Residency · Residency · General Surgery

Damage Control Surgery

Overview

Damage control surgery is an abbreviated surgical intervention focused on hemorrhage control and contamination control, with definitive repair deferred to a later time. It is designed to break the "lethal triad" of hypothermia, acidosis, and coagulopathy. The approach consists of three phases: damage control surgery in the operating room, resuscitation in the ICU, and definitive repair at planned reoperation. The principles of damage control surgery apply to trauma, emergency general surgery, and vascular emergencies.

The Lethal Triad

Hypothermia (core temperature below 35 degrees Celsius) impairs coagulation factor function, platelet aggregation, and cardiac function. Acidosis (pH below 7.2, base deficit greater than -6) impairs clotting factor activity, reduces cardiac contractility, and causes vasodilation. Coagulopathy may be dilutional (from crystalloid resuscitation), consumptive (from disseminated intravascular coagulation), hypothermia-induced, or due to factor depletion. Each component worsens the others in a vicious cycle. Once the triad is fully established, it is very difficult to reverse, which is why damage control surgery aims to prevent its development in the first place.

Indications for Damage Control Laparotomy

Damage control laparotomy is indicated when hemodynamic instability persists despite resuscitation, when there is severe metabolic derangement (pH below 7.2, base deficit greater than -15, lactate above 5 mmol/L), when core temperature falls below 35 degrees Celsius, when clinical coagulopathy with non-mechanical bleeding is present, when massive transfusion (more than 10 units of packed red blood cells) is required, when definitive repair cannot be completed due to time pressure or the patient's physiology, when complex injuries would require prolonged operative time, or when reassessment of bowel viability (second-look) is needed.

<image>The lethal triad diagram showing the interrelationship between hypothermia, acidosis, and coagulopathy and how damage control surgery interrupts this cycle</image>

Phase 1: Damage Control Surgery in the OR

Goals

The goals of Phase 1 are to control hemorrhage, control contamination from bowel spillage, achieve temporary closure of the abdomen, and get out of the operating room as quickly as possible.

Hemorrhage Control Techniques

Packing is one of the most effective maneuvers, with perihepatic packing being the most common application. Laparotomy pads are placed to apply direct pressure on bleeding surfaces, and packing is highly effective for venous and parenchymal bleeding. Vessel ligation is performed when repair is not feasible, and for critical vessels such as the iliac artery, a temporary shunt should be considered. Temporary vascular shunts maintain distal perfusion until definitive repair at reoperation, using devices such as Pruitt-Inahara shunts, Argyle shunts, or improvised shunts. Splenectomy is faster than repair in the damage control setting. Nephrectomy is appropriate for grade V renal injuries with hemodynamic instability. For hepatic hemorrhage, the Pringle maneuver (compression of the porta hepatis) is used along with packing, direct suture, and balloon tamponade. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) serves as a temporizing measure: Zone I (supraceliac) for abdominal or pelvic hemorrhage, and Zone III (infrarenal) for pelvic hemorrhage, maintaining proximal perfusion while achieving surgical control.

Contamination Control

Bowel injuries are managed with rapid stapled resection without anastomosis, leaving the bowel in discontinuity. Primary anastomoses are not performed during damage control surgery because the high leak risk from edema, coagulopathy, and hypothermia makes them unsafe. Enterotomies are rapidly closed with suture or staple. Pancreatic injuries are managed with wide drainage, with definitive management deferred. Biliary injuries are managed with external drainage.

Abbreviated Techniques

Liver injuries are managed with packing, hemostatic agents (topical thrombin, fibrin sealant), and mesh hepatorrhaphy. Pancreatic injuries receive drainage only with no resection during damage control, except for distal pancreatectomy if it can be performed rapidly. Ureteral injuries are managed by ligation with later nephrostomy or by temporary stenting. Bladder injuries receive simple suture closure or catheter drainage. Duodenal injuries may be managed with tube duodenostomy or delayed pyloric exclusion.

Phase 2: ICU Resuscitation

Goals

The goals of Phase 2 are to correct the lethal triad and optimize the patient's physiology for planned return to the operating room in 24-72 hours.

Resuscitation Priorities

Rewarming uses forced-air warming (Bair Hugger), warmed IV fluids, and warmed ventilator gases, with a target core temperature above 36 degrees Celsius. Severe hypothermia may require pleural or peritoneal lavage with warm saline, or rarely ECMO. Acidosis is corrected by optimizing oxygen delivery, volume resuscitation, and vasopressor support. Bicarbonate infusion is avoided as it is only a temporary fix, and the underlying cause should be addressed. Serial lactate and base deficit guide assessment of resuscitation adequacy. Coagulopathy is corrected using guidance from viscoelastic testing (TEG/ROTEM), with FFP, cryoprecipitate when fibrinogen is below 150 mg/dL, and platelets administered as needed. Calcium is replaced to maintain ionized calcium above 1.0 mmol/L, as citrate in blood products chelates calcium. Tranexamic acid is administered if hyperfibrinolysis is detected. Ongoing monitoring includes serial arterial blood gases, lactate, hemoglobin, coagulation studies, electrolytes, and urine output.

Endpoints of Resuscitation

Endpoints include normalizing or downward-trending lactate, improving base deficit, core temperature above 36 degrees Celsius, correction of coagulopathy (INR below 1.5, fibrinogen above 150, platelets above 50,000), adequate urine output (greater than 0.5 mL/kg/hr), and hemodynamic stability without escalating vasopressors.

Phase 3: Definitive Repair (Planned Reoperation)

Timing

Definitive repair typically occurs 24-72 hours after damage control surgery, once physiology is optimized. Patients should not return to the operating room until the lethal triad is corrected. Multiple reoperations may be required for complex injuries.

Procedures

At reoperation, packing is removed and the abdomen is assessed for ongoing hemorrhage. Temporary vascular shunts are replaced with definitive vascular repairs. Bowel anastomosis or diversion with ostomy creation is performed. Duodenal, pancreatic, and biliary injuries receive definitive repair. Bowel viability is reassessed (second-look for questionable segments). Definitive abdominal wall closure is performed if possible, and the abdominal cavity is washed out.

<image>Three phases of damage control surgery: Phase 1 (abbreviated laparotomy with packing and contamination control), Phase 2 (ICU resuscitation correcting the lethal triad), and Phase 3 (definitive repair and closure)</image>

Temporary Abdominal Closure (TAC)

Indications

Temporary abdominal closure is indicated after damage control laparotomy, for abdominal compartment syndrome, when planned reoperation or second-look is needed, and when the abdomen cannot be closed due to visceral edema.

Techniques

Negative pressure wound therapy (NPWT/VAC) is the preferred technique, using a visceral protective layer, sponge, adhesive drape, and suction. Options include the Barker's VAC (original), ABThera, or improvised systems. NPWT prevents lateral fascial retraction, controls edema, allows quantification of fluid output, and achieves delayed primary fascial closure in 60-80% of cases. The Bogota bag, a sterile IV bag sewn to the skin edges, is simple but lacks suction and has been largely replaced by NPWT. The Wittmann patch uses a Velcro-like system that allows sequential tightening toward fascial closure. Skin-only closure with towel clips or running suture is a simple alternative.

Fascial Closure

The goal is primary fascial closure at the earliest safe opportunity. Delay beyond 7-10 days significantly reduces successful fascial closure rates. Sequential NPWT changes with progressive fascial approximation are performed. If delayed primary closure is impossible, the management plan becomes a planned ventral hernia with skin grafting of the granulation tissue, followed by definitive abdominal wall reconstruction at 6-12 months.

Abdominal Compartment Syndrome (ACS)

Definition

Abdominal compartment syndrome is defined as a sustained intra-abdominal pressure greater than 20 mmHg with new organ dysfunction. | IAH Grade | Intra-abdominal Pressure | Management |

Intra-abdominal hypertension is defined as intra-abdominal pressure of 12 mmHg or greater and is graded as Grade I (12-15), Grade II (16-20), Grade III (21-25), and Grade IV (greater than 25 mmHg).

Measurement

Bladder pressure is measured by instilling 25 mL of saline into the Foley catheter and transducing at the level of the symphysis pubis. The measurement is taken at end-expiration in the supine position.

Clinical Effects

ACS causes decreased cardiac output from reduced venous return due to IVC compression, respiratory failure from an elevated diaphragm and decreased compliance, renal failure from renal vein compression and decreased renal perfusion, mesenteric ischemia, and increased intracranial pressure.

Management

Medical management includes nasogastric decompression, sedation and paralysis, diuresis, and percutaneous drainage of abdominal collections. Surgical decompression (decompressive laparotomy) is indicated for ACS refractory to medical management or with progressive organ failure. Prophylaxis involves avoiding primary fascial closure in patients with massive resuscitation, severe visceral edema, or when closure would be tight.

<image>Temporary abdominal closure with negative pressure wound therapy (VAC system) showing the visceral protective layer, foam dressing, adhesive drape, and suction setup</image>

Damage Control in Non-Trauma Settings

Damage control principles apply equally to emergency general surgery (perforated viscus with sepsis, mesenteric ischemia), ruptured abdominal aortic aneurysm, and necrotizing soft tissue infections (which require serial debridements). The approach is the same: abbreviated initial procedure, ICU optimization, and definitive repair at a later time.

Clinical Pearls

The decision to perform damage control surgery should be made early, ideally before the lethal triad fully develops, rather than waiting until the patient is in extremis. The goal of damage control surgery is to keep the patient alive, not to fix everything, and the temptation to perform definitive repair in a dying patient must be resisted. Bowel anastomosis should never be performed during damage control, as the combination of hypothermia, acidosis, and coagulopathy guarantees a high leak rate. Perihepatic packing is one of the most effective maneuvers in damage control and is vastly underused by junior surgeons. Successful fascial closure rates decline dramatically after 7-10 days of open abdomen, so serial NPWT changes with progressive fascial approximation should be planned. Abdominal compartment syndrome should be monitored for in any patient receiving massive resuscitation, and bladder pressure measurement should be routine in the ICU. Calcium is the "forgotten" electrolyte in massive transfusion because citrate in blood products chelates calcium, and ionized calcium must be maintained above 1.0 mmol/L.

References

• Rotondo MF, et al. "Damage control": An approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375-383.
• Balogh ZJ, et al. Abdominal compartment syndrome and intra-abdominal hypertension. J Trauma. 2014;76(4):1116-1125.
• Roberts DJ, et al. Negative-pressure wound therapy for critically ill adults with open abdominal wounds: A systematic review. J Trauma Acute Care Surg. 2012;73(3):629-639.
• Kirkpatrick AW, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: Updated consensus definitions. Crit Care Med. 2013;41(5):1321-1328.
• Brenner M, et al. Use of resuscitative endovascular balloon occlusion of the aorta for proximal aortic control in patients with severe hemorrhage. JAMA Surg. 2018;153(2):130-135.

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