CHAPTER 60 SURGICAL TECHNIQUES FOR THORACIC, ABDOMINAL, PELVIC, AND EXTREMITY DAMAGE CONTROL
Injury severity and spectrums of injury have continually evolved, resulting in greater and different challenges for the modern trauma surgeon. High energy blunt trauma, with resultant multisystem organ injury, as well as increasingly sophisticated firearms with greater wounding capacity, has resulted in greater severity of injury. Despite the fact that these injury patterns are more likely to result in the death of a patient, improvements in prehospital transport and trauma resuscitation have allowed more moribund patients to reach the hospital alive but in extremis. Damage control surgery, addressing the life-threatening injuries immediately but delaying definitive repair until the metabolic and physiologic perturbations have been corrected, has evolved to address this population of patients.
Indications for damage control strategy are multiple. The goal of the damage control procedure is to preserve life in the face of devastating injuries with profound hemorrhagic shock. As described by Moore et al., they include an inability to achieve hemostasis resulting from ongoing coagulopathy, a technically difficult or inaccessible major venous injury, a time-consuming procedure in the face of under-resuscitated shock, and a need to address other life-threatening injuries. These indications have been expanded to include hemodynamically unstable patients with high-energy blunt torso trauma or multiple penetrating injuries, or any trauma patient presenting in shock with hypothermia and coagulopathy (Table 1). Most commonly applied to the abdomen, damage control approaches have now been applied successfully to both devastating thoracic and orthopedic injuries.
Table 1 Indications for Damage Control Procedures
Adapted with permission from Rotondo MF, Zonies DH: The damage control sequence and underlying logic. Surg Clin North Am 77:761–777, 1997.
INITIAL RESUSCITATION CONCERNS
A systematic approach to the initial management of the injured patient has been promulgated by the Advanced Trauma Life Support course of the American College of Surgeons Committee on Trauma. The primary and secondary surveys as described in that course allow the rapid identification of life-threatening injuries and allow the surgeon to prioritize subsequent operative management of the unstable trauma patient. Patients with exsanguinating hemorrhage should be expeditiously transported to the operating room, where a decision regarding the initiation of damage control should be made early in the operative course, based on the patient’s physiologic status, body temperature, and intravascular volume status (see Table 1). In patients with obvious ongoing resuscitation requirements, a central venous catheter should be placed for aggressive volume resuscitation. Given the multiple factors that predispose these patients to coagulopathy, early consideration should be given to the administration of coagulation factors (fresh frozen plasma and cryoprecipitate) and platelets, in addition to the standard crystalloid and packed red blood cell resuscitation.
PHASE I: DAMAGE CONTROL OPERATION
Damage Control Laparotomy
There are several options available for the management of major vascular injuries. Some venous injuries will respond to packing. Ongoing bleeding, however, requires direct surgical intervention. Many abdominal vascular injuries can be managed with simple ligation of the bleeding vessel (Table 2). Ligation, however, is not tolerated in aortic or proximal superior mesenteric artery injuries, and is not technically feasible in retrohepatic caval injuries. These injuries are typically initially approached by an attempt at repair or the placement of a temporary intraluminal shunt, with planned repair at a second operation (phase 3). Commonly, Argyle carotid shunts and Javid shunts have been used for this purpose. Chest tubes may be used when larger conduits are necessary. The shunts should be secured using umbilical tapes, vessel loops, or suture, and do not require anticoagulation to maintain patency. Another technique for the management of exsanguinating vascular injury is the use of endoluminal balloon catheters to obtain proximal and distal control of hemorrhage. The catheters are inserted into the vessel at the site of injury, and the balloon inflated. This technique allows repair of the injured vessel in a relative dry operative field.
Table 2 Abdominal Vessel Ligation and Expected Complications
| Vessel | Complication | Recommendations |
|---|---|---|
| Celiac axis | None | |
| Splenic artery | None if the short gastric vessels are intact | |
| Common hepatic artery | None if the portal vein is intact, possible gallbladder ischemia | Cholecystectomy (may be done at second look) |
| Superior mesenteric artery | Bowel ischemia | Second-look procedure |
| Superior mesenteric vein | Bowel ischemia | Second-look procedure |
| Portal vein | Bowel ischemia | Second-look procedure |
| Suprarenal inferior vena cava | Possible renal failure |
