Damage Control Surgery for Exsanguinating Abdominal Trauma Patients

Background/Aim: Damage control surgery (DCS) has become a well-established in the past few decades as a surgical strategy to be applied in the unstable trauma patients. 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 or the lethal triad (hypothermia, metabolic acidosis and coagulopathy) than from failure to complete organ repairs. The aim of this study was to analyze the role of damage control surgery in abdominal trauma patients in terms of morbidity and mortality. Patients and methods: A retrospective review of all patients undergoing a laparotomy and damage control surgery in a level 1 trauma center over a 3-year period was performed. This study includes 42 severely injured patients who presented in the emergency room of a tertiary referral hospital in the eastern province in Saudi Arabia. These patients were hemodynamically unstable because of life-threatening hemorrhage following either blunt or penetrating abdominal trauma. After stat shifting to the operating theatre, both resuscitation and operative intervention were done simultaneously. Variable procedures of damage control surgery like abdominal packing for hepatic and pelvic trauma, major abdominal vessel ligation and temporary shunting using silastic tubes for vascular injury were done in phase I. In phase II patients were managed in the surgical intensive care unit (SICU) for hypothermia, acidosis, and coagulopathy. Phase III for definitive treatment was done after 24-72 hours once the patients got stable. Results: Over the duration of this 3-year study, 42 patients underwent a damage control laparotomy following trauma. There were 93 organ injuries in these 42 patients. The mechanism of injury was blunt trauma in 31 patients (74%), stab wound in 7 patients (17%) and gunshot wounds in 4 patients (9.5%), 28 patients (66.7%) had been involved in motor vehicle accidents and 3 patients (7%) are involved in fall from height. Average time interval between presentation in emergency department and surgical intervention was 17 minutes, and average operating time was 50 minutes. Twenty patients died, giving an overall mortality rate of 47.6%. The mean age of the patients who survived was 24 years, compared with 36 years in the non-survivor group. Increasing age was found to be a statistically significant factor predicting mortality, with a p-value of 0.001. The development of DIC (p < 0.001), the need for inotropes (p < 0.001) and the presence of septic shock (p=0.017) were found to be significant predictors of mortality. Conclusion: Damage control surgery still represents an important refuge to reduce morbidity and mortality in trauma resuscitation as it gives the patient a chance to survive in an otherwise hopeless situation. The results obtained from our study are in accordance with other studies published to-date i.e. Reducing mortality and morbidity in addition to an improved outcome. The management of this complex problem requires a multidisciplinary team approach with patient counseling and communication with the family.