Reinterventions after damage control surgery

Abstract

Damage control has well-defined steps. However, there are still controversies regarding whom, when, and how re-interventions should be performed. This article summarizes the Trauma and Emergency Surgery Group (CTE) Cali-Colombia recommendations about the specific situations concerning second interventions of patients undergoing damage control surgery. We suggest packing as the preferred bleeding control strategy, followed by unpacking within the next 48-72 hours. In addition, a deferred anastomosis is recommended for correction of intestinal lesions, and patients treated with vascular shunts should be re-intervened within 24 hours for definitive management. Furthermore, abdominal or thoracic wall closure should be attempted within eight days. These strategies aim to decrease complications, morbidity, and mortality.

Keywords: Laparotomy; abdominal wall; anastomosis surgical; cardiac surgical procedures; colostomy; intensive care units; intra-abdominal hypertension; ostomy; postoperative period; reoperation; surgical wound infection; thoracic cavity.

Figure 1. Abdominal Packing. Patient with a severe liver trauma that had been controlled via perihepatic packing to control of hemorrhage.

Figure 2. Deferred Intestinal Anastomosis. A. Small bowel injury is left in discontinuity as damage control surgery. B. Intestinal reconstruction via deferred small bowel anastomosis using stapple technique.

Figure 3. Vascular Shunt on Aorta artery. Infrarenal aorta injury is temporally treated using a vascular shunt

Figure 4. Negative Pressure Wound Therapy to deferred closure of the abdomen. A fenestrated plastic separates intra-abdominal organs, while foam sponges or dressings are placed over it and secured beneath a double layer of adhesive sheets. The suction device is installed over the adhesive film by cutting out a 3 to 3.5 cm diameter circle

Figure 5. Closure of the abdominal skin. A. Abdominal wall that does not allow closure of fascia and skin. B. The abdomen is closed using 2-0 Prolene interrupted suture of the skin.

Figura 1. Empaquetamiento Abdominal. Paciente con trauma hepático severo que ha sido controlado mediante empaquetamiento peri hepático para control de la hemorragia.

Figura 2. Anastomosis Intestinal Diferida. A. Lesión del intestino delgado manejada a través de cirugía de control de daños dejando en discontinuidad el intestino. B. Reconstrucción intestinal a través de una anastomosis diferida con grapadora

Figura 3. Shunt Vascular en Aorta. Lesión de la Aorta Abdominal Infrarrenal que es manejada temporalmente con la colocación de un shunt vascular (tubo de tórax).

Figura 4. Sistema de presión negativa para el cierre diferido del abdomen. Sistema de Presión Negativa para el cierre diferido abdominal. La interfaz de plástico fenestrado separa los órganos intraabdominales, mientras que las espumas o apósitos se ubican encima y se fijan con una capa doble de plástico adhesivo. El dispositivo de succión se instala sobre el plástico adhesivo recortando un círculo de 3 a 3.5 cm de diámetro.

Figura 5. Cierre del abdomen con afrontamiento de solo piel. A. Imposibilidad para el cierre de la fascia del abdomen a pesar del control abdominal de la lesión. B. Se realizan afrontamiento con puntos separados con prolene 2-0. C. Afrontamiento de la pared abdominal por cierre únicamente de piel.