Damage Control Surgery

PRINCIPLES OF TRAUMA LAPAROTOMY
AND DAMAGE CONTROL SURGERY
DR LAWAL GBENGA DAMILARE
REGISTRAR, DEPARTMENT OF SURGERY
NATIONAL HOSPITAL ABUJA
02/10/2015

OUTLINE
 INTRODUCTION
 RELEVANT ANATOMY
 PRINCIPLES OF TRAUMA LAPAROTOMY
 DAMAGE CONTROL SURGERY
 COMPLICATIONS
 CONCLUSION

INTRODUCTION
 Laparotomy is an abdominal surgery performed using
the traditional full size incision rather than a minimally
invasive approach
 Exploratory laparotomy allows adequate access to
examine abdominal tissues and organs when a
diagnosis has not been made
 When done following a trauma, it is undertaken after
evidence of intraabdominal haemorrhage(a positive
FAST, DPL, or other overwhelming evidence of internal
haemorrhage) or peritonitis

RELEVANT ANATOMY
 Anterior abdomen
 Flank
 Back
 Intraperitoneal contents
 Retroperitoneal space contents
 Pelvic cavity contents

o Anterior abdomen:
trans-nipple line, , anterior
axillary lines, inguinal
ligaments and symphysis
pubis.
o Flank:
anterior and posterior
axillary line ;sixth intercostal
to iliac crest
o Back:
posterior axillary line; tip of
scapula to iliac crest

 Peritoneal cavity:
upper-diaphragm, liver,
spleen, stomach, and
transverse colon; lower-small
bowel, sigmoid colon
 Retroperitoneal space:
aorta, inferior vena cava,
duodenum, pancreas,
kidneys, ureters,ascending
and descending colons
 Pelvic cavity:
rectum, bladder, iliac vessels
and internal genitalia

MECHANISM
 Blunt trauma:
 MVC
 Seatbelt injury
 fall from height
 crash injury
 sport injury
 Blast injury

MECHANISM
Penetrating injuries.
 stab wound,
 gunshot
 blast injury

Blunt abdominal injuries carry a greater risk of morbidity
and mortality than peneterating abdominal injuries.;
 associated with severe trauma to multiple intraperitoneal
organs and extra-abdominal systems
 altered mental status, intoxication
 Peritoneal signs are often subtle and may be obscured by
other painful injuries
 Up to 20% of patients with hemoperitoneum have benign
abdominal exams on initial presentation.

 BLUNT ABDOMINAL INJURY
• Spleen (40-55%)
• Liver (35-45%)
• Small bowel (5-10%)
• Retroperitoneal hematoma: 15%

Clinical Indications for Laparotomy
Following Penetrating Trauma

Clinical Indications for Laparotomy
after Blunt Trauma

PRINCIPLES OF TRAUMA
LAPAROTOMY

PERIPROCEDURAL CARE
PREPROCEDURAL PLANNING
The patient's physiologic status at laparotomy
is an important determinant of outcome.
• Optimize whenever possible - correction of fluid
and electrolyte imbalances, blood transfusions,
oxygen support
• Nasogastric tube
• Urethral catherization

Equipment
 operating room (OR) - anesthetic equipment,
overhead lights, electrodiathermy equipment,
and suctioning systems.
 standard laparotomy tray
 vascular instruments - If vascular intervention is
anticipated, may be required.
 If major abdominal organ resection may be
needed, appropriate instruments, facilities, and
expertise should be available

Patient preparation
 Anesthesia - general anesthesia, cuffed ET, adequate
muscle relaxant
 Positioning - supine position, with the arms abducted at
right angles to the body.
- The lithotomy position may be employed instead when
a pelvic pathology is suspected and a simultaneous
vaginal or rectal intervention is necessary.

OPERATIVE SEQUENCE
Access and exposure
↓
Temporary hemorrhage control
↓
Exploration
Definitive Repair Damage Control

Access
 MIDLINE INCISION –
XYPHISTERNUM TO PUBIS
 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

Once Inside…
 Evisceration
 Up and to the right, remove clot/blood
 Blunt trauma
 Empiric, yet directed packing
 Penetrating trauma
 Direct hemorrhage control
 Exsanguinating hemorrhage
 Supraceliac aorta

Empiric Packing
 Right upper quadrant—Above and below liver
 Right gutter
 Left upper quadrant—Above and medial to spleen
 Left gutter
 Pelvis

Survey
 Survey solid organs, look back at the
eviscerated bowel, start making decision
 Difficult situations :
 Combined major vascular / viscus injuries
 Penetrating injury to the aorta
 High-grade liver injury
 Pelvic fracture with expanding hematoma
 Injuries requiring surgery in another cavity

Explore
 Divide the peritoneal cavity at the transverse
mesocolon
 Supramesocolic
 Liver, stomach, spleen
 Inframesocolic
 Small bowel, colon, bladder, female reproductive
organs

Supramesocolic Exploration
 Move transverse colon caudad
 Inspect and palpate
 Liver, Gall bladder
 Stomach to GE junction and diaphragms
 Duodenum
 Spleen, left kidney
 Lesser sac

Inframesocolic Exploration
 Lift transverse mesocolon cranially
 Run the gut
 Visualize the pelvis and female reproductive
organs

BRIEF DESCRIPTION OF SPECIFIC ORGAN INJURIES
Diaphragm
 Penetrating injuries to the diaphragm are graded as
follows:
 (I) Contusion
 (II) Laceration, < 2 cm
 (III) Laceration, 2-10 cm
 (IV) Laceration, >10 cm
 (V) Total tissue loss, >25 cm2
 Lower-grade injuries may be repaired either via
laparotomy – nonabsorbable sutures ± CTTD

Liver
Liver injuries are also classified by grade
 (I) Non bleeding capsular tears, < 1 cm deep
 (II) Lacerations, 1-3 cm deep and < 10 cm long
 (III) Laceration, >3 cm deep
 (IV) Parenchymal disruption involving 25-75% of a lobe or 1-3
segments
 (V) Parenchymal disruption of >75% of a lobe or >3 segments or
juxtahepatic venous injury
 (VI) Hepatic avulsion

Liver
 Simple lacerations - direct pressure, electrocautery, or topical
hemostatic agents. cautery, sutures, clips, or stapler device
 The Pringle maneuver - more serious injuries
The laceration may then be approached with finger
fracture and direct ligation of the bleeding vessels. After
obtaining hemostasis, the laceration is often tamponaded
with a vascularized omental flap.

Spleen
 On the basis of the patient's hemodynamic status,
comorbidities, and operative access, the surgeon will
plan for splenorrhaphy or splenectomy.
 Splenorrhaphy includes electrocautery, topical
hemostatic agents, compressive mesh, or partial
splenectomy.
 Penetrating injuries to the spleen can cause significant
bleeding.
 Irreparable vascular injuries, including total avulsion and
extensive lacerations, are indications for splenectomy.

Stomach
 Exposure and thorough inspection of the stomach is
necessary to evaluate and treat penetrating injuries to
the stomach.
 This is facilitated by opening of the gastrocolic ligament,
which allows entrance into the lesser sac.
 Injuries repaired with a stapling device or vicryl sutures

Colon
The management of colonic injuries depends on:
 the extent of the defect,
 the amount of contamination,
 and the stability of the patient.
 Primary repair may be considered if the patient is
hemodynamically stable and if the injury is fairly small with
minimal fecal contamination.

Colon
A diverting colostomy should be performed if the patient has
any of the following:
 Multiple injuries
 Requirement for significant blood product resuscitation
 Acidosis, hypothermia, and coagulopathy
 A large defect (>50% of the circumference) and
considerable fecal spillage

Duodenum
Injuries to the duodenum are graded as follows:
 (I) Hematoma
 (II) Partial-thickness laceration
 (III) Laceration disrupting < 50% circumference of D1, D3, or
D4, or 50-75% circumference of D2
 (IV) Laceration disrupting 50-100% circumference of D1, D3, or
D4, or >75% circumference of D2, or involving the ampulla or
distal common bile duct
 (V) Massive disruption of the duodenopancreatic complex or
devascularization of the duodenum

Duodenum
 The Kocher maneuver is used to mobilize the duodenum, along with
the pancreatic head and distal common bile duct, so that penetrating
injuries can be fully explored.
 Primary repair of injury is the goal, with protection of the repair using
closed-suction drainage.
 Duodenal diverticulization diverts biliary and pancreatic secretions
using T-tube drainage and gastric decompression with a gastrostomy.
 Pyloric exclusion involves closure of the pylorus with non absorbable
suture with bypass via gastrojejunostomy.
 Grade V injuries require pancreaticoduodenectomy, which is often
done as a staged procedure in the unstable trauma patient.

Pancreas
 Most pancreatic injuries are diagnosed intraoperatively.
 Pancreatic duct status and injury location are determinants in
the management of pancreatic injuries.
Pancreatic injuries are graded according to the presence or
absence of ductal injuries, as follows:
 (I) Superficial laceration or minor contusion without ductal
injury
 (II) Major laceration or contusion without ductal injury
 (III) Distal transections without duct injury or tissue loss
 (IV) Proximal transection or parenchymal injury involving the
ampulla
 (V) Massive disruptions of the pancreatic head

Pancreas
 Grade I and II injuries can be managed conservatively
 grade III injuries are best treated with distal
pancreatectomy and splenectomy
 Grade IV injuries require near total pancreatectomy with
reconstruction of pancreatic drainage into the
gastrointestinal tract with either Roux-en-Y
pancreaticojejunostomy or pancreaticogastrostomy

Retroperitoneal Exploration
 Clinical suspicion
 Duodenal hematoma? Mobilize to see
duodenum and pancreatic head
 Colon injury? Mobilize to check posterior wall
and adjacent ureter
 Limited exposure of relevant structures—
medial visceral rotation

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

LEFT (MATTOX MANEUVER)
 Kidney up or kidney down?
 Periaortic tissues
 Left lumbar vein
 Branch of left renal vein, crosses left lateral aorta
immediately below left renal artery

RIGHT MEDIAL VISCERAL ROTATION
(CATTELL-BRAASCH MANEUVER)
 Cattell-Braasch
 Medial side of cecum, incise line of fusion small
bowel mesentery and posterior peritoneum to
ligament of Treitz

KOCHER MANEUVER
 Classic Kocher
 Duodenum from CBD
to SMV
 Extended Kocher
 Infrahepatic IVC,
renal hilum, right iliacs

Kidney
Injuries to the kidney are graded according to severity, as follows:
 (I) Contusion
 (II) Lacerations, < 1 cm
 (III) Lacerations, >1 cm
 (IV) Lacerations to the collecting system
 (V) Vascular avulsion
 The kidney is salvaged with renography, using pledgeted sutures
and wrapping, and capsular reapproximation if possible.
 Nephrectomy - severe injury or instability of the patient
(intraoperative intravenous pyelogram to confirm function of the
contralateral kidney)

VASCULAR CONTROL
 Zone 1
 Supramesocolic—Proximal
aorta
 Inframesocolic—Infrarenal
aorta
 Zone 2
 Proximal control of renal
pedicle
 Zone 3
 Expose bifurcation, control
common iliacs, distal
external iliacs

VASCULAR CONTROL
VENA CAVA
 Suprahepatic
 Median sternotomy with pericardiotomy
 Infrahepatic
 Right to left medial visceral rotation

DAMAGE CONTROL SURGERY
„The modern operation is safe for the
patient. The modern surgeon must make
the patient safe for the modern operation“
Lord Moynihan

INTRODUCTION
 Also known as ‘staged laparotomy’, ‘Bailout surgery’
 The most technically demanding and challenging surgery a trauma
surgeon can perform.
 The concept of ‘damage control’ has as its objective the delay in
imposition of additional surgical stress at a moment of physiological
frailty.
 The primary reason is to minimize hypothermia and metabolic
acidosis in other to prevent coagulopathy,
 Multiple trauma patients (ISS ≥35) are more likely to die from their
intra-operative metabolic failure than from a failure to complete
operative repairs

The trauma triad of death:
- Hypothermia
- Acidosis
- Coagulopathy

Hypothermia:
 Clinically important if less than 36*C for more than 4 hr
 Can lead to cardiac arrhythmias, decreased cardiac
output, increassed systemic vascular resistance
 Can induce and exacerbate coagulopathy by inhibition of
clotting cascade reaction

Acidosis:
 Uncorrected haemorrhagic shock leads into inadequate
cellular perfusion, anaerobic metabolism and the
production of lactatic acid
 Interferes with blood clotting mechanisms and promotes
coagulopathy and blood loss

Coagulopathy:
 Hypothermia, acidosis and the consequences of massive
blood transfusion all lead to the development of a
coagulopathy
 Platelet dysfunction at low temperature
 Activation of the fibrinolytic system
 Haemodilution following massive resuscitation

PARAMETERS as a guideline for instituting damage control:
 pH less then or equal to 7.2
 serum bicarbonate level less than or equal to
15 mEq/L
 core temperature less than or equal to 34*C
 transfusion volume of packed RBCs more than
or equal to 4000 ml
 total blood replacement more than or equal to
5000 ml
 total fluid replacement more than or equal to
12 000 ml
If all - death
If one - DCS

PRINCIPLES OF DAMAGE CONTROL SURGERY
These are:
 Control haemorrhage
 Prevention contamination
 Avoid further injury

NOTE:
 Time is of essence
 Minimum investigations
 Rapid transport to the operating room without repeated
attempts to restrore circulating volume- surgery is part of
the resuscitation

STAGE 1 (OF DCS)
 initial laparotomy
 identify the main source of bleeding
 perihepatic packing (superior and inferior)
 small gastotomies and enterotomies can be rapidly closed
 resect non-viable bowel and close the ends
 minor pancreatic injuries not involving duct - NO TREATMENT
 distal injury including the panceratic duct - DISTAL PANCREATECTOMY
 abdominal closure is rapid and temporary- towel clips, vacuum-pack
technique, intravenous or silo bag, polypropelene mesh. (if there is any
doubt about abdominal compartment syndrome, leave open)

TEMPORARY CLOSURE WITH TOWEL CLIPS

TEMPORARY CLOSURE WITH SILO BAG

STAGE 2
 Begins in ICU
 The next 24 to 48 hours are crucial
 Correction of metabolic disorder
 Core rewarming
 Correction of coagulopathy
 Complete ventilatory support
 Correction of acidosis

STAGE 3
 Window of opportunity is 24-48 hours after the trauma
 Removal of the abdominal packs
 Primary repair with end-to-end anastomosis undertaken
 Copious washout should be performed and the abdomen
closed
The patient sometimes needs early unplanned reoperation
ongoing haemorrhage, abdominal compartment syndrome
or peritonitis

COMPLICATIONS
 Abdominal compartment syndrome
 General copmlications:
 wound sepsis
 wound dehiscence
 intra abdominal abscess
 enteric fistula formation
 ICU-related infections
 pneumonia

CONCLUSION
 Laparotomy is mandatory if shock, evisceration, or
peritonitis is present
 The accuracy of physical examination is limited in cases
of blunt and penetrating trauma. It is less reliable by
distracting injury, altered sensorium
 Clinical indications for laparotomy are more dependable
and more frequently applicable to cases of penetrating
trauma than cases of blunt trauma.

CONCLUSION
 Damage Control is a principle of staged operative
management with control and resuscitation prior to
definitive repair
 Abdominal compartment syndrome is a common
problem in abdominal trauma, and its better anticipated
and prevented

REFERENCES
 Schwartz principles of surgery, 10th ed.
 Sabiston textbook of surgery, 19th ed.
 www.ncbi.nlm.nih.gov.pubmed.
 www.emedicine.medscape.com
 www.trauma.org
 ATLS student manual 9th ed.

Damage Control Surgery

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