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KEY POINTS

KEY POINTS

  • Damage control is a US Navy term defined as the “capacity of a ship to absorb damage and maintain mission integrity.”

  • An abbreviated laparotomy with diffuse intra-abdominal packing in patients with significant intra-abdominal injuries and an intraoperative coagulopathy was first described by H. Harlan Stone, MD, at Grady Memorial Hospital, Atlanta, Georgia, in 1983.

  • In the modern era, agreed-upon indications for a damage control laparotomy include temperature less than 34°C; arterial pH less than 7.2; an international normalized ratio, prothrombin time, or partial thromboplastin time greater than 1.5 times normal; or a clinically observed coagulopathy in the pre- or intraoperative setting.

  • The early coagulopathy of trauma, as demonstrated on laboratory testing, is present upon admission in over 25% of injured patients with a base deficit greater than –6.

  • Examples of thoracic damage control include cross-clamping the hilum, a hilar twist after division of the inferior pulmonary ligament, and pulmonotomy with selective vascular ligation.

  • Examples of abdominal damage control include perihepatic packing, suture repair and packing of grade I or II splenic injuries, and Whipple procedure or distal pancreatectomy delayed to reoperation.

  • Examples of vascular damage control anywhere in the body include insertion of temporary intraluminal shunts, ligation of selected major veins, and early fasciotomy in high-risk patients with injuries to the extremities.

  • Abdominal compartment syndrome is defined as a sustained intra-abdominal pressure greater than 20 mm Hg that is associated with new organ dysfunction or failure.

  • The temporary silo over open abdomen technique was initially described by Oswaldo Borraez G. at the San Juan de Dios Hospital in Bogota, Colombia, in 1984.

  • Indications for an emergent return to the operating room after a damage control laparotomy performed in a patient with blunt trauma include a normothermic patient who is bleeding greater than 2 units of packed red blood cells per hour or the development of an abdominal compartment syndrome with ongoing blood loss.

  • Maintenance of the peritoneal domain and prevention of adherence of the viscera to the underside of the abdominal wall are critical to allow progressive closure of the linea alba after an open abdomen.

HISTORY AND DEFINITION

Damage control is a US Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity.”1 When applied to surgery and critically ill patients, abdominal damage control surgery (DCS) incorporates fundamental tenets that include the following: (1) stopping surgical hemorrhage; (2) controlling gastrointestinal spillage; (3) inserting surgical packs; and (4) applying a temporary abdominal closure. This truncated operation is then followed by immediate transfer to the intensive care unit with subsequent rewarming, hemodynamic stabilization, correction of coagulopathy, and general supportive care for stunned organs. A return to the operating room then occurs 6 to 48 hours later for definitive repairs, exploration for missed injuries, insertion of a feeding tube, and primary fascial closure, if possible. In essence, a typical operative sequence is interrupted by completing only the ...

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