapid Evaluation. FAST, ICD insertion, CXR, Pelvis X-ray Damage Control Resuscitation to systolic 80-90 mmHg. (permissive hypotension) This phase should take 20-30 min.

16. PROCESS (DC-0 TO 1) Inform Blood Bank Inform OR Stop air conditioning Start warmers Start the timer Prepare trolley Sterile towels + lap sponges Good self retaining retractor Laparotomy/ Thoracotomy set Vascular set

17. MASSIVE TRANSFUSION PROTOCOL Definition: Greater than or equal to 10 units of PRBCs/ 24hrs 25% of patients who are severely injured can be coagulopathic. New ways of measuring coagulopathy: Thromboelstography (TEG) Rotational thromboelastometry (ROTEM) Institutional Protocols allow for clear communication between the trauma team, blood bank, nurses, and other staffs.

18. DAMAGE CONTROL RESUSCITATION (DCR) DCR combines two strategies  Permissive Hypotension : a strategy of restricting crystalloids administration until the bleeding is controlled, while accepting a limited period of suboptimal end-organ perfusion.  Hemostatic Resuscitation : means providing PRBCS, FFP & platelets in correct ratio to maintain normal whole blood characteristics. Prolonged permissive hypotension can lead to aggravated postinjury coagulopathy, ischemic damage secondary to poor tissue perfusion including the brain, mitochondrial dysfunction and lactic acidosis.

19. BLOOD & BLOOD PRODUCTS (1:1:1)

20. PHASE 2: DAMAGE CONTROL SURGERIES Damage control laparotomy Damage control thoracotomy Damage control vascular surgery Damage control orthopaedic surgery

21. PHASE II- DCS PRINCIPLES: Control hemorrhage Prevention contamination Avoid further injury Aims to restore physiology at the expense of anatomical reconstruction. On- going DCR This phase should take less than 90 mins .

22. PRE-OP PREPARATION Good IV line Blood & blood products Long instruments Vascular instruments Effective suction Auto-transfusion set Strong assistant Antibiotics Tranexamic acid

23. ANAESTHESIA General anaesthesia Cricoid pressure No contraindication to GA

24. POSITION OF THE PATIENT Midline incision Xiphoid to pubic bone Three passes Skin and subcutaneous tissue Land on the Linea alba Divide the fascia, expose preperitoneal fat Push through the peritoneum just cranial to umbilicus Cut peritoneum, divide falciform ligament

25. HEMORRHAGE CONTROL Initial suction and four quadrant packing with towels. Remove packs one by one.

26. ORGAN SPECIFIC INJURIES LIVER peri-hepatic packing- anteroposterior plane, hepatorenal space Pringles manoeuvre transfer to angiography suite immediately after the operation to identify any ongoing arterial haemorrhage which may be controlled with selective angiographic embolization. SPLEEN splenectomy or control the pedicle. Minor splenic injuries- direct suture techniques Damage Control Surgery Karim Brohi , trauma.org 5:6, June 2000

27. PANCREAS: rarely requires or allows definitive surgery Minor injuries not involving the duct (AAST I,II,IV) require no treatment. Distal Injury (Left of SMV- AAST III) with extensive tissue destruction including pancreatic duct-- rapid distal pancreatectomy. Massive injuries to the pancreaticoduodenal complex (AAST V)  debrided only. Duodenal injuries- single suture/ temporarily close ends(major)

28. ABDOMEN VASCULATURE ARTERIAL "Ligatable" arteries: Common and external carotid Subclavian, axillary Internal iliac Celiac axis, IMA ICA ligation 10-20% risk of CVA EIA, CFA, SFA ligation >> high risk limb ischemia SMA: gut necrosis VENOUS Almost all veins (including the IVC) can be ligated when needed

29. RIGHT MEDIAL VISCERAL ROTATION CLASSIC KOCHER: Duodenum from CBD to SMV  EXTENDED KOCHER: Infrahepatic IVC, renal hilum, right iliac  CATTELL-BRAASCH: Medial side of cecum, incise line of fusion small bowel mesentery and posterior peritoneum to ligament of Treitz

30. LEFT MEDIAL VISCERAL ROTATION(MATTOX) To approach: Midline supramesocolic area, aorta and branches To Start low and lateral Pull the colon towards you and move upward Rotate spleen, pancreas, left kidney toward the midline Sweep from below, upward and medial

31. PELVIC FRACTURE- BLEEDING CONTROL Pelvic binder External fixation Angiographic embolization Surgery rarely required Involves packing only

32. APPLICATION OF PELVIC CIRCUMFERENTIAL COMPRESSION DEVICE (BINDER) 

33. HEMORRHAGE CONTROL Renal pedicle injury/ shattered kidney : Palpate contralateral kidney before nephrectomy Pelvic : - B/L internal iliac artery ligation with packs.

34. LIMIT CONTAMINATION Linear stapling devices / Skin staplers Bowel clamps Umbilical tapes can all be used to control leakage. Non-circumferential holes in the bowel: defect quickly repaired with 2-0 or 3-0 silk sutures. Liberal Drainage Damage Control Surgery Karim Brohi , trauma.org 5:6, June 2000

35. ORGAN SPECIFIC: GIT control of haemorrhage prevention of further contamination by controlling spillage of gut contents. Small gastrotomies or enterotomies rapidly closed primarily with a single layer suture. Colonic injuries, multiple small bowel lesions - resect non-viable bowel, close the ends, re-look at 2nd procedure. - Linear stapler usage. - Ileostomy, colostomy avoided if abdomen to be left open

36. TEMPORARY ABDOMINAL CLOSURE (TAC) Skin only using towel clips Silastic Sheet Urobag Sterile-drapes Prolene Mesh Zippers Bogota Bag Velcro Vacuum Assisted Device

37. DAMAGE CONTROL THORACOTOMY Exposure : Antero-lateral thoracotomy/ Clamshell thoracotomy Strategies Pulmonary tractotomy Stapling of cardiac wounds Ligating or temporary bypassing main vessels Twisting the hilum & staged lobectomy/ pneumonectomy Stapling the hilum en masse Packing +/- Temporary closure of thorax- skin only

38. VASCULAR INJURY MANAGEMENT

39. DAMAGE CONTROL VASCULAR SURGERY FASCIOTOMY: To do when in doubt. Temporary intravascular shunts Soft tissue cover Stabilization of fractures bone: External fixator.

40. PHASE III: IN ICU The outcome of the patient is determined here. Not an average post-op patient Preparedness Leadership Multidisciplinary Team effort

41. PHASE III: RESUSCITATION DCR : This may only require 12h, many will require 24-36 h Require collaborative efforts of multiple critical care physicians, nurses, and ancillary staff.  GOAL : reverse the sequelae of hypotension related metabolic failure. Physiological and biochemical restoration. Adequate oxygen delivery to body tissues Intensive monitoring Aggressive core rewarming Aggressive approach to correction of coagulopathy Tertiary Survey

42. PHASE IV: DEFINITIVE SURGERY Timing is critical. With focused, critical care management and resuscitation one may obtain this physiological state within 24-36 hours.  To l ook for hidden injuries  To a ddress the definitive repair and tension free abdominal closure.

43. MISSED INJURIES The posterior portions of transverse mesocolon Hepatic and splenic flexures

44. COMPLICATIONS OF DCS ACS Enterocutaneous fistula Sepsis Pancreatic injury can be recognised by the presence of a tensely distended abdomen, elevated peak airway pressures, inadequate ventilation, hypoxia and oliguria or anuria.

45. ACS: ABDOMINAL COMPARTMENT SYNDROME Recognised by the presence of a tensely distended abdomen Elevated peak airway pressures Inadequate ventilation, hypoxia Oliguria or anuria. Normal intra-abdominal pressure is 0 cm of H 2 O. Pressure over 30 cm of H 2 O or 20mmhg is diagnostic.

46. SUMMARY:

47. TAKE HOME MESSAGE DCR is a vital part of the management should be performed before metabolic exhaustion. Delay in the decision to perform DCR contribute to a higher morbidity and mortality. Multidisciplinary approach and coordination among various teams gives best results. Preparedness for disaster is the key to successfully managing it.

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