**9.4 Damage control phase III (DCIII)**

DCIII involves definite repair of the injuries once the patient is stabilized and has returned to his "physiologic normality" and commonly takes place within 24–72 hours after admission to the ICU. The patient is taken back to the operating room for re-exploration and packing removal (preferably after 48 hours) [21]. That is also the stage when an anatomic liver resection may be performed (**Figure 3**), along with the removal of devitalized tissue or vascular shunts, anastomosis of vessels or bowel, or even a feeding jejunostomy. The phase ends with the permanent closure of the abdominal wall. This should be performed with the approximation of the fascial edges if gentle adduction permits; if this is not possible due to retroperitoneal or bowel wall edema, then the abdominal wall should be again only temporarily closed with the fascia left open. In that scenario, the patient is taken back to the ICU and provided the patient is hemodynamically stable, administration of diuretics to decrease the bowel edema should be considered [30]. This situation should then be managed with washouts and re-inspection of the abdomen regularly, while primary closure should be completed within seven days, particularly in the absence of signs

**Figure 3.** *Surgical management of severe liver injury with active bleeding.*

of infection. Other abdominal closure alternatives should be considered if this is not possible. This will lead to a large ventral hernia that will require repair at some future time point [30].
