**8. Damage control surgery**

#### **8.1 Background**

Besides all advances portrayed, the prognosis of hemodynamically unstable patients with complex (AAST Organ Injury Scale 4 IV–V) liver injury is still poor, as their treatment and decision-making process are extremely challenging for the trauma team [21]. It is known that approximately 10% of the patients in this scenario will present life-threatening injuries and hemodynamic shock and that the primary and ultimate repair of severe traumatic injuries in patients with unstable physiology is detrimental to outcome [1, 22, 23]. A staged management approach known as "damage control surgery" (DCS) has been demonstrated to improve the survival in these cases [1, 22]. The principles of DCS involve abbreviated surgery to control blood loss and contamination in the abdomen with simultaneous resuscitation of physiology. Once the hemodynamic state is restored, the definitive surgical repair is performed [22, 24].

Although the term "damage control surgery" was first described for trauma management by Rotondo et al. [22], the idea of the procedure was already existent for a long time before. The proposal to use this surgery in trauma and emergencies has succeed during the Second World War, in the mid-1940s, when the structure for hospital care was insufficient and the number of victims exceeded the capacity to give support to the injured [25]. There are older reports of the application of this technique with similar purposes in Edwin Smith's Surgical Papyrus, more than 8000 years ago, a conduct used by the absence of other options at the time the idea was conceived [26].

According to a review by Benz and Balogh about damage control surgery, its modern model emerged in the late 1970s from clinical experience with major hepatic trauma [27]. Perihepatic packing consists in manually approximating the liver parenchyma followed by the consecutive placing of dry abdominal packs around the liver and straight over the injury. This technique was firstly incorporated by Pringle [28] in enthusiasm for staged laparotomy. Since then, numerous clinical reviews were conducted in order to study this technique.

Elerding et al. [29] observed that 82% of deaths following liver trauma were due to uncontrolled hemorrhage and progressive coagulopathy, even after primary vascular injuries had been addressed. The whole lethal coagulopathic state apparently was impaired by hypothermia and acidosis, the observation upon which the "lethal triad" term was suggested [23]. In 1981, Feliciano et al. [30] reported on the observed merit of temporary laparotomy pad tamponade for postinjury coagulopathy. Nine out of 10 patients with persistent hepatic parenchymal ooze, despite all attempts at surgical control, survived with intra-abdominal packing and delayed

**59**

*Liver Trauma Management*

option for using this technique.

**8.2 Intra-abdominal packing**

hemorrhage control [21].

volume replacement).

*DOI: http://dx.doi.org/10.5772/intechopen.92351*

removal. This finding led the authors to advocate the technique as a lifesaving maneuver in select trauma patients with persistent coagulopathy. Two years later, Svoboda et al. [31] reaffirmed the survival benefit of intra-abdominal packing.

Despite being initially organized as an emergency strategy in patients who have suffered severe trauma, the principles of damage control have also been approached in nontraumatic abdominal emergencies, in order to reduce mortality compared to definitive primary surgery [32]. According to the 10th edition of ATLS [33], damage control surgery is an important component of crisis management care, given that in many disasters, hospitals are destroyed and transportation to medical facilities may not be feasible or the environment may be contaminated, so this context is an

Damage control surgery by intra-abdominal packing has shown to be effective and able to significantly decrease morbidity and mortality, both in trauma and nontraumatic massive intra-abdominal hemorrhage [34]. In the last decades, consensus has been reached about considering the accomplishment of an effective perihepatic packing [35] to be the most effective and quickest way in order to obtain

This procedure consists in the placement, after fast and complete mobilization of the right liver lobe, of a total number of eight lap pads all around the posterior paracaval surface (avoiding vena cava compression), the lateral right side, the anterior surface, and posteroinferior visceral surface of the liver (avoiding any intrahepatic packing) [36, 45]. The diaphragmatic surface must remain free in order to avoid any respiratory compromise. Reoperation after appropriate resuscitation

Regarding the indications for damage control surgery, it is known that there is a wide range of conditions in which it can be used, and the decisive moment for the use of these techniques is not preoperative adequacy, but the intraoperative

Overall, in the context of severe trauma with hemodynamic instability, the rationale of performing a "shortened laparotomy" is usually based upon the concept of the lethal triad [25], composed of hypothermia (due to inadequate environmental conditions, deficient thermal protection, blood loss, and infusion of unheated liquids), metabolic acidosis (inadequate tissue perfusion, caused by hemorrhage and shock, which predisposes to anaerobic metabolism and metabolic acidosis), and coagulopathy (metabolic acidosis with interference on coagulation factors and

In a practical manner, there are some absolute indications for the procedure, such as estimated blood loss greater than 4 L and the administration of more than 10 red blood cell concentrates [37]. Although there are classic indications for performing damage control surgery, new studies have questioned these indications and proposed other observations to better elucidate the cases eligible for the procedure [37]. Among them, those who presented moderate accuracy were systolic blood pressure (BP) < 90 mmHg or central body temperature < 34°C, and five indications produced major and conclusive changes in the pretest probability of performing damage control surgery during emerging laparotomy: discovery of pancreas, duodenum, or pancreatic-duodenal complex devascularized or completely ruptured;

allows packing removal and definitive repair of liver injuries.

**8.3 Indications for damage control surgery**

becomes essential for the evaluation [37].

#### *Liver Trauma Management DOI: http://dx.doi.org/10.5772/intechopen.92351*

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

*Surgical techniques used to treat liver injuries in patients with liver trauma.*

Besides all advances portrayed, the prognosis of hemodynamically unstable patients with complex (AAST Organ Injury Scale 4 IV–V) liver injury is still poor, as their treatment and decision-making process are extremely challenging for the trauma team [21]. It is known that approximately 10% of the patients in this scenario will present life-threatening injuries and hemodynamic shock and that the primary and ultimate repair of severe traumatic injuries in patients with unstable physiology is detrimental to outcome [1, 22, 23]. A staged management approach known as "damage control surgery" (DCS) has been demonstrated to improve the survival in these cases [1, 22]. The principles of DCS involve abbreviated surgery to control blood loss and contamination in the abdomen with simultaneous resuscitation of physiology. Once the hemodynamic state is restored, the definitive surgical

Although the term "damage control surgery" was first described for trauma management by Rotondo et al. [22], the idea of the procedure was already existent for a long time before. The proposal to use this surgery in trauma and emergencies has succeed during the Second World War, in the mid-1940s, when the structure for hospital care was insufficient and the number of victims exceeded the capacity to give support to the injured [25]. There are older reports of the application of this technique with similar purposes in Edwin Smith's Surgical Papyrus, more than 8000 years ago, a conduct used by the absence of other options at the time the idea

According to a review by Benz and Balogh about damage control surgery, its modern model emerged in the late 1970s from clinical experience with major hepatic trauma [27]. Perihepatic packing consists in manually approximating the liver parenchyma followed by the consecutive placing of dry abdominal packs around the liver and straight over the injury. This technique was firstly incorporated by Pringle [28] in enthusiasm for staged laparotomy. Since then, numerous clinical

Elerding et al. [29] observed that 82% of deaths following liver trauma were due to uncontrolled hemorrhage and progressive coagulopathy, even after primary vascular injuries had been addressed. The whole lethal coagulopathic state apparently was impaired by hypothermia and acidosis, the observation upon which the "lethal triad" term was suggested [23]. In 1981, Feliciano et al. [30] reported on the observed merit of temporary laparotomy pad tamponade for postinjury coagulopathy. Nine out of 10 patients with persistent hepatic parenchymal ooze, despite all attempts at surgical control, survived with intra-abdominal packing and delayed

reviews were conducted in order to study this technique.

**8. Damage control surgery**

repair is performed [22, 24].

was conceived [26].

**8.1 Background**

**Table 2.**

**58**

removal. This finding led the authors to advocate the technique as a lifesaving maneuver in select trauma patients with persistent coagulopathy. Two years later, Svoboda et al. [31] reaffirmed the survival benefit of intra-abdominal packing.

Despite being initially organized as an emergency strategy in patients who have suffered severe trauma, the principles of damage control have also been approached in nontraumatic abdominal emergencies, in order to reduce mortality compared to definitive primary surgery [32]. According to the 10th edition of ATLS [33], damage control surgery is an important component of crisis management care, given that in many disasters, hospitals are destroyed and transportation to medical facilities may not be feasible or the environment may be contaminated, so this context is an option for using this technique.
