Overview
Definition:
Damage control laparotomy (DCL) is a staged surgical approach used in severely injured patients with intra-abdominal hemorrhage or contamination, involving rapid control of bleeding and contamination, temporary closure of the abdomen, and planned re-exploration
Temporary abdominal closure (TAC) techniques aim to facilitate fluid management, prevent evisceration, and prepare for definitive repair in a less compromised patient.
Epidemiology:
DCL is employed in approximately 5-10% of abdominal trauma cases requiring laparotomy
The incidence is higher in penetrating trauma, particularly gunshot wounds to the abdomen, and in patients with significant coagulopathy and hypothermia (the "lethal triad").
Clinical Significance:
DCL and TAC are life-saving strategies for patients with severe abdominal trauma or intra-abdominal sepsis who are hemodynamically unstable and cannot tolerate prolonged definitive surgery
They allow for resuscitation and correction of physiological derangements before attempting definitive repair, significantly improving survival rates.
Indications
Indications For Dcl:
Hemodynamic instability (hypotension with acidosis and coagulopathy) despite aggressive fluid resuscitation and blood transfusion
Presence of intra-abdominal hemorrhage, widespread contamination (e.g., hollow viscus perforation, mesenteric devascularization), or suspected occult injury
Inability to achieve adequate hemostasis or control contamination within a reasonable timeframe during initial laparotomy.
Indications For Tac:
Following DCL, abdominal compartment syndrome, or situations where definitive closure would compromise organ perfusion or respiratory function
Severe edema of bowel loops preventing closure
Patients with anticipated need for further intra-abdominal interventions (e.g., repeat laparotomy for sepsis, re-exploration for bleeding).
Contraindications To Dcl:
Stable hemodynamics
Limited intra-abdominal pathology
Clear operative field without significant bleeding or contamination
Patients for whom definitive repair can be safely accomplished in a single setting.
Diagnostic Approach
Initial Assessment:
Rapid primary survey according to ATLS protocols
Assessment of ABCs (Airway, Breathing, Circulation)
Identification of shock and coagulopathy
History from EMS or patient if available, focusing on mechanism of injury and time elapsed.
Imaging:
FAST (Focused Assessment with Sonography for Trauma) examination for free fluid
CT scan of the abdomen and pelvis in stable patients to identify solid organ injury, bowel perforation, and vascular injury
Diagnostic peritoneal lavage (DPL) may be used in hemodynamically unstable patients where FAST is equivocal.
Laboratory Investigations:
Complete blood count (CBC) for hemoglobin and platelet count
Coagulation profile (PT, INR, aPTT)
Blood gas analysis for acidosis
Serum lactate for tissue hypoperfusion
Cross-matching for blood products.
Management
Surgical Management Dcl:
Initial laparotomy is performed to rapidly identify and control sources of bleeding and gross contamination
Packing of the abdomen is used to control oozing
Resuscitation with blood products, crystalloids, and colloids is continued
Correction of coagulopathy and hypothermia is paramount
The abdomen is then temporarily closed using various TAC techniques, avoiding tension on the abdominal wall.
Temporary Abdominal Closure Techniques:
Bogota bag technique (using a sterile drainage bag sutured to the fascial edges)
Mesh repair (using synthetic or biological mesh, which may be sutured or secured with clips)
Zipper closure systems
Vacuum-assisted closure (VAC) systems, often applied over a barrier like a plastic sheet or mesh
Simplest methods include approximation of fascial edges with sutures or clamps, if feasible.
Resuscitation And Optimization:
Aggressive fluid and blood resuscitation
Correction of coagulopathy with fresh frozen plasma, cryoprecipitate, and platelet transfusions
Administration of warming blankets and warmed intravenous fluids to combat hypothermia
Management of acidosis with bicarbonate if severe.
Definitive Repair And Reoperation:
Planned re-exploration within 24-72 hours, once the patient is physiologically stable and coagulopathy is corrected
During re-exploration, the abdomen is opened, irrigated, and definitive repairs are performed, including resection and anastomosis of bowel, vascular repair, and solid organ management
The abdomen is then closed definitively if possible, or TAC may be reapplied if indicated.
Complications
Early Complications:
Abdominal compartment syndrome due to inadequate decompression or excessive fluid resuscitation
Postoperative bleeding
Sepsis from retained contamination or anastomotic leak
Enterocutaneous fistula formation
Ventilator-associated pneumonia
Deep vein thrombosis and pulmonary embolism.
Late Complications:
Incisional hernia formation, especially after mesh use or multiple reoperations
Adhesions and bowel obstruction
Chronic pain
Psychological sequelae.
Prevention Strategies:
Judicious use of fluid resuscitation
Prompt correction of coagulopathy
Aggressive management of hypothermia and acidosis
Early recognition and management of abdominal compartment syndrome
Meticulous surgical technique during definitive repair
Use of prophylactic antibiotics
Early mobilization and DVT prophylaxis.
Prognosis
Factors Affecting Prognosis:
Severity of injury (ISS score)
Degree of initial shock and coagulopathy
Presence of multiple comorbidities
Promptness and adequacy of resuscitation and DCL/TAC
Occurrence of intra-abdominal sepsis or organ failure
Time to definitive repair.
Outcomes:
Mortality rates for DCL vary significantly, ranging from 20% to over 50%, depending on the severity of the initial injury and patient condition
Survival has improved with the widespread adoption of DCL and TAC principles
Patients undergoing DCL often have prolonged hospital stays and higher rates of morbidity.
Follow Up:
Close monitoring for signs of infection, bleeding, or organ dysfunction
Regular assessment of abdominal girth and urine output
Management of nutritional support
Plans for hernia repair if indicated, typically after 6-12 months post-injury or definitive closure.
Key Points
Exam Focus:
Understand the "lethal triad" (hypothermia, coagulopathy, acidosis) and its management
Know the indications for DCL and TAC
Recognize different TAC techniques and their advantages/disadvantages
Recall the staged nature of DCL: control, temporary closure, resuscitation, re-exploration, definitive repair.
Clinical Pearls:
Do not be afraid to temporize! The goal of DCL is to buy time for resuscitation
Aggressively manage coagulopathy
even minor improvements can be life-saving
Use warming measures proactively
Document all findings meticulously in the abdomen during initial laparotomy, as re-exploration may be challenging.
Common Mistakes:
Attempting definitive repair in a hemodynamically unstable patient
Inadequate resuscitation and correction of derangements before re-exploration
Over-reliance on a single TAC technique without considering patient-specific factors
Premature definitive abdominal closure in edematous bowel
Failure to plan for timely re-exploration.