Supplement 23:
Trauma Damage Control Laparotomy:
The “damage control” (DC) approach to managing severe trauma involves an abbreviated
resuscitative surgical approach with the primary goal being rapid control of hemorrhage and
contamination with restoration of metabolic function at the expense of normal anatomy [[1-5]].
Damage control laparotomy is typically a component of a larger DC approach that includes
DCR. Although it remains difficult to prove that this approach improves mortality and other
outcomes, it has been associated with unexpected patient survival [[6, 7]].
Evidence Summary:
We identified no studies that specifically addressed the effect of damage control
laparotomy on outcomes among those with IAH/ACS. In no related studies were routine IAP
measurements or the incidence of IAH assessed. Most related evidence was inferential. One
retrospective cohort study reported a reduction of ACS from 10% to 0% for trauma patients
receiving DC after the implementation of a trauma exsanguination protocol in a level I trauma
center [[8]]. A second retrospective cohort study reported IAP to be lower in the DC/DCR group
[[4]].
Recomendation:
The WSACS SUGGESTS that patients undergoing laparotomy for trauma suffering
from physiologic exhaustion be treated with the prophylactic use of the open abdomen
versus closure and expectant IAP management (Management Suggestion 7; GRADE 2D).
Rationale:
DCR may reduce the need for DC laparotomy [[9]]. However, until this has been clearly
established, those patients who are appropriately selected as requiring DC laparotomy are at high
risk of developing post-operative ACS if the abdomen is formally closed with use of expectant
IAP management.
References
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35: 642-648
Kirkpatrick AW, Ball CG, D'Amours SK, Zygun D, (2008) Acute resuscitation of the unstable adult
trauma patient: Bedside diagnosis and therapy. Can J Surg 51: 57-69
Rotondo MF, Schwab CW, McGonigal MD, Phillips GR, 3rd, Fruchterman TM, Kauder DR,
Latenser BA, Angood PA, (1993) 'Damage control': an approach for improved survival in
exsanguinating penetrating abdominal injury. The Journal of trauma 35: 375-382; discussion
382-373
Cotton BA, Reddy N, Hatch QM, LeFebvre E, Wade CE, Kozar RA, Gill BS, Albarado R, McNutt MK,
Holcomb JB, (2011) Damage control resuscitation is associated with a reduction in resuscitation
volumes and improvement in survival in 390 damage control laparotomy patients. Annals of
surgery 254: 598-605
Cirocchi R, Abraha I, Montedori A, Farinella E, Bonacini I, Tagliabue L, Sciannameo F, (2010)
Damage control surgery for abdominal trauma. Cochrane database of systematic reviews:
CD007438
Johnson JW, Gracias VH, Schwab CW, Reilly PM, Kauder DR, Shapiro MB, Dabrowski P, Rotondo
MF, (2001) Evolution in damage control for exsanguinating penetrating abdominal injury. J
Trauma 51: 261-271
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surgery 91: 83-85
Cotton BA, Au BK, Nunez TC, Gunter OL, Robertson AM, Young PP, (2009) Predefined massive
transfusion protocols are associated with a reduction in organ failure and postinjury
complications. J Trauma 66: 41-48; discussion 48-49
Schreiber MA, (2012) The beginning of the end for damage control surgery. The British journal of
surgery 99 Suppl 1: 10-11