Damage control in the abdomen and beyond.

Department of Surgery, Johannesburg Hospital, University of the Witwatersrand, Johannesburg, South Africa.
British Journal of Surgery (Impact Factor: 5.21). 10/2004; 91(9):1095-1101. DOI: 10.1002/bjs.4641
Source: PubMed

ABSTRACT Damage control is not a modern concept, but the application of this approach represents a new paradigm in surgery, borne out of a need to care for patients sustaining multiple high-energy injuries.
A Medline search was performed to locate English language articles relating to damage control procedures in trauma patients. The retrieved articles were manually cross-referenced, and additional academic and historical articles were identified.
Damage control surgery, sometimes known as 'damage limitation surgery' or 'abbreviated laparotomy', is best defined as creating a stable anatomical environment to prevent the patient from progressing to an unsalvageable metabolic state. Patients are more likely to die from metabolic failure than from failure to complete organ repairs. It is with this awareness that damage control surgery is performed, enabling the patient to maintain a sustainable physiological envelope.

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    ABSTRACT: This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries. From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann-Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05. Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005). The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.
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    ABSTRACT: Aim To review our local experience with presentation and management of retroperitoneal haematomas (RPH) discovered at laparotomy and factors affecting outcome. Methods Patients with retroperitoneal haematomas (RPH) were identified from a prospective database. Data collected included demographics, clinical presentation, zones and organs involved, management and outcome. Results Of a total of 488 patients with abdominal trauma, 145 (30%) with RPH were identified 136 of whom were male (M:F = 15:1). Mean age was 28.8 (SD 10.6) years and Median delay before surgery was 7 hours. The injury mechanisms were firearms (109), stabs (24), and blunt trauma (12). Twenty four patients (17%) presented with shock. There were 58 Zone I, 69 Zone II, and 38 Zone III haematomas. The median Injury Severity Score (ISS) was 9. Fifty two patients (36%) developed complications and 26 (18%) patients died. Sixty four (44%) patients required ICU with median ICU stay of 3 days. All Zone I injuries were explored; Zone II and III were explored selectively. The mortality for Zones I, II, III and IV was 14%, 4%, 29% and 35% respectively. Mortality was highest for blunt trauma and lowest for stabs (p = 0,146). Twelve of 24 patients with shock died (50%) compared to 14 of 121 (12%) without shock (p < 0.0001). Eighteen of 64 patients with <6-hours delay before surgery died (28%) compared to 8 of 81 (10%) with >6-hours’ delay (p <0.017). mortality increased with increasing ISS. Median hospital stay was 8 days. Conclusion RPH accounted for 30% of abdominal trauma. Injury mechanism, presence of shock, delay before surgery and ISS showed a significant association with mortality.
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