Trauma Damage Control

Amy D. Wyrzykowski and David V. Feliciano

A number of new approaches to the management of patients with major truncal or extremity trauma have evolved over the past 20 years. These include the following: minimizing time at the scene of trauma and in the emergency department; the presence of in-house attending surgeons, particularly in centers with a significant percentage of penetrating trauma; minimizing admission laboratory testing; initiating resuscitation in the operating room for patients with severe hypotension, cardiac arrest, or external hemorrhage; and early operative control of hemorrhage. All of these are now accepted as major factors in decreasing morbidity and mortality.^1–4 Another major change has been the recognition that conservative operative techniques and shortened operative times, even when all organ repairs have not been completed, will increase survival in civilian and military patients with cervical, truncal, or extremity injuries and intraoperative “metabolic failure.”^5–22 Finally, it has been recognized that standard closure of a thoracotomy or the midline abdominal incision is impossible to achieve in many severely injured patients, is too time-consuming in others, and may cause an abdominal compartment syndrome in the postoperative period after a laparotomy.^23–33

This chapter will describe the techniques used during “damage control” operations (as named by Rotondo et al.);⁷ prevention and sequelae of primary or secondary abdominal compartment syndrome; the alternate techniques for closure of a thoracic, abdominal, or extremity incision in patients with major trauma;^34–43 care of the patient in the surgical intensive care unit (SICU) after a damage control operation; the approach to reoperation; and late repair of incisional hernias when the abdomen has been left open at a reoperation.^41,44–47

DAMAGE CONTROL OPERATIONS

Definition

Damage control operations are performed in injured patients with profound hemorrhagic shock and preoperative or intraoperative metabolic sequelae that are known to adversely affect survival. The widely accepted three stages of damage control are:

1. Limited operation for control of hemorrhage and contamination. Includes control of hemorrhage from the heart or lung; conservative management of injuries to solid organs; resection of major injuries to the gastrointestinal tract without reanastomosis; control of hemorrhage from major arteries and veins in the neck, trunk, or extremities; packing of organs or spaces should a coagulopathy occur; and use of an alternate coverage or closure of a cervical incision, thoracotomy, laparotomy, or site of exploration of an extremity.

2. Resuscitation in the SICU. Includes vigorous rewarming of the hypothermic patient; restoration of a normal cardiovascular state by the infusion of blood, blood products, and fluids and the use of inotropic and related drugs; correction of residual coagulopathy after hypothermia is reversed; and supportive care to minimize the magnitude of acute lung injury (ALI) and acute kidney injury (AKI).

3. Reoperation. Includes completion of definitive repairs, search for missed injuries, and formal closure of the incision, if possible.

Clinical Recognition of Patients Likely to Need Damage Control Operations

Reports to the hospital from prehospital providers or a rapid evaluation in the emergency department by experienced members of the trauma team are the mechanisms used to select patients for abbreviated resuscitation and immediate operation with damage control techniques in the operating room.

Unless an emergency department thoracotomy is indicated, patients in this small subset (Table 38-1) should stop in the emergency department only long enough to obtain control of the airway, decompress an obvious pneumothorax, draw blood for type and cross match, and apply an identification bracelet. These patients should then be transported immediately to the operating room. Patients arriving by air with hypotension or mangled extremities should bypass the emergency room entirely and be taken directly to the operating room from the helipad.

TABLE 38-1 Patients Likely to Need Damage Control Operations

Intraoperative Indications to Perform Damage Control Operations

The primary indication to modify the conduct of an operation for major trauma to the neck, chest, abdomen, or an extremity is unresolved metabolic failure despite control of hemorrhage by suture, resection, or packing. Metabolic failure is characterized by severe hypothermia despite warming maneuvers initiated in the emergency department and continuing in the operating room, persistent acidemia despite vigorous resuscitation and control of hemorrhage, and a coagulopathy (nonmechanical bleeding) not amenable to operative control.^48–58Patients are more likely to die from their intraoperative metabolic failure than they are from the failure to complete organ repairs.^{5–9,12–14,51–58} Most have been massively transfused and have a mortality of 20–50%.^{7,12–14,52,59–63}

Hypothermia

Hypothermia continues to be a common problem in victims of major trauma. In one older series, 66% of severely injured patients with an Injury Severity Score (ISS) greater than or equal to 25 admitted to a level I trauma center were hypothermic (<36°C [96.8°F] on an esophageal temperature probe), including 23% who were severely hypothermic (<34°C [93.2°F]).⁶⁴ Another older review documented that 57% of 74 trauma patients admitted directly to the operating room from the emergency department developed hypothermia (<36°C [96.8°F]) between the time of injury and the time they were moved out of the operating room.⁶⁵

There are many causes of hypothermia in victims of major trauma. Hypovolemic shock in the preoperative period adversely affects oxygen delivery and leads to decreases in oxygen consumption and, therefore, diminished production of heat.^66–68 Should the patient be intoxicated at the time of injury, vasodilatation will further compromise the ability to retain heat. The trauma team itself may be responsible for accelerating the loss of heat from a victim in shock. Undressing the patient in a cool resuscitation room, failing to cover the patient’s head with a turban and the trunk and extremities with warm blankets or the Bair Hugger patient warming system (Augustine Medical, Inc, Eden Prairie, Minnesota) during resuscitation, and infusion of unheated crystalloids and packed red blood cells (PRBCs) are all sources of heat loss in the emergency department. Paralyzing the patient, which prevents shivering, and administering anesthetic agents, which prevent vasoconstriction; failing to cover areas of the body not undergoing operation; opening one or more body cavities in a cold operating room; and irrigating body cavities with unheated crystalloid solutions all further exacerbate heat loss during a thoracotomy or laparotomy. These multiple sources of heat loss cannot be adequately compensated for by increasing heat production in the patient in shock. The resuscitation and surgical teams are responsible for preventing or reversing hypothermia using the techniques listed in Table 38-2.⁴⁸

TABLE 38-2 Maneuvers to Prevent or Reverse Hypothermia During Damage Control Operations

The effect of hypothermia on mortality in severely injured patients is no longer controversial except for one study. In one large retrospective review, mortality among euthermic and hypothermic trauma patients was not significantly different when patients in both groups were stratified by physiologic and anatomic indicators of injury severity.⁶⁹ This is in marked contrast to the review of iliac vascular injuries by Cushman et al. who noted that the risk of dying was nearly four times greater when the patient’s initial body temperature in the operating room was less than 34°C (93.2°F).⁷⁰ If the patient’s last body temperature in the operating room was less than 35°C (95.0°F), the risk of death was nearly 41 times greater than it was for patients with a body temperature greater than 35°C.

While hypothermia is helpful in certain elective operative procedures and has been used for cerebral protection in patients with injury to the brain, it has well-known adverse effects on the cardiovascular, respiratory, renal, gastrointestinal, endocrine, central nervous, and coagulation systems (see Chapter 49).^48,71,72 Both terminal cardiac dysfunction and irreversible nonmechanical bleeding have been noted in many injured hypothermic patients dying in the postoperative period after a trauma operative procedure. It would appear logical, therefore, to practice damage control and rapidly complete any trauma operation in which the patient’s initial body temperature is less than 34–35°C (93.2–95.0°F) or the temperature decreases below this level at any time during the operation.^27,30,73 This is particularly true in patients undergoing thoracotomy or laparotomy because hypothermia will not be correctable until the chest or abdomen is closed.

Acidosis

Prolonged hypovolemic shock produces a state of persistent metabolic acidosis in the patient with major trauma. This leads to a “circular” phenomenon in which secondary decreases in cardiac output, hypotension, and an increased susceptibility to ventricular arrhythmias may be irreversible, despite adequate volume replacement.^{8,49,50,55,58,74–76} Also, severe acidosis may cause the uncoupling of β-adrenergic receptors, with a secondary decrease in the patient’s response to endogenous and exogenous catecholamines.⁷⁷ While acidosis by itself is an unusual reason to terminate a laparotomy being performed for trauma, it often accompanies hypothermia and a coagulopathy.^{49,50,51,53,55} A persistent metabolic acidosis is a manifestation of anaerobic metabolism occurring during hypoperfusion. Markers of this phenomenon in the injured patient that should initiate damage control operations are listed in Table 38-3.^{49,70,75,76,78}

TABLE 38-3 Intraoperative Indications to Perform Damage Control Operations^{49,69,74,75,77}

Coagulopathy

Nonmechanical bleeding has been common during emergency trauma thoracotomies, laparotomies, or operative procedures in patients with exsanguination from an injury to an extremity in the past. With current massive transfusion protocols using a goal of 1 U PRBCs:1 U fresh frozen plasma:1 platelet pack, coagulopathies resulting in irreversible bleeding have become a less significant cause of mortality in the immediate postoperative period and have led to improved survival in massively transfused patients.^63,79,80 It is now recognized that the historic replacement of volume losses with large amounts of crystalloid solutions and cold PRBCs leads to clotting abnormalities secondary to dilution, deficiency of clotting factors, and hypothermia.^{8,50,58,59,81–83} Hypothermia has a well-known adverse effect on enzymes associated with the coagulation cascade and on the function of platelets.^{7,12,13,59,81–83} In addition to a decrease in the incidence of coagulopathies, the implementation of improved transfusion ratios has been associated with reductions in multiorgan failure, fewer infectious complications, and a decreased incidence of the abdominal compartment syndrome.⁸⁴ Improved transfusion ratios have been associated with decreased mortality in injured civilians, also.^85–88

The role of recombinant activated factor VII (Novoseven, Novo Nordisk A/S, Bagsvaerd, Denmark) in the management of a life-threatening coagulopathy remains controversial. While the administration of rFVIIa appears to be safe in the trauma population and has not been associated with an increased risk of severe thrombotic events,^89–91 it is extremely costly and the benefits remain unclear. Whereas early studies had promising results including decreased transfusion requirements and decreased 30-day mortality,^91,92 more recent work has not found an improvement in outcome.⁹³ When a coagulopathy does result, surgical attempts to control such nonmechanical bleeding, especially from the liver and retroperitoneum, are usually unsuccessful. In the major trauma patient who develops a coagulopathy characterized by an international normalized ratio (INR) or partial thromboplastin time 50% greater than normal during any major operative procedure after major sources of hemorrhage have been controlled, damage control would include the techniques to be described (see Table 38-3).

Operative Techniques in Thoracic Trauma

Lung

Exsanguinating hemorrhage from the lung is most rapidly controlled by the application of a DeBakey aortic clamp to the hilum or by twisting the hilum to kink the major vessels in the emergency department or operating room (see Chapter 25).⁹⁴ When the site of blood loss has been a stab wound deep into the pulmonary parenchyma or a gunshot wound completely through a lobe, the technique of pulmonotomy (sometimes called nonneurosurgical “tractotomy”) is used.^95–97 Pulmonotomy refers to the division of pulmonary parenchyma between noncrushing vascular clamps or by using a linear stapling and cutting device to expose injured parenchymal vessels. After selective ligation of these, the pulmonary parenchyma is closed in the usual fashion using a continuous 0 or 2-0 absorbable suture, with reinforcement material added to the staple line, if possible. When the divided lung is edematous, it may not be possible to fully close the pulmonotomy.

Heart

Other than compression with a finger, the quickest way to control hemorrhage from a small wound or rupture of a ventricle in the emergency department or operating room is to apply 6-mm-wide skin staples (Auto Suture 35 W, United States Surgical Corporation, Norwalk, Connecticut) (see Chapter 26).^98,99 Formal cardiac repair with Teflon pledgets may then be accomplished over the staples or as they are sequentially removed in the operating room.

Larger wounds or ruptures of a ventricle in patients surviving by virtue of tamponade may be controlled by the insertion of a Foley balloon catheter into the hole.^100,101 With the balloon inflated and traction applied to the catheter, Teflon-pledgeted sutures can then be passed through the ventricle from side to side over the balloon. The thin wall of the right ventricle puts the inflated balloon at significant risk of puncture as each suture is placed. Pushing the catheter and balloon into the ventricle with each bite of the suture will avoid this complication, although blood loss may be significant.

With a longitudinal perforation or significant rupture of a ventricle, the time-honored technique of inflow occlusion is useful in avoiding cardiopulmonary bypass.¹⁰² Curved aortic or angled vascular clamps are first applied to the superior and inferior vena cavae. As the heartbeat slows, horizontal mattress sutures are inserted rapidly on either side of the defect and then crossed to control hemorrhage. A continuous suture is placed to close the defect, and, before it is tied down, air is vented out of the elevated ventricle by releasing the clamps on the cavae.

Operative Techniques in Abdominal Trauma

Liver

The liver has a blood supply of 1,500 mL/min and is the major site of synthesis of all the coagulation factors except factor VIII (see Chapter 29). Therefore, appropriate operative management of a major hepatic injury is a key component of a successful damage control laparotomy.

There is ample historical evidence that an emergency hepatic resection performed by a general or trauma surgeon with little experience in a similar elective procedure will result in a mortality rate of 20–44%.^103–108 This excessive mortality is certainly related to the magnitude of the hepatic injury, but also to the belated decision to resect at the same time that the aforementioned metabolic failure occurs in many patients. For this reason, more limited techniques of hemostasis should be applied when a hepatic injury is present and damage control is to be performed.^109,110

Indirect control of hepatic hemorrhage may be accomplished by extensive compressive hepatorrhaphy, using a continuous suture or interrupted vertical mattress sutures of absorbable material. While this technique is used much less frequently than it was in the past, it is appropriate for a damage control operation.

Damage control techniques in which the sources of hepatic hemorrhage are approached directly include hepatotomy with selective vascular ligation, resectional debridement with selective vascular ligation, and rapid resectional debridement.¹⁰⁹ Both former techniques are performed with a vascular clamp on the porta hepatis (Pringle maneuver), and experience with the finger fracture technique should allow for early control of hemorrhage.^109–111 When a coagulopathy is already present, hepatotomy or resectional debridement is not appropriate if the surgeon has only modest experience with hepatic trauma. After the Pringle maneuver is performed, rapid resectional debridement is initiated by applying a large Kelly clamp or vascular clamp just outside of a lateral area of partial avulsion (i.e., hepatic segments VI, VII on the right or II, III on the left) or by applying two clamps around the contused sides of a central laceration. The tissue within the clamps is then rapidly debrided, and an O-chromic tie can then be placed around the clamp and all the enclosed tissue ligated en bloc. An alternate technique is to use deep horizontal mattress sutures on either side of the debrided laceration and fill the space between with a viable omental pack (Fig. 38-1).

FIGURE 38-1 Technique of rapid resectional debridement using large vascular clamps, horizontal mattress sutures, and omental pack. (Reproduced with permission from Feliciano DV, Pachter HL. Hepatic trauma revisited. Curr Probl Surg. 1989;26:453. © Elsevier.)

Damage control techniques in which compression or tamponade rather than a suture or metal clip is used to control hepatic hemorrhage include balloon catheter tamponade, absorbable mesh tamponade, and perihepatic packing. Balloon catheter tamponade using a Foley or Fogarty balloon catheter or an inflated Penrose drain over a red rubber catheter is most useful to control hemorrhage from a deep lobar stab or missile track.^101,112,113 Inflation of the balloon is performed at different levels of the track until hemorrhage is controlled. Removal of the balloon catheter is performed at a reoperation when the patient’s metabolic failure has been corrected. Alternatively, an absorbable mesh may be used to create a tamponade effect. Absorbable mesh can be used to reapproximate a disrupted lobe with viable fragments that are still attached to the hilum or to replace a disrupted Glisson’s capsule after rupture of a subcapsular hematoma and may be an excellent alternative to major hepatic resection.^114,115 For the former, the technique involves mobilization of the injured lobe and circumferential wrapping with a mesh sewn to itself at various locations. Although it may be time-consuming in the patient with a severe coagulopathy, it does avoid the need for reoperation. The insertion of dry laparotomy pads as perihepatic packs continues to be necessary in less than 10% of patients undergoing operative repair of hepatic injuries. Primary indications, in addition to the onset of metabolic failure, include the need to transfer the patient to a center with more experienced hepatic surgeons, a desire to avoid opening a large subcapsular hematoma, and the presence of bilobar injuries.^57,116–118 The insertion of perihepatic packs mandates a reoperation and remains one of the classical indications for use of the alternate closures of the midline incision to be described. When placing perihepatic packs, one should be mindful of the possible need for hepatic angiography as an adjunct to laparotomy. If the radiopaque markers of the laparotomy pads are not strategically placed away from the hilum, they may obscure the visualization required for successful angiography.

Operative venovenous bypass of the liver, postoperative venous stenting, and postoperative arterial embolization are all adjuncts to the standard damage control techniques described earlier. All have been applied successfully in selected patients in recent years.^119–124

Spleen

With American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) grade III, IV, or V injuries, splenectomy remains the safest choice when damage control is necessary (see Chapter 30).^125,126 Should an AAST OIS grade I or II injury be present, rapid mobilization and direct suture may be faster than splenectomy and will avoid the creation of a denuded retroperitoneal area in the patient with a coagulopathy (Fig. 38-2). With rupture of the capsule, a topical agent such as microfibrillar collagen (Avitene, Bard, Murray Hill, New Jersey) or fibrin glue is applied to the parenchyma under an absorbable mesh. If the condition of the patient does not permit the time needed to suture absorbable mesh as a replacement capsule, a mesh sheet is compressed against the parenchyma with a laparotomy pad pack.

FIGURE 38-2 Rapid two-suture splenorrhaphy is faster than splenectomy for patients with AAST grade I or II injuries. (Reproduced with permission from Feliciano DV, Spjut-Patrinely V, Burch JM, et al. Splenorrhaphy: the alternative. Ann Surg. 1990;211:569.)

Gastrointestinal Tract

Near transections of the duodenum are stapled shut, while an associated injury to the head of the pancreas is packed (see Chapters 31–33). At the reoperation after metabolic failure has been corrected, duodenal continuity can be restored with an end-to-end anastomosis. A pyloric exclusion with polypropylene suture (Fig. 38-3) and an antecolic gastrojejunostomy (Fig. 38-4) are added in selected patients with severe duodenal contusion, narrowing after a suture repair, or a combined complex pancreatoduodenal injury.^127,128

FIGURE 38-3 (A and B) Pyloric exclusion is performed through a dependent gastrotomy and completed with no. 1 polypropylene suture. (Reproduced with permission from Baylor College of Medicine.)

FIGURE 38-4 An antecolic gastrojejunostomy is added to the pyloric exclusion to allow for oral intake before the pyloric exclusion opens. (Reproduced with permission from Baylor College of Medicine.)

In the patient with a limited number of enterotomies or colotomies from a penetrating wound, a rapid one-layer, full-thickness closure using a continuous suture of 3-0 or 4-0 polypropylene material is appropriate. Multiple large perforations within a short segment of the small bowel or colon are treated with segmental resection, using metallic clips for mesenteric hemostasis and staples to transect the bowel. In the unstable patient, neither an end-to-end anastomosis nor the maturation of a colostomy is performed until the reoperation in 12–72 hours.¹²⁹ With shotgun wounds and multiple partial and full-thickness perforations of the jejunum, a jejunectomy may be appropriate as all of its absorptive capabilities are duplicated by the ileum.

Pancreas

Parenchymal defects not involving the duct are either ignored at the damage control procedure or filled with omentum held in place by a tacking suture (see Chapter 32). The insertion of a closed-suction drain is delayed until the reoperation. Ductal transections to the left of the mesenteric vessels that do not involve the splenic vessels are packed or drained, with the distal pancreatectomy and splenectomy once again delayed until the reoperation (Fig. 38-5). Major parenchymal or ductal injuries in the head or neck of the pancreas are also packed or drained, once hemorrhage from the gland or underlying mesenteric–portal vessels is controlled. Pancreatoduodenectomy or reconstruction after a pancreatoduodenectomy caused by the original injury is obviously delayed until the reoperation.¹²⁹

FIGURE 38-5 Distal pancreatectomy with splenectomy may be completed at the reoperation rather than at the damage control laparotomy. (Reprinted with permission from Cushman JG, Feliciano DV. Contemporary management of pancreatic trauma. In: Maull KI, Cleveland HC, Feliciano DV, et al., eds. Advances in Trauma and Critical Care. Vol. 10. St. Louis: Mosby; 1995:309–336. © Elsevier.)

Abdominal Arteries

In any patient with multiple upper abdominal visceral and vascular injuries, a significant injury to the celiac axis or one of its branches is treated with ligation (see Chapter 34). An injury to the renal artery is also best treated with ligation and nephrectomy in the presence of a palpably normal contralateral kidney and multiple associated injuries, although the nephrectomy can be delayed until the reoperation. The use of a large intraluminal shunt (thoracostomy tube) is a theoretical consideration when there has been segmental loss of either the suprarenal or infrarenal aorta in a patient with profound shock; most experienced trauma surgeons, however, would choose to rapidly insert a 12-, 14-, or 16-mm woven Dacron, albumin-coated Dacron, or polytetrafluoroethylene (PTFE) interposition graft and accept an operative procedure that would be 20–25 minutes longer. The superior mesenteric artery or common or external iliac artery is smaller in young trauma patients, and an intraluminal Argyle, Javid, or Pruitt-Inahara shunt may be rapidly inserted under proximal and distal ties to avoid the need for ligation or emergency interposition grafting.^17,130 Should arterial ligation be chosen rather than repair or shunting for a significant injury to the common or external iliac artery, a rapid ipsilateral two-skin incision, four-compartment below-knee fasciotomy may prevent myonecrosis with its associated renal and septic problems should the patient survive to undergo an early (within 6 hours) extra-anatomic revascularization procedure.¹²⁶

When life-threatening arterial hemorrhage from either a blunt pelvic fracture or a penetrating wound occurs in the deep pelvis and cannot be controlled by packing, several innovative approaches have been used in the past. The first is to insert a Fogarty balloon catheter into the internal iliac artery beyond a proximal tie on the side of the hemorrhage. Advancement of the balloon and sequential inflation is performed until the hemorrhage ceases.¹³¹ The catheter may then be folded on itself, the excess cut off, and a ligature applied to maintain inflation of the balloon.^100,101,131 The other option is for the surgical team to inject a slurry of autologous clot, two cans of microfibrillar collagen (Avitene, MedChem Products, Inc, Woburn, Massachusetts), one packet of bovine topical thrombin (Armour Pharmaceutical Co, Kankakee, Illinois), and 1 g calcium chloride into the distal internal iliac artery beyond a proximal ligature.¹³²

Abdominal Veins

Ligation is the treatment of choice whenever there is a significant injury to the common or external iliac vein, infrarenal inferior vena cava, superior mesenteric vein, or portal vein in a patient with profound shock (see Chapter 34).^133–137 After ligation of the infrarenal inferior vena cava, bilateral four-compartment below-knee fasciotomies should be performed immediately if the pressure in the anterior compartment of the leg is greater than 25–35 mm Hg, depending on the patient’s hemodynamic status. Bilateral thigh fasciotomies will likely be necessary, as well, within the first 48 hours after ligation. When there are large defects in the sacrum or pelvic sidewall involving numerous pelvic veins or in the paravertebral area, a number of innovative approaches are available to rapidly control hemorrhage. Included among these are packing the missile track with several vaginal packs (to allow for postoperative pelvic or paravertebral arteriography), inserting fibrin glue, or placing a Foley catheter with a 30-mL balloon inflated at the site of hemorrhage as previously described. Placing packs outside the blast cavity in the deep pelvis or paravertebral area often fails to control hemorrhage in the patient who develops a coagulopathy. Bleeding from presacral veins can be controlled by inserting sterile tacks directly into the visible defect or by suturing a free piece of omentum into an obvious area of perforation.

Intra-Abdominal Packing

When severe shock, hypothermia, acidosis, and massive transfusion have led to a coagulopathy and diffuse nonmechanical bleeding, the insertion of intra-abdominal packing for tamponade is appropriate.^{57,116–118,138–140} Diffuse intra-abdominal packing has been found to be particularly useful when a coagulopathy occurs and extensive retroperitoneal or pelvic dissection has been necessary during a laparotomy for a trauma. Dry, folded laparotomy pads much as described for perihepatic packing are preferred followed by an alternate form of incisional closure. In general, a relaparotomy is performed to remove the packs, irrigate out old blood and clot, and rule out injuries missed at the original damage control laparotomy.

In the original series from Grady Memorial Hospital reported by Stone et al.,¹³⁸ 17 trauma patients with intraoperative coagulopathies underwent damage control laparotomy including the insertion of diffuse packing with laparotomy pads. Reexploration was performed at 15–69 hours in 12 surviving patients, and 11 survived removal of the packs and definitive laparotomy.¹³⁸

Operative Techniques with Vascular Trauma in an Extremity

Damage control operations on an extremity are appropriate when exsanguination has caused intraoperative metabolic failure (shotgun wound of femoral triangle); when multisystem injuries have occurred and an emergent craniotomy, thoracotomy, or laparotomy needs to be performed in addition to the vascular repair of the extremity (occlusion of superficial femoral artery from a femur fracture); or when the instability of an open fracture precludes formal repair of the associated vascular injury (mangled extremity) (see Chapter 41).¹⁴¹

After rapid control of hemorrhage, an intraluminal Argyle or Javid shunt is inserted into the debrided ends of the injured femoral or popliteal artery and tied in place to preserve distal flow as the patient is resuscitated in the intensive care unit.¹⁷ The Pruitt-Inahara shunt may be used also and has inflatable balloons on either end so that tying the shunt in place is not necessary. This shunt has a T-port, which allows for the infusion of heparin, a vasodilator such as papaverine, or for arteriography in the postoperative period. A recent 10-year review of the use of 101 intravascular shunts at a single center found that shunts have a thrombosis rate of 5% and a limb/patient survival rate of 73% supporting their use in damage control procedures.¹⁷ In spite of their utility, the use of shunts nationwide is very limited.¹⁴²

While ligation of major venous injuries in the extremities has been well tolerated in many stable patients,^143,144 patients undergoing damage control operations often have severe sequelae.¹⁴¹ Among these are a compartment syndrome below the level of ligation in the lower extremity and excessive hemorrhage from soft tissue injuries and fasciotomy sites. Even if a compartment syndrome does not occur immediately, reperfusion injury as the patient undergoes resuscitation in the intensive care unit will often cause the syndrome to develop. For these reasons, venous outflow after segmental resection of an injured femoral or popliteal vein should be restored with a temporary intraluminal shunt as part of a damage control operation. Short segments of thoracostomy tubes (size 24–28 French) are used as shunts for the popliteal, superficial femoral, or common femoral veins. After removal of the shunt at a reoperation, an externally supported PTFE graft is used for segmental replacement.¹⁴⁵

When vascular control has been difficult to obtain with combined femoral or popliteal arterial and venous injuries, there may be some delay before the intraluminal shunts are inserted. In such a situation or when ligation of the femoral or popliteal vein has been necessary to prevent exsanguination, additional time should be spent to complete an ipsilateral four-compartment below-knee fasciotomy as part of the damage control operation. With two attending surgeons or senior residents performing these procedures, they can be completed within 20 minutes. The additional time involved prevents myonecrosis in the early postoperative period and allows the critical care team to focus on respiratory, cardiac, and renal resuscitation.

INDICATIONS FOR ALTERNATE CLOSURES OF INCISIONS

Intraoperative Metabolic Failure

In the previously described patients with hypothermia (temperature <35°C [95.0°F]), persistent acidemia , and/or the onset of an intraoperative coagulopathy, a damage control operation should be terminated with an alternate closure of the incision.

Planned Reoperation

One of the fundamental principles of the damage control operation is that a reoperation will be necessary to complete repairs and resections, perform anastomoses, look for missed injuries, change thoracostomy tubes, insert drains, and attempt closure of the incision. There are also techniques utilized at first operations for trauma, whether damage control was necessary or not, that mandate an early reoperation. Patients in whom the following techniques are used will also benefit from alternate forms of closure of the thoracic or abdominal incision:

• Insertion of perihepatic packing

• Insertion of intra-abdominal packing

• Planned second-look operation

Examples of patients who may require an early second-look procedure after laparotomy for abdominal trauma include those with primary repair of the renal or superior mesenteric artery and those with ligation of the superior mesenteric or portal vein. In the former group, repair of a small vasoconstricted artery in a hypotensive patient often leaves the surgeon with concern about an early postoperative thrombosis.^137,146 Early reoperation allows for visual inspection of the end organ after the patient has become hemodynamically stable. With major venous injuries, the dusky and congested appearance of the bowel after major splanchnic venous ligation during the initial operation often prompts concerns about secondary infarction of the involved intestine.^134–136 Planned reoperation is worthwhile in such patients, particularly if the base deficit does not correct in the first 8–12 hours after the ligation was performed.

Closure of the Incision Cannot Be Performed or Will Cause an Abdominal Compartment Syndrome

Edema and distention of the midgut have been commonly noted in the past during prolonged laparotomies for trauma in which patients in shock have been treated with the old paradigm of massive crystalloid resuscitation in addition to blood. Presumably, these changes are related to cellular edema from metabolic failure of the sodium pump in the cell membrane, a “capillary leak” phenomenon with secondary interstitial edema related to the release of vasoactive substances, reperfusion injury, the development of an ileus, or some combination of these.^{23,24,147–150} The volume of the midgut may increase significantly and, if perihepatic or intra-abdominal packs have been inserted as well, make formal fascial closure of the midline abdominal incision time-consuming and extraordinarily difficult. Should fascial closure be completed successfully, the increased volume and secondary increase in pressure (normal: 0 to subatmospheric) in the abdominal cavity may have severe adverse systemic effects, manifesting as the abdominal compartment syndrome.^23–33

ABDOMINAL COMPARTMENT SYNDROME

Definition

The abdominal compartment syndrome refers to new organ dysfunction/failure (especially decreased blood flow to the body wall and abdominal organs and secondary pressure effects on the respiratory, cardiovascular, and central nervous systems) when the intra-abdominal pressure (IAP) is sustained at greater than 20 mm Hg level.^23,24,151 While occasionally discussed in the literature since the 1800s, it is only in the past 25 years that the diagnosis has been made on a regular basis in patients on a variety of surgical and medical services.^{25–33,151,152}

The current subtypes of the abdominal compartment syndrome are defined as follows:¹⁵¹

1. Primary—acute or subacute intra-abdominal hypertension from an abdominal cause;

2. Secondary—subacute or chronic intra-abdominal hypertension from an extra-abdominal cause;¹⁵³ and

3. Recurrent—redevelopment of the abdominal compartment syndrome following treatment of a primary or secondary type.

Measurement of Intra-Abdominal Pressure

Direct measurement of IAP is accomplished by inserting an intraperitoneal catheter attached to a manometer or transducer.¹⁵⁴ In the clinical setting, indirect measurement is possible through a catheter inserted into the urinary bladder,^155,156 stomach,¹⁵⁷ or inferior vena cava.¹⁵⁸

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