Injury, Int. J.

Care Injured (2004) 35, 708—712

Damage control surgery in children

J. Hamill*

Trauma Service and the Department of Paediatric Surgery, Starship Children’s Hospital, Park Road,
Private Bag 92 024, Auckland, New Zealand

KEYWORDS Summary Whilst the principles of damage control are the same in paediatric surgery as
Abdominal injuries; in adults the unique qualities of children must be appreciated. Children are more
Acidosis; Compartment susceptible to hypothermia and multiple trauma. Technical aspects of the damage
syndromes; control laparotomy specific to children are outlined. Lessons learnt from damage
Damage control surgery; control in neonatal surgery are transferable to paediatric trauma.
ß 2004 Elsevier Ltd. All rights reserved.
Hypothermia;
Multiple trauma

Introduction vicious cycle.’’ This is statistically correlated with

hypothermia and acidosis.6 These three, coagulo-
The damage control approach is a paradigm shift pathy, hypothermia and acidosis form ‘‘the deadly
from definitive repair of all injuries to focused triad.’’
haemorrhage and contamination control and later
definitive repair as needed.18,21 In children the Hypothermia
principles of damage control surgery are the same
as in adults. Children are anatomically and physio- The adverse effects of hypothermia include cardiac
logically different to adults in many respects how- dysfunction (arrhythmias, decreased contractility),
ever (Table 1). Although most paediatric solid organ increased inotropic requirement, coagulopathy
injuries are successfully managed non-operatively, (suppressed enzymatic activity, platelet dysfunc-
expeditious damage control surgery is lifesaving for tion), left shift in the oxyhaemoglobin dissociation
the occasional child who presents with exsanguinat- curve (impaired oxygen delivery) worsening acido-
ing hepatic and/or vascular injuries. sis, and endotheliopathy with increased fluid leak.29
The present paper outlines the paediatric litera- With their small body mass and large surface area to
ture pertinent to damage control surgery and high- volume ratio, hypothermia rapidly ensues in infants
lights differences in the surgical care of the and children undergoing surgical procedures. Pre-
paediatric trauma patient. vention is essential (Table 2).

Acidosis
The deadly triad
Although not harmful per se, acidosis is a marker of
Massive haemorrhage and transfusion resulting in tissue hypoxia and a marker of mortality in paedia-
coagulopathy have been termed ‘‘the bloody tric (as in adult) trauma. An admission base deficit
of
10 meq./l in paediatric trauma patients corre-
*Tel.: þ64-9-3797440; fax: þ64-9-3078952. sponds to a mortality of 10% in non-head injured and
E-mail address: [email protected] (J. Hamill). 43% in head injured children.15
0020–1383/$ — see front matter ß 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2004.03.009
Damage control surgery in children 709

Table 1 Differences in children compared to adults Table 3 The three stages of damage control

Size smaller 1. Theatre–—damage control surgery

Surface area to volume ratio larger Rapid haemostasis
Thin skin Control contamination
Little subcutaneous fat Temporary abdominal closure
Elasticity of tissues greater
2. Intensive care–—resuscitation
Smaller thoracic and pelvic abdominal compartments
Re-warming
Small blood volume (80 ml/kg)
Correct shock–—optimise oxygen delivery
Heat loss rapid Correct coagulopathy
Multiple trauma the rule Correct acidosis
Internal organ injury without skeletal injury common Detect abdominal compartment syndrome
Haemostatic abilities of blunt liver and splenic
3. Theatre–—second look laparotomy
injuries greater
Definitive repair
Non-operative management of solid organ injury
Abdominal closure
common
Primary
Blood pressure maintained until hypovolaemia severe
Prosthetic
(>25—50%)

<5 years old. A traditional trauma midline incision is

The damage control approach appropriate for older children.

The need for damage control is often appreciated Rapid haemostasis–—abdominal packing
pre-operatively in the shocked trauma patient with
transient or no response to resuscitation, and is The liver in neonates is soft, ‘unforgiving’ and must
indicated intra-operatively by hypothermia, acido- be handled gently. Haemostasis is generally best
sis and small-vessel ‘oozing’ (coagulopathy) in the achieved by packing. The value of temporary
face of massive transfusion. The approach is three abdominal packing for haemostasis in damage con-
staged (Table 3). trol surgery is recognised in the paediatric litera-
ture.25—27 Stylianos reported 22 children aged 6 days
to 20 years, 13 of whom were trauma patients.
Damage control laparotomy Ninety percent were coagulopathic, hypothermic
and acidotic at the time of packing. Packs con-
trolled haemorrhage in 95%. Temporary abdominal
Laparotomy closure was required in 45%. Eighty-two percent
survived.26
In small children the thoracic and pelvic compart-
ments of the abdominal cavity are relatively shallow Control contamination
and the abdomen is wider than it is ‘long’. Good
exposure to the entire abdominal cavity is achieved In small children bowel resection is rapidly per-
with a transverse supraumbilical incision in children formed by using bipolar diathermy or non-toothed
forceps with monopolar diathermy to divide the
mesentery close to the bowel wall.
Table 2 Prevention of hypothermia in children The ‘clip and drop back’ technique has been
undergoing laparotomy developed in paediatric surgery for the rapid con-
trol of contamination, preservation of bowel length
Warm operating room and avoidance of stomas in cases of extensive bowel
Overhead radiant heater necrosis, perforations and peritonitis. Perforated/
Forced-air warming blanket under patient
necrotic bowel is resected and the ends closed with
Plastic sheets surrounding operative field to minimise
either large (12 mm) titanium clips or a linear sta-
evaporative heat loss
Cover head and limbs with wool or blankets pling device.28 Alternatively the bowel ends may be
Warm IV fluids tied or rapidly anastomosed.2 Intestinal continuity
Warm inhaled gases is achievable at subsequent laparotomy.
Warm irrigation fluids When a stoma is required, many paediatric sur-
Limit use of irrigation fluids geons will site the stoma at one corner of the
Expeditious laparotomy laparotomy wound which avoids a separate scar
on a small child’s abdomen.
710 J. Hamill

Temporary abdominal closure Acute respiratory distress syndrome occurs in 2—

14% of paediatric trauma patients and is related to
Paediatric surgeons pioneered techniques for tem- the severity of the injury.7 Lung protective venti-
porary abdominal closure in neonates with abdom- lator strategies should be utilised. These may
inal the wall defects. Gross, in 1948, described a include permissive hypercapnia, volume control,
technique for skin-only closure of large omphalo- incremental changes in positive end-expiratory
celes.12 Schuster used polyethylene sheets sewn to pressure and Fi02 as needed and prone positioning
the rectus muscle for staged closure.22 In the 1960s to address V/Q mismatch.7
prosthetic material was used primarily for closure of
large abdominal wall defects.1 Prosthetic material Abdominal compartment syndrome
sutured to the fascial edge is gradually reduced to
eventually achieve delayed primary closure.10 Pre-
formed spring-loaded silos of the type used for Clinical manifestations
gastroschisis closure have been recommended for In children with their thin compliant abdominal
rapid abdominal decompression in abdominal com- walls, a tense distended abdomen is an important
partment syndrome (ACS). When sutured to the indication of ACS.9,23 Also indicative are respiratory
fascial edges they are secure and provide good distress, tachycardia, raised peak inspiratory pres-
visualisation of underlying bowel.31 sures, increasing oxygen requirements, hypercapnia
A polypropylene mesh silo was used for tempor- and oliguria.9,20,23 Rectal prolapse has been
ary abdominal closure in a case of blunt transaction reported in a 4-year-old child with ACS from a
of the vena cava and right renal vein from a motor thoracoabdominal crush injury.9 Cyanosis of the
vehicle crash.8,9 A more rapid alternative, the Vac- lower extremities and absent femoral pulses may
Pac technique, has been successfully utilised in be present in severe acute ACS in children.14
children.3,19 This technique involves:
Objective measurement of intra-abdominal
1. A bowel bag with multiple perforations placed pressure
against the bowel and tucked under the perito- In Kron’s classic description of abdominal compart-
neum. ment syndrome in 1984 (in adults) abdominal
2. A moist surgical towel folded to fit the decompression was recommended when intra-
abdominal wall defect. abdominal pressure exceeded 20 mmHg.16 Prior to
3. Two large-bore soft flat silicone drains placed this, Wesley et al. used intragastric pressures mea-
over the towel and tunnelled beneath the skin surements to avoid cardiovascular and respiratory
to exit 3—5 cm from the skin edge. The drains compromise in infants during closure of abdominal
are joined by a Y-adaptor and placed under wall defects, aiming to keep intra-abdominal pres-
suction. sure <20 cmH2O (15 mmHg).30 Other groups, using
4. Skin is dried and painted with tincture of intragastric32,33 or bladder17 pressure monitoring,
benzoin. minimised complications from abdominal wall
5. A plastic polyester drape with iodophor-impreg- defect closure by maintaining intra-abdominal pres-
nated adhesive is applied taking care to obtain sure <20 mmHg.
an airtight seal.
CT findings in ACS
A rounded appearance of the abdomen on CT scan,
Resuscitation flattening of the cava, renal parenchymal compres-
sion and bowel wall enhancement, thickening and
Re-warming and optimisation of tissue perfusion dilatation are indicative of ACS.11 The bowel signs
and oxygen delivery takes place in the intensive are features of the ‘hypoperfusion complex’.24
care unit (ICU). Fluid resuscitation is best guided by
peripheral perfusion, urine output, blood pressure Abdominal decompression
and heat rate. The vast majority of children have Neville et al. found significant improvements in
healthy hearts. Central venous pressure (CVP) is oxygen requirement and peak inspiratory pressure
therefore a poor indication of intravascular volume after patch abdominoplasty for abdominal compart-
and attempts to raise the CVP to a predefined level ment syndrome in children. Various materials were
may lead to fluid overload, abdominal compartment used (see below under second look laparotomy).20
syndrome and cerebral oedema.29 The relative mer- De Cou et al. found release of ACS and placement of
its of crystalloid versus colloid fluid resuscitation a polypropylene mesh silo successful in a case of
are still debated.4 thoracoabdominal crush injury with lung, liver and
Damage control surgery in children 711

splenic injuries.9 Hobson et al. reported a 50% 2. Banieghbal B, Davies MR. Damage control laparotomy
for generalized necrotizing enterocolitis. World J Surg
survival in six children with extensive (67% body
2004;28:183—6.
surface area) third-degree burns and ACS. Two were 3. Barker DE, Kaufman HJ, Smith LA, et al. Vacuum pack
decompressed with a haemodialysis catheter and technique of temporary abdominal closure: a 7-year
the remainder with laparotomy and application of a experience with 112 patients. J Trauma 2000;48:201—7.
silastic sheet.13 4. Cocks AJ, O’Connell A, Martin H. Crystalloids, colloids and
kids: a review of paediatric burns in intensive care. Burns
1998;24:717—24.
Paracentesis for abdominal compartment 5. Corcos AC, Sherman HF. Percutaneous treatment of
syndrome secondary abdominal compartment syndrome. J Trauma
Intraperitoneal fluid contributes significantly to 2001;51:1062—4.
intra-abdominal pressure. Decompression of raised 6. Cosgriff N, Moore EE, Sauaia A, et al. Predicting life-
threatening coagulopathy in the massively transfused
intra-abdominal pressure has been achieved by
trauma patient: hypothermia and acidoses revisited. J
paracentesis.5,13,23 Sharpe et al. reported two cases Trauma 1997;42:857—61 [discussion 861-2].
of conservatively managed liver trauma, one in a 11- 7. Cullen ML. Pulmonary and respiratory complications of
year-old boy and the other in a 3-year-old girl, in pediatric trauma. Respir Care Clin N Am 2001;7:59—77.
which ACS was successfully treated by serial para- 8. DeCou JM, Abrams RS, Gauderer MW. Seat-belt transaction
centesis of the haemoperitoneum/ascites. In the of the pararenal vena cava in a 5-year-old child: survival
with caval ligation. J Pediatr Surg 1999;34:1074—6.
first case, the third paracentesis revealed a bile leak 9. DeCou JM, Abrams RS, Miller RS, Gauderer MW. Abdominal
which was treated with endoscopic biliary and per- compartment syndrome in children: experience with three
cutaneous peritoneal drainage.23 cases. J Pediatr Surg 2000;35:840—2.
10. de Lorimier AA, Adzick NS, Harrison MR. Amnion inversion in
the treatment of giant omphalocele. J Pediatr Surg 1991;
26:804—7.
Second-look laparotomy 11. Epelman M, Soudack M, Engel A, et al. Abdominal compart-
ment syndrome in children: CT findings. Pediatr Radiol
Second-look laparotomy is performed following suc- 2002;32:319—22.
cessful resuscitation. Packs are removed and defi- 12. Gross RE. A new method for surgical treatment of large
nitive repair performed. Fascia is primarily closed if omphaloceles. Surgery 1948;24:277.
13. Hobson KG, Young KM, Ciraulo A, et al. Release of
intra-abdominal pressure <20 mmHg is maintained. abdominal compartment syndrome improves survival in
If not, Silastic, polytetrafluorethylene (PTFE), patients with burn injury. J Trauma 2002;53:1129—33
absorbable synthetic and polypropylene sheets/ [discussion 1133-4].
meshes have all been utilised for temporary abdom- 14. Kawar B, Siplovich L. Abdominal compartment syndrome in
inal closure in children.20 Polypropylene mesh with children: the dilemma of treatment. Eur J Pediatr Surg
2003;13:330—3.
a self-adhesive polyethylene sheet lining its under- 15. Kincaid EH, Chang MC, Letton RW, et al. Admission base
surface, sutured to fascia with a strong nonabsorb- deficit in pediatric trauma: a study using the National
able monofilament is ideal. The day-by-day reduc- Trauma Data Bank. J Trauma 2001;51:332—5.
tion of this should permit delayed primary fascial 16. Kron IL, Harman PK, Nolan SP. The measurement of intra-
closure. abdominal pressure as a criterion for abdominal re-
exploration. Ann Surg 1984;199:28—30.
17. Lacey SR, Carris LA, Beyer III AJ, Azizkhan RG. Bladder
pressure monitoring significantly enhances care of infants
Conclusion with abdominal wall defects: a prospective clinical study. J
Pediatr Surg 1993;28:1370—4 [discussion 1374-5].
Although rarely required in paediatric trauma, the 18. Mattox KL. Introduction, background, and future projec-
tions of damage control surgery. Surg Clin North Am
damage control approach is life-saving when 1997;77:753—9.
applied to the right patient expeditiously. Every 19. Markley MA, Mantor PC, Letton RW, Tuggle DW. Pediatric
attempt should be made to avoid hypothermia, vacuum packing wound closure for damage-control lapar-
achieve surgical control of massive haemorrhage otomy. J Pediatr Surg 2002;37:512—4.
and contamination and avoid abdominal compart- 20. Neville HL, Lally KP, Cox Jr CS. Emergent abdominal
decompression with patch abdominoplasty in the pediatric
ment syndrome. For adult surgeons treating pae- patient. J Pediatr Surg 2000;35:705—8.
diatric trauma patients, early consultation with a 21. Rotondo MF, Zonies DH. The damage control sequence
paediatric surgeon is recommended. and underlying logic. Surg Clin North Am 1997;77:761—
77.
22. Schuster SR. A new method for the staged repair of large
omphaloceles. Surg Gynecol Obstet 1967;123:837—50.
References 23. Sharpe RP, Pryor JP, Gandhi RR, et al. Abdominal compart-
ment syndrome in the pediatric blunt trauma patient
1. Allen RG, Wrenn EL. Silon as a sac in the treatment of treated with paracentesis: report of two cases. J Trauma
omphalocele and gastroschisis. J Pediatr Surg 1969;4:3—8. 2002;53:380—2.
712 J. Hamill

24. Sivit CJ, Taylor GA, Bulas DI, et al. Posttraumatic shock in 30. Wesley JR, Drongowski R, Coran AG. Intragastric pressure
children: CT findings associated with hemodynamic instabil- measurement: a guide for reduction and closure of the
ity. Radiology 1992;182:723—6. silastic chimney in omphalocele and gastroschisis. J Pediatr
25. Stylianos S, Jacir NN, Hoffman MA, Harris BH. Pediatric Surg 1981;16:264—70.
blunt liver injury and coagulopathy managed with packs and 31. White JJ, Haller Jr JA. Routine insertion of a silastic
a silo: case report. J Trauma 1990;30:1409—10. springloaded silo for infants with gastroschisis. J Pediatr
26. Stylianos S. Abdominal packing for severe hemorrhage. J Surg 2000;35:1014.
Pediatr Surg 1998;33:339—42. 32. Yaster M, Buck JR, Dudgeon DL, et al. Hemodynamic effects
27. Stylianos S. Liver injury and damage control. Semin Pediatr of primary closure of omphalocele/gastroschisis in human
Surg 2001;10:23—5. newborns. Anesthesiology 1988;69:84—8.
28. Vaughan WG, Grosfeld JL, West K, et al. Avoidance of stomas 33. Yaster M, Scherer TL, Stone MM, et al. Prediction of
and delayed anastomosis for bowel necrosis: the ‘clip and successful primary closure of congenital abdominal wall
drop-back’ technique. J Pediatr Surg 1996;31:542—5. defects using intraoperative measurements. J Pediatr Surg
29. Wetzel RC, Burns RC. Multiple trauma in children: critical 1989;24:1217—20.
care overview. Crit Care Med 2002;30:S468—77.