**5. Back to OR**

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

The layer can be made by two layers of surgical drape made with a robust, conformable, and breathable polyester incise film coated with medical-grade acrylate adhesive containing molecular iodine as the active antimicrobial agent. Between the layers, we use large swabs. After making the layer, we shape it and cut according to the gap we would like to cover. Because of the surgical drape that covers both sides, this layer can be inserted inside the abdomen and be in touch with the bowel without problems. Then, the whole abdomen (all four quadrants) is covered with an extra surgical drape offering adequate sealing. We need to highlight the need for insertion of two large abdominal drains (usually 30Fr) to drain potential intra-abdominal fluid and, most importantly, to prevent abdominal compartment

We surgeons have done what we could and had to do. The patients need now an Intensivist and an ICU. Your colleagues are expecting them to arrive at any time, the anesthetist has already called them, and everything is ready. Intensivists are well aware of what is at stake. They know that grade III and IV diverticulitis implies the presence of intestinal macro-perforations responsible for the appearance of purulent or fecaloid peritonitis, which is associated with a high percentage of complications such as peritoneal abscesses, pyogenic liver abscesses due to the dissemination of the process through the portal circulation, small intestine obstruc-

The most common germs are gram-negative bacilli such as enterobacteria, anaerobes, and less frequently Enterococci and *Pseudomonas aeruginosa*. In post-surgical patients, there is an increase in cases of *Staphylococcus aureus* infection resistant to methicillin and *Candida* sp. if they have received the previous

Secondary peritonitis can trigger a dysregulated response by our organism that can lead to sepsis or septic shock and multiorgan failure depending on the severity,

If the patient needs vasoactive substances after adequate volume replacement to maintain MAP >60 mmH and serum lactate is >2 mmol/l, it is called septic shock. For treatment, from the first hours of admission, an attempt will be made to maintain adequate hemodynamic stability thanks to the administration of fluid therapy (30 ml/kg in the first 3 h) with intravenous crystalloids. The therapeutic and hemodynamic response will be re-evaluated frequently, to maintain Average Arterial Pension (MAP) >65 mmHg, Heart Rate (HR) >60, Oxygen Saturation (SO2) >90%, Central Venous Pressure (CVP) 12–8 mmHg, Temperature <37°C, and Diuresis greater than 0.5 ml/kg/h. We will try to optimize different analytical parameters such as ions, renal function, liver function, lactate levels, presence of acidotic, alkaline or mixed pattern, platelet count, and hemoglobin, indicating the

The recognition of a septic patient is based on the alteration of clinical and analytical parameters such as mean blood pressure (MAP) <70 mmHg or systolic pressure (SBP) <100 mmHg, renal failure with the presence of oliguria/anuria and increased creatinine levels >1.2 mg/dl, at the respiratory level may lead to respiratory distress syndrome that occurs with severe hypoxemia and need for respiratory support with high flow oxygen systems or invasive mechanical ventilation. Neurologically, obnubilation, or low level of consciousness may be seen. In terms of analytical parameters in the blood, metabolic acidosis, hyperlactacidemia, con-

which implies significant morbidity and mortality.

sumptive coagulopathy, and plaquetopenia stand out.

transfusion of red blood cells with hemoglobin levels ≤7 g/dL [15].

**78**

syndrome.

tions, fistulas, etc.

antibiotherapy.

**4. Intensive care unit (ICU)**

The operation has been done and the patient has been left in the experienced hands of ICU.

We do not fool ourselves: some (maybe many) of them will die in the next 12–24 h. The toll to pay is simply too much, especially in the case of elderly patients, or in the ones with many comorbidities. Usually the sicker, and more unstable, they were in theater, the sooner are expected to pass. We cannot give any percentage, because we do not have it, and also because it would be not pertinent to our story. Suffice to say that the reality is just a little better than what the P-POSSUM score told you, but not so much better as you would like.

For those who actually improve, they will eventually need a second operation, a so-called "second look."

The planning and decision making for a second look ideally were made by the operating surgeon while performing the initial damage-control surgical procedure. The second-look laparotomy is based on the fact that the surgeon should explore the patient's abdomen within 24 or 48 h, depending on the patient's hemodynamic stability. That means that a second-look laparotomy is a scheduled procedure and should ideally be performed in a patient that is stable with as less inotropic support as possible.

In any case, negative pressure abdominal dressings should be changed after 72 h most.

One of the most important parameters to have is the intra-abdominal pressure, or IAP. IAP should have been measured in ICU and you should prepare to measure it when attempting the closure.

Anesthetic-wise, usually the second-look poses no big challenges.

Intraoperatively, we have to assess if there is still contamination, the viability of the colonic stumps and whether or not there are any other issues that need to be dealt with (i.e., iatrogenic damages from the first surgery). Also, this is the time to finish the preparation of the proximal colon for the terminal colostomy.

In very selected cases, those who have improved very well in ICU and without comorbidities, we can opt for a primary anastomosis. Unfortunately, collectively, we have encountered very few of them. But we know that other colleagues have been more lucky.

Just a word about the rectal stump. It is quite uncommon to detect any problem at this level now, but not uncommon to have a dehiscence of the stump later on. We always leave a pelvic drain, only to drain the stump should it leak.

Usually, the "bowel" part of the second-look causes no big problem: whatever you do, it is more or less easy.

The challenge of the second-look is often the abdominal closure. Sometimes, it can be difficult to approximate the abdominal wound edges, mainly because of the edema of the intra-abdominal organs that can result in a high intra-abdominal pressure and difficulty to approximate the midline laparotomy edges successfully. The extent to which you can close the abdomen under tension is difficult to judge. We rely much on IAP, and feel safe to close if IAA is <12 mmHg. But also the quality of the tissue is crucial, and this is something that you cannot judge objectively.

As a rule, we do primary closure of the fascia is IAP <12 mmHg and accept the need of following surgeries for incisional hernia. We do not routinely do advanced abdominal wall reconstruction surgery at this stage, and prefer to do them, if indicated, during a former repair of an incisional hernia.

In the few cases, where you cannot close the abdomen due to elevated IAP, we use a **mesh**-**mediated** vacuum-assisted wound closure as proposed by Petersson et al., which in our hands is what works best [1].

An in-depth discussion of abdominal wall reconstruction is beyond the topic of this chapter.

Usually, after the second look, the patient will go back to the ICU. If the evolution is favorable in the following days, we can minimize the necessary support measures. In patients who have presented septic shock and multiorgan failure, we will progressively withdraw invasive mechanical ventilation, renal replacement therapies, and vasoactive drugs, depending on the recovery of these organs.

It is essential after overcoming the initial shock situation, at 24–48 h, to initiate adequate nutritional therapy since patients in septic shock suffer a hypercatabolic phase mediated by increased cytokines and lipid mediators with a peak between 3 and 4 days but which can be maintained for 7–10 days.
