Prehospital resuscitation with limited crystalloid of the trauma patient in extremis begins until arrival to the trauma bay, where damage control resuscitation with a 1:1:1 ratio of blood component therapy is initiated. Hypothermia has to be prevented with external rewarming measures. Communication with the anesthesia team about the operative plan and the ongoing resuscitation efforts is crucial.

An abbreviated laparotomy , with the primary goals of controlling hemorrhage and then intestinal spillage is performed. To achieve rapid hemostasis, large vessels can be repaired or shunted, small vessels ligated, liver packed, large wound tracts tamponaded with a balloon catheter, injured solid organs such as the spleen and kidney removed. Intestinal spillage should be managed with suture closure of smaller and stapling of larger injuries leaving the gastrointestinal tract in discontinuity. At the end of the procedure, the abdomen should be left open in order to prevent the development of abdominal compartment syndrome (ACS) while enabling easy reentry into the abdomen. Currently, the most widely used temporary abdominal closure techniques are the commercially available Abthera (KCI, San Antonio, TX) and the Barker wound vacuum pack (see Chaps. 1 and 4). Both of them are vacuum-assisted devices that provide the benefit of visceral protection, control of drainage, and preservation of fascia for latter definite closure. As previously mentioned, more antiquated techniques like the Bogotá bag, towel-clip and skin-only closure are generally slower, can provide neither adequate effluent control nor preservation of fascia. In case of severe liver bleeding with multiple packs in the right upper quadrant, the skin-only and towel-clip closure techniques may occasionally provide a desirable tamponade effect.

The goal of this phase is restoration of patient’s physiologic state. Each individual component of the lethal triad (acidosis, hypothermia, coagulopathy) is corrected. The resuscitation is completed using established end points. A concerted effort is made to prevent under and over resuscitation; the former being associated with an increased incidence of MODS, the latter with secondary ACS and difficulty achieving primary fascial closure. A vigilant reassessment is performed in the intensive care unit (ICU) to monitor the patient for the early development of secondary ACS which is possible notwithstanding an open abdomen with temporary closure. When recognized, this condition mandates immediate decompression and reexploration at the bedside if necessary. Other indications for early reexploration are worsening acidosis despite adequate resuscitation and continuous bleeding despite normothermia and correction of the coagulopathic state. Otherwise, following normalization of physiology, most patients are returned to the operating room in 48–72 h for reexploration.

Recently, direct peritoneal resuscitation (DPR) was evaluated as a resuscitation strategy in severely injured trauma patients with hemorrhagic shock requiring damage control surgery, and the impact on time to definitive fascial closure was among the end point studied. Twenty patients undergoing standardized wound closure and adjunctive DPR were identified and matched to 40 controls by Injury Severity Score (ISS), age, gender, and mechanism of injury. The DPR technique consists of suffusing the peritoneal cavity with a hypertonic glucose-based peritoneal dialysis solution. Previously, animal studies have shown this treatment to cause microvascular vasodilation and increase visceral and hepatic blood flow; reversal of endothelial cell dysfunction; improve of survival and downregulation of the inflammatory response; reversal of established microvascular constriction; normalization of capillary perfusion density; and normalization of systemic water compartments.