Presentation on theme: "The Concept of Damage Control Surgery"— Presentation transcript:
1 The Concept of Damage Control Surgery Dr. Derek TL FungDepartment of SurgeryQueen Elizabeth Hospital
2 Damage Control Surgery (DCS) Multiple abdominal traumaThoracic injuryVascular surgeryOrthopaedicsAbdominal sepsis
3 Damage ControlOriginated in the US Navy, refers to the capacity of a ship to absorb damage and maintain mission integrity
4 In 1970s & 1980s, surgeons tended to perform complex and lengthy operation in multiple trauma case Extensive resectionExtensive reconstructionAggressive resuscitationExtracorporeal support
5 History Idea originated from liver trauma Pringle published a case series of packing liver injuries in 1908Pringle JH. V. Notes on the Arrest of Hepatic Hemorrhage Due to Trauma. Ann Surg Oct;48(4):541-9.Calne in 1979 published a series of liver trauma patients whose abdomens were packed prior to transfer and definitive surgery at another centreCalne RY, McMaster P, Pentlow BD. The treatment of major liver trauma by primary packing with transfer of the patient for definitive treatment. Br J Surg May;66(5):338-9.
6 Stone et al.Coagulopathy in trauma patient leads to exsanguination and mortalityIn his series, 31 patients with major bleeding tendency11 out of 17 patient who was managed with packing and staged re-laparotomy survived.1 out of 14 patients with standard treatment survivedStone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg May;197(5):532-5.
7 Rotondo et al.Rotondo and co-workers published a further series and coined the phrase ‘damage control surgery’ in 19937-fold of improvement in survival in a subgroup of patient with major vascular injury and 2 or more visceral injuries if they were managed with damage control approach10/13 (77%) survived with damage control surgery1/9 (11%) with traditional definitive laparotomyRotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, Latenser BA, Angood PA. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma Sep;35(3):375-82; discussion 382-310/13 Vs 1/9
9 Hypothermia Central thermoregulation lost Platelet dysfunction Metabolic activityCold IV fluidPlatelet dysfunctionClotting factors kinetics disturbanceCardiac dysfunctionVasoconstrictionHypoperfusion
10 Acidosis Cardiac contractility Dysrhythmias Synergize with hypothermia in its detrimental effect on the coagulation cascade
11 Coagulopathy Uncontrolled bleeding from all cut surfaces Platelet dysfunctionClotting cascade disturbedHaemodilution
12 6 causes: tissue trauma, shock, hemodilution, hypothermia, acidemia, and inflammation.Hypoperfusion->inflammatory and metabolic change->acidosis-> affect innate coagulation systemconsumptive coagulopathyhypothermia begins to have an impact on the body’s ability to alter fibrin and form clots.
13 Principles of DCSQuickly abort the vicious cycle by haemorrhage and contamination controlMinimize further trauma created by SurgeonRestore normal physiology before definitive surgery in reoperation
14 Stages of Damage Control Surgery 1. Patient selection2. Intraoperative stage3. Critical care stage4. Return to the operating theatre5. Formal closureMoore EE. Thomas G. Orr Memorial Lecture. Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am J Surg Nov;172(5):
16 Other factors to be consideredno No definitive†standard†to†allow†objective†evaluation†when†abbreviated laparotomy†is†necessary¨†as†different†authors†have†different†criteriaRotondo M, Zonies D. The damage control sequence and underlying logic. Surg Clin N Am 1997; 77:
17 No Definite Selection Criteria Too Liberal Unnecessary staged operationToo Strict Adverse physiological outcome established Too late to salvageExperience, rapid surgical assessment and liaison with anesthetist are the keys in decision making
18 Stage 2: Intraoperative Aim:Controlling HaemorrhageLimiting contaminationHaemorrhage control may be achieved by ligation, suture, tamponade (by packing or balloon), or shunting. Definitivevascular repair by grafting or anastomosis is not considered a DCS procedure.
20 Solid organ injuries management should be similarly directed at achieving haemorrhage control. This may be by removal without attempt at preservation in those organs where this is feasible (such as the spleen and kidney) or by therapeutic packing such as in the liver,Packing the liver is most effectively accomplished by packing pads above the liver under the costal margin and under both the right and left hepatic lobes
21 Bowel ends are closed without attempt to regain gastrointestinal continuity, by tapes, staples or suture.
22 duodenum and bile duct may be dealt with by simply placing drainage tubes to control leakage
23 exsanguinating from pelvic trauma pre-peritoneal pelvic packing can be performed to gain control of bleeding.
25 Risk of abdominal compartment Syndrome Ineffective Drainage Skin approximation by suture/ clipsBogota bag/ silo bagAbsorbable/ non-absorbable meshRisk of abdominal compartment SyndromeIneffective Drainage
26 Negative Pressure Therapy System, eg. VAC 3 layers: protective barrier against the viscera, surgical towel, drains, and occlusive adhesive drape
27 Negative Pressure Therapy Evacuation of abdominal fluidMinimize risk of Intra-abdominal hypertensionLow fistula ratesGood early closure rates
28 Stage 3: Critical Care Stage Active rewarmingCorrection of AcidosisCorrection of CoagulopathyMonitor the need for early return to theatreOngoing surgical bleedingAbdominal compartment syndrome
29 Stage 4: Return to the Theatre Timing:24-48hrs later whenBase deficit < 4 mmol/LLactate of < 2.5 mmol/LCore temperature > 35 CINR < 1.25
30 Stage 4: Return to the Theatre Definitive surgeryRemoval of packsAnastomoses or stomasVascular repairsSolid organ debridementPlacement of feeding tube
31 Stage 5: Formal ClosureMay not be feasible due to significant bowel edema or risk of abdominal compartment syndrome% closure rate in the 1st reoperationHirshberg A, Wall MJ, Mattox KL. Planned reoperation for trauma: a two-year experience with 124 consecutive patients. J Trauma 1994;37(3):365– 9.Hatch QM, Osterhout LM, Ashraf A, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Current use of damage-control laparotomy, closure rates, and predictors of early fascial closure at the first take-back. J Trauma Jun;70(6):The highest closure rates are achieved during the first 7–10 daysRegner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg Mar;36(3):Hirshberg A, Wall MJ, Mattox KL. Planned reoperation for trauma: a two-year experience with124 consecutive patients. J Trauma 1994;37(3):365– 9.
34 A total of 1523 studies were identified DCS Vs Immediate and definitive repair (in patients with major abdominal trauma)A total of 1523 studies were identifiedA total of 1521 studies were excluded because they were not relevant to the review topicTargets were not suffering from major abdominal trauma/ narrow spectrumNot directly comparing DCS Vs definitive repairTwo studies were excluded because they were case-control studies. (Rotondo 1993, Stone 1983)Cirocchi R, Abraha I, Montedori A. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev Jan 20;(1):CD
35 Evidence No RCT, systemic review could not be done Most of the studies were case seriesDifferent patient groupsDifferent methodologyConclusion: Evidence is LIMITED.Cirocchi R, Abraha I, Montedori A. Damage control surgery for abdominal trauma. Cochrane Database Syst Rev Jan 20;(1):CDDCS still remain an useful tool for surgeon to deal with patients with multiple trauma and exhausted physiological resource
36 ComplicationSurgical site infection & intraabdominal abscess: up to 83% of casesEnterocutaneous fistula: 5-19%Chronic Ventral Hernia %Smith BP, Adams RC, Doraiswamy VA. Review of abdominal damage control and open abdomens: focus on gastrointestinal complications. J Gastrointestin Liver Dis Dec;19(4): Review.
37 Overuse of DCS Complications Long intensive care unit stays Increased use of blood productsMultiple operationsHigher hospital costHiga G, Friese R, O'Keeffe T, Wynne J, Bowlby P, Ziemba M, Latifi R, Kulvatunyou N, Rhee P. Damage control laparotomy: a vital tool once overused. J Trauma Jul;69(1):53-9.Hatch QM, Osterhout LM, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma Dec;71(6):With the advancement of DCR, the need of DCS may be decreasedCodner PA, Brasel KJ, Deroon-Cassini TA. Staged abdominal repairs reduce long-term quality of life. Injury Sep;43(9): => poorer physical and mental QOL
39 Damage Control Resuscitation Proactive early treatment to address the lethal triad (by rapid reversal of acidosis, prevention of hypothermia and coagulopathy) on admission to combat hospital.Assumption that coagulopathy is actually present very early after injuryHolcomb J, Jenkins D, Rhee P et al. Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma. J Trauma 2007; 62:Holcomb J, Jenkins D, Rhee P et al. Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma. J Trauma 2007; 62:Hodgetts TJ, Mahoney PF, Kirkman E. Damage control resuscitation. J R Army Med Corps Dec;153(4):UK group: A systematic approach to major trauma combining the catastrophic bleeding, airway, breathing and circulation (<C>ABC) paradigm with a series of clinical techniques from point of wounding to definitive treatment in order to minimize blood loss, maximize tissue oxygenation and optimize outcome
40 Damage Control Resuscitation Permissive HypotensionSatisfied with MAP = 50-60mmHgMinimize dilution effect and hypothermia secondary to overzealous fluid replacementEarly use of blood product over isotonic fluid for volume replacementEarly correction of coagulopathy with components, ie. Massive transfusion protocolPRBCs: FFP: Platelet = 1:1:1Danger of over resuscitationHypothermiaDilution of clotting compoundsReverse important homeostatic reflex, exert pressure on extravascular clots, increase blood loss
41 This resuscitation strategy begins from ground zero in the emergency room (ER) and continues through the OR and into the ICUThromboelastometry allows early diagnosis ofcoagulopathies and monitoring of therapy.12 Other near patienttests of acidebase status and electrolyte abnormalities are alsoavailable together with other monitoring techniques such as nearinfra-red spectroscopy (NIRS)13 to measure tissue oxygenationallow near continuous physiological monitoring and tailoringtherapeutic approaches to individual casualty responsesRecent reports of this in vascular surgery in a combat support hospital setting have allowed extended operating (median time 4.5 hours) with more definitive revascularization to be undertakenFox Charles J, Gillespie David L, Cox EDarrin, et al. Damage control resuscitation for vascular surgery in a combat support hospital. J Trauma 2008; 65: 1e9.Midwinter MJ. Damage control surgery in the era of damage control resuscitation. J R Army Med Corps Dec;155(4):323-6.
42 ConclusionDamage control surgery was an useful tool in handling patients with multiple injury, though high level of evidence is lackingDCS is not without risk and complication, over- utilization may lead to more harm than benefitWith DCR integrating into DCS, the need of DCS may reduce as coagulopathy is corrected earlier