Damage control and serious illness surgery Dr. Clemens Gerstenkorn, MD, PhD, FRCS; Surgeon Trauma and acute Illness Hospital, Pristhina, Kosovo Medical Conference 8.11.2012 Prizrin, Kosovo

Definition of Damage Control Surgery (DCS) and serious illness Surgery DCS: Damage control surgery is the rapid termination of an operation after control of life-threatening bleeding and contamination followed by correction of physiologic abnormalities and definitive management Serious illness Surgery: wide term covering a broad field of acute illness and trauma surgery

Possible causes: Infection Workplace injuries Gunshot Road traffic accident Acute abdomen

R a r e

Common

History of DCS Term used in Military surgery, intensive care context and Trauma Surgery Traditional Surgery: Operation is completed definitively regardless of the condition of the patient. This can lead to complex reconstruction surgery in a severely compromised patient and ultimatively to his death

The lethal Triad Uncontrolled hemaorrhage and iatrogenic intervention can lead to hypothermia, coagulopathy and acidosis each of these abnormalities exacerbates the others contributing to a spiraling cycle < 35 degrees C results in coagulopathy with activation of the coagulation cascade, loss of platlet function and increased fibrinolytic activity Acidosis (PH < 7.2) leads to lactate production from anaerobic metabolism, decreased cardiac output and relative anemia

Damage control Surgery This strategy involves a staged approach to multiply injured patients designed to avoid or correct the lethal triad of: A Hypothermia (< 35 degree C) B Acidosis (PH < 7.2) C Coagulopathy (uncontrolled bleeding) before definitive management of injuries. But this concept is applicable to a wide variety of disciplines (Neurosurgery, Thoracic Surgery, Abdominal Surgery, Vascular Surgery, Fracture surgery of the limbs, spinal and pelvic Surgery)

DCS During the traditional first stage of damage control hemaorrhage is stopped and contamination is controlled using the simplest and most rapid means available. The second stage is characterised by correction of physiologic abnormalities in the ICU. Patients are warmed and resuscitated and coagulation defects are corrected. In the final phase definitive operative management is completed in a stable patient.

Different types of Damage Control Surgery A Chest: usually urgent thoracotomy and or chest drainage; these injuries most commonly require a one stage procedure: control of bleeding, repair of pulmonary damage (atypical lung resection), cardiac injuries - for example stab wounds and or pericardial tamponade – immediate life threatening require urgent intervention thoracotomy and or drainage of pericardial tamponade

B Abdomen: blunt and penetrating injuries: liver, abdominal vascular injuries, spleen, urological structures (kidney, ureter, bladder), bowel or intestine damage Control of bleeding, use of inflatable ballon catheters, clamps, spleenectomy, abdominal packing, temporary repair of bowel, bladder and ureter Avoidance of abdominal compartment syndrome and other complications: secondary hemorrhage, infection, fistula, intestinal necrosis, pancreas pseudocyst, systemic complications such as sepsis and ARDS (acute respiratory dystress syndrom), ischaemia / reperfusion injury, visceral swelling, decreased abdominal compliance with ileus

Damage control surgery: Use of external fixation in an open fracture of the tibia

Strategies to avoid the death of the patient and to have an acceptable good outcome: For example: rapid amputation of severe leg injuries; Pringle procedure (portal vein occlusion in 1908) during liver injury and packing of liver lacerations; damage control principles can be applied to all disciplines of surgical trauma and surgical acute illness care

Treatment: Resuscitation and correction of acidosis to avoid depressed myocardial contractility and to increase inotropic response to catecholamins and avoid ventricular arrhythmias, Acidosis also leads to increased intracranial pressure During Coagulopathy PTT is prolonged and Factor V activity decreases causing DIC (Disseminated intravascular coagulation) with consumptive coagulopathy PH of < 7.2 causes activation of coagulation by tissue factor exposure

Usage of X-ray images during assessment of hand trauma

Acute illness surgery Volvulus of the terminal ileum

Recovering of the ileum after correction of the Volvulus Recovering small bowel after surgical correction of a Volvulus (Twisted and rotated bowel)

Volvulus of the small bowel Acute onset with compromised blood supply and serious ischaemia to the small bowel due to complete or incomplete rotation of the superior mesenteric vessel supply of the bowel If untreated this disease leads to bowel necrosis, perforation and death due to faecal peritonitis and sepsis After acute surgical treatment and restoration of the blood supply the bowel can recover and if the intervention was fast enough bowel resection (as in this case) can be avoided

Other personal experience for DCS and serious illness surgery during the last 12 months Knife wound to left axilla, control of bleeding via clamping of Arteria and Vena subclavia, thereafter exploration and direct vascular repair of left axilla Road traffic accident with open abdominal rupture of the spleen, immediate spleenectomy Butcher knife chest wound to the right atrium, immediate thoracotomy and direct repair of the right atrium with 3-0 Prolene continous stiching with partial clamping of the right atrium, pericard and chest drainage

Ruptured aortic aneurysm: rapid laparotomy with aortic clamping and direct graft repair Acute mesenteric infarct due to cardial embolus: urgent laparotomy, extended right hemicolectomy (large bowel), embolectomy of arteria mesenterica superior (SMA) with Fogarthy ballon catheter and resection of 2 parts of small bowel due to ischaemia, after reperfusion of SMA temporary partial closure of abdomen (abdomen apertum), ICU resuscitation, after 48 hours second look laparotomy for inspection of viability of small and remaining large bowel, abdomen apertum to avoid abdominal compartment, after further 48 hours third laparotomy final inspection of bowel and anastomoses and definitive closure of abdomen