The Concept of

Damage Control Surgery

Professor G. Korakhashvili
Caucasus International University
During the last two decades, numerous factors have resulted in the
arrival of more severely injured patients. First, advances in prehospital
care and the adoption of the “scoop and run” philosophy has resulted in
the expedient arrival of sicker trauma patients who typically might have
died in the field or en route to the hospital. Second, there has been a
definite shift toward the use of more powerful rapid firing guns with the
capacity for greater tissue destruction. Moreover, patients wounded with
automatic weapons are arriving with multiple penetrations, often in
multiple body cavities, literally exsanguinated and physiologically
depleted. The “traditional approach” to these patients is not effective.
While the physical or mechanical completion of the operation is often
technically possible, the pathophysiology is so extreme that death occurs
despite anatomic repair.
Standard surgical practice (early total care):
o the best operation for a patient is one, definitive
procedure
o the first chance of any surgical intervention is the
best chance for any definitive repair or
reconstruction

ER→OR→ICU

but
Multiple trauma patients are more likely to die from
their intra-operative metabolic failure that from a
failure to complete operative repairs
In 1970s & 1980s, surgeons
tended to perform complex and
lengthy operation in multiple
trauma case
Extensive resection
Extensive reconstruction
Aggressive resuscitation
Extracorporeal support
DEFINITION • Damage control surgery is
defined as the rapid initial control of hemorrhage
and contamination with packing and temporary
closure, followed by resuscitation in the ICU, and
subsequent re-exploration and definitive repair
once normal physiology has been restored.
 Damage Control Surgery
(DCS)
Multiple abdominal trauma

Thoracic injury

Vascular surgery

Orthopaedics

Abdominal sepsis
 Damage Control
Originated in the US Navy, refers to the capacity of a ship to absorb
damage and maintain mission integrity
A combination of profound acidosis, hypothermia, and coagulopathy,
also known as the “lethal triad” is commonly seen in these patients. It
often precludes the completion of the operation. In this context, the
concept of “damage control” has emerged. Borrowed from the United
States Navy it represents “the capacity of a ship to absorb damage
and maintain mission integrity”. In surgery, “damage control” refers
to those maneuvers designed to ensure patient survival. It is a staged
strategy for the treatment of severe exsanguinating injury occurring
from either blunt or penetrating mechanisms.
 History
The concept of abdominal packing for uncontrolled hemorrhage, one of the initial damage control
maneuvers, is not a new one. It has been described most often in patients with massive liver trauma
and has been met by tempered enthusiasm. Pringle, in 1908, was the first to describe the concept of
hepatic packing in patients with portal venous hemorrhage. Halsted later encouraged the placement
of rubber sheets between the packs and liver to protect the liver parenchyma. The United States
military discouraged the practice of packing during
World War ll and the Vietnam War. Several reports since the Vietnam War revalidated the concept in
civilian trauma, and Lucas and Ledgerwood were first to report a prospective five-year evaluation of
637 patients treated for liver injury. Three of these patients had their livers therapeutically packed; all
three survived. Five years later, Feliciano et al. reported a 90 % survival rate in ten patients with severe
liver injuries treated with liver packing. Stone, in 1983, introduced the concept of abbreviated
laparotomy and intra-abdominal packing for the exsanguinating hypothermic and coagulopathic
trauma patient. Once hemodynamic stability was restored and the coagulopathy corrected, definitive
surgical repairs were later completed. This strategy resulted in the survival of 11/17 patients felt to
have a lethal coagulopathy. The application of these
techniques to trauma patients continued to evolve over the next several years.
Rotondo and Schwab in 1992 coined the term “damage control” and outlined the logistics of performing this
three phased approach. Part one (DC I) consists of immediate exploratory laparotomy with control of bleeding
and contamination, abdominal packing and abbreviated wound closure. Part two (DC II) consists of the ICU
resuscitation; immediate endpoints include physiological and biochemical stabilization. A tertiary exam should
be performed at this time to identify all injuries. Part three (DC III) consists of re-exploration and definitive
repair of all injuries. In this paper, they reported a survival rate of 77 % in those patients with major vascular
injury and two or more visceral injuries, i.e. a maximum injury subset who were “damage controlled.” Johnson
and Schwab have recently introduced a fourth part. Coined “Damage Control Ground Zero” (DC 0), it
represents the earliest phase of “damage control” in the pre-hospital arena and the emergency department.
“Ground zero” focuses on injury pattern recognition and early decision to proceed with damage control. It
includes strategies such as minimizing pre-hospital time and a very abbreviated emergency department
resuscitation that includes intubation, blood transfusion, and rapid access to the OR. Throughout all the early
phases they also emphasized rewarming as well as restoring red cell and plasma volume. Their reported 90 %
survival in their damage control
population demonstrates the effectiveness of these strategies and is the best thus far reported in the literature.
Given its success with such profoundly injured and dying patients, the popularity of this approach and its use
has continued to grow. A recent collective review by Shapiro et al. of over 1000 damage control patients showed
an overall 50 % survival. The damage control philosophy is grounded in the principle that the survival of the
patient is the only priority and thus the potential for significant morbidity must be accepted. Thus, the high
complication rate comes as no surprise. In effect, by preserving life, one must accept the possibility of a
prolonged, complicated course. This article will first review the indications for damage control, briefly review
the pathophysiology, and discuss the four parts of damage control (including “ground zero”). Finally, more
recent applications of the damage control philosophy to extraabdominal locations (i.e. the chest) as well as
trauma system applications will be discussed.
 Lethal Triad

Acidosis

Hypothermia

Coagulopathy
 Hypothermia

Central Platelet dysfunction

thermoregulation lost
Clotting factors kinetics
Metabolic activity disturbance
Cold IV fluid Cardiac dysfunction

Vasoconstriction

Hypoperfusion
Hypothermia:

oClinically important if less than 370C for more than 4 h

oCan lead to cardiac arrhythmias, decreased cardiac output, increassed
systemic vascular resistance
oCan induce and exacerbate coagulopathy by inhibition of clotting
cascade reaction
 Acidosis

 Cardiac contractility

Dysrhythmias

Synergize with hypothermia in its detrimental effect on

the coagulation cascade
Acidosis:

oUncorrected haemorrhagic shock leads into inadequate cellular

perfusion, anaerobic metabolism and the production of lactatic acid
oInterferes with blood clotting mechanisms and promotes
coagulopathy and blood loss
 Coagulopathy

Platelet dysfunction Uncontrolled bleeding

Clotting cascade from all cut surfaces
disturbed

Haemodilution
Coagulopathy:

oHypothermia, acidosis and the consequences of massive blood

transfusion all lead to the development of a coagulopathy
oPlatelet dysfunction at low temperature
oActivation of the fibrinolytic system
oHaemodilution following massive resuscitation
 Parameters as a guideline for instituting
damage control:
o pH less then or equal to 7.2
o serum bicarbonate level less than or equal to 15 mEq/L
o core temperature less than or equal to 340C
o transfusion volume of packed RBCs more than or equal to
4000 ml
o total blood replacement more than or equal to 5000 ml
o total fluid replacement more than or equal to 12 000 ml
If all - death
If one - DCS
 Principles of DCS

Control haemorrhage

Prevention contamination

Avoid further injury

 Principles of DCS
Quickly abort the vicious cycle by haemorrhage
and contamination control
Minimize further trauma created by Surgeon
Restore normal physiology before definitive
surgery in reoperation
 Principles of DCS
o Prehospital and emergency department times should be minimized
o BTLS
o NO unnecessary and superfluous investigations
o Rapid transport to the operating room without repeated attempts to
restrore cisculating volume- they require operative control of
haemorrhage and simultaneous vigorous resuscitation
Stages of Damage Control Surgery
1. Patient selection
2. Intraoperative stage
3. Critical care stage
4. Return to the operating theatre
5. Formal closure

Moore EE. Thomas G. Orr Memorial Lecture. Staged laparotomy for the hypothermia,
acidosis, and coagulopathy syndrome. Am J Surg. 1996 Nov;172(5):405-10.
Stage 1: Patient Selection
Rotondo M, Zonies D. The damage control sequence and underlying logic. Surg Clin N Am 1997; 77: 761-777.
No Definite Selection Criteria
Too Liberal → Unnecessary staged operation
Too Strict → Adverse physiological outcome
established → Too late to salvage
Experience, rapid surgical assessment and
liaison with anesthetist are the keys in decision
making
 Preoperative Indicators in ED
oPhysiologic parameters
o hypotension > 50 minutes
oMetabolic parameters
o hypothermia < 35ºC
o acidemia pH < 7.15, BE < 8mmol/L
o coagulopathy PT >15, PTT > 42, platelet count <200K
 Stage 2: Intraoperative
Aim:
Controlling Haemorrhage
Limiting contamination
 Intraoperative Indications
omechanism and type of injury
ocoagulopathy, hypothermia
opersistent metabolic acidosis
ohemodynamic instability
omassive transfusion: >8U, total volume
oExtra-abdominal injuries: aortic injury, severe CHI or
pulmonary contusion
oComplex injuries, lack of resources or experience
(transfer)
oDo it before complications arise !
o Proactive
o Not a “bail out” position
 Damage Control Surgery

Operating Room
o Avoid hypothermia – operating in the “tropics”
o Surgical equipment
✓ laparotomy sponge packs
✓ abdominal, vascular, thoracic equipment
✓ suture and autosuture equipment
✓ abdominal “dressing”
 Damage Control Surgery
oinitial laparotomy
oidentify the main source of bleeding
operihepatic packing (superior and inferior)
osmall gastotomies and enterotomies can be rapidly closed
oresect non-viable bowel and close the ends
ominor pancreatic injuries not involving duct- no treatment
odistal injury including the panceratic duct- distal
pancreatectomy
oNO pancreaticoduodenectomy (drainage)
oabdominal closure is rapid and temporary- if there is any
doubt about abdominal compartment syndrome, left it
open (silo-bag, vacuum-pack technique)
 Damage Control Laparotomy

o Packing of upper quadrants, flanks and pelvis

o Identify vascular injuries
✓ pinch
✓ peanut
o Identify solid organ injuries - compress
o Expeditious control of GI spillage
 Damage Control Laparotomy
oPacking of upper quadrants, flanks and pelvis
oIdentify vascular injuries
o pinch
o peanut
oIdentify solid organ injuries - compress
oExpeditious control of GI spillage
 Control of Hemorrhage
LIVER
o Manual compression ± Pringle
o let anesthesia “catch up”
o 2 suctions ready
o Selectively ligate discrete vessels
o Mass suture (big Chromics)
o Packing
o Selective hepatic artery ligation (SHAL)
} one
run
Sources of Hemorrhage
SPLEEN

SPLENECTOMY !
 Sources of Hemorrhage
KIDNEY
o Nephrectomy
o Retroperitoneal packing
 Sources of Hemorrhage
VASCULAR INJURIES

oVenous Injuries
o repair versus ligation
oArterial Injuries
o Ligate (if non-critical)
o Repair (if easy)
o Temporary shunt
 Damage Control Surgery

Visceral Injuries
o GI tract injuries
o Primary repair
o Staple or tie
o External drainage
o Goal is control of contamination
Abdominal Wall Closure

Uh-Ooh!
 Ideal Temporary Closure
oFast and simple
oPrevent evisceration
oGentle with bowel
oMinimal damage to fascia and skin
oDoesn’t compromise definitive closure
 Temporary Closure
If need is the mother of invention,
then trauma surgeons are her favorite children
 Silastic Bag
DISADVANTAGES
ADVANTAGES
o need to remove
oavailable
o infection
ocheap
onon-adherent
osee through
osuture to skin
 Vacuum Pack
oHome made
o Non-
adherent
o Laps, Kerlex,
or towels
o JPs in gutters
o Adherent
drape
oCommercial VAC
 Temporary Abdominal Closure
oAvoid at initial operation
o Tubes
o Ostomies
o Drains
Temporary Closure
- Risk of abdominal
compartment Syndrome
- Ineffective Drainage
Negative Pressure Therapy System,
eg. VAC
Negative Pressure Therapy
Evacuation of abdominal fluid
Minimize risk of Intra-abdominal hypertension
Low fistula rates
Good early closure rates
 Damage Control
Not Just for the Abdomen
Orthopedics Extremities
Thoracic Damage Control
Stage 3: Critical Care Stage

Active rewarming
Correction of Acidosis
Correction of Coagulopathy
Monitor the need for early return to
theatre
Ongoing surgical bleeding
Abdominal compartment syndrome
Stage 4: Return to the Theatre
Timing:
24-48hrs later when
Correction of metabolic abnormalities
coagulopathy, hypothermia, acidosis
Base deficit < 4 mmol/L
Lactate of < 2.5 mmol/L
Core temperature > 35 C
INR < 1.25
direct relationship with sepsis
Stage 4: Return to the Theatre

Definitive surgery
Removal of packs
Anastomoses or stomas
Vascular repairs
Solid organ debridement
Placement of feeding tube
Abdominal wall – may take several return trips
 Stage 5: Formal Closure
May not be feasible due to significant bowel edema or risk of
abdominal compartment syndrome

30 - 80% closure rate in the 1st reoperation

Hirshberg 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. 2011 Jun;70(6):1429-36.

The highest closure rates are achieved during the first 7–10 days
Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World
J Surg. 2012 Mar;36(3):497-510.
 Complications of DCS
oAbdominal compartment syndrome
oGeneral copmlications:
wound sepsis
wound dehiscence
fistula formation
ICU-related infections
skin complications
oDCS is a treathement method
oDCS is one of the major advances in surgical
technique in the past 30 years
oDCS is recognized all over the world for treathing
polytraumatized patients
oPatients who had a death rate according to standard
surgery 90%, survived
oHow much surgery polytrauma patient can tolerate?
Damage Control Resuscitation
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 injury

Holcomb J, Jenkins D, Rhee P et al. Damage Control Resuscitation: Directly Addressing

the Early Coagulopathy of Trauma. J Trauma 2007; 62: 307-310.
Damage Control Resuscitation
Permissive Hypotension
Satisfied with MAP = 50-60mmHg
Minimize dilution effect and hypothermia secondary to
overzealous fluid replacement

Early use of blood product over isotonic fluid for

volume replacement

Early correction of coagulopathy with components, ie.

Massive transfusion protocol
PRBCs: FFP: Platelet = 1:1:1
Midwinter MJ. Damage control surgery in the era of damage control resuscitation. J R Army Med
Corps. 2009 Dec;155(4):323-6.
 Conclusion
Damage control surgery was an useful tool in handling
patients with multiple injury, though high level of
evidence is lacking

DCS is not without risk and complication, over-

utilization may lead to more harm than benefit

With DCR integrating into DCS, the need of DCS

may reduce as coagulopathy is corrected earlier
The concept of damage control was created as a lifesaving strategy to improve outcome in selected patients with
exsanguinating trauma and intra-abdominal injuries. Simply stated, with damage control the goal becomes
preservation of life. Definitive timely repairs are delayed and the initial operation is used only for control of
bleeding and contamination.
Early efforts must be focused on the rapid correction of low temperature, clinical coagulopathy, and acidosis
resulting from the severe hypovolemia and profound shock. Resuscitation and return of the body’s normal
physiology occurs in the ICU.
Definitive repair then takes place days after the initial consult. While survival with this strategy is improving, it
comes with a price of attendant morbidity. Future studies need to focus on improving technology to gauge
resuscitations, better methods of wound closure, and limiting intra-abdominal infection. At this time, however,
damage control has proven itself clinically as the most successful approach to the exsanguinating, dying patient.
Thank you