Although abdominal packing and abbreviated laparotomy had been described prior to this landmark manuscript, this sentence written by H. Harlan Stone in 1983 initiated a major paradigm shift in the operative management of patients with hemorrhagic shock after trauma. Previously, injured patients with or without shock underwent similar operations. All definitive procedures were completed at a first operation or the patient died in the process. A number of papers describing the coagulopathy associated with hypothermia and metabolic acidosis in injured patients with hemorrhage were then published over the next decade.^{1,2,3,4,5,6,7,8} Simultaneously, several centers began to practice the concept of Stone’s abbreviated laparotomy and assess the results.^9,10,11,12 In 1993, Rotondo et al from the University of Pennsylvania labeled these abbreviated procedures as “damage control” surgery; also, they documented that the strategy substantially improved survival (11% vs 77%) in patients with combined abdominal visceral and vascular injuries.¹³ Originally implemented for injured patients with “metabolic failure” or “physiologic exhaustion” (hypothermia, metabolic acidosis, coagulopathy), damage control surgery quickly became a technique used by multiple surgical specialties including the following: general surgery, thoracic surgery, vascular surgery, orthopedic surgery, gynecologic surgery, etc.^{14,15,16,17,18,19,20,21,22,23,24,25,26,27}

This chapter reviews the definition, indications, and techniques of “damage control” surgery on injured patients. Emerging concepts including damage control resuscitation, thromboelastography directed infusions of blood components, and resuscitative endovascular balloon occlusion of the aorta (REBOA—see Chapter 34) will be discussed, as well.

Definition

The abbreviated laparotomy in “damage control” surgery controls bleeding and limits further contamination from the gastrointestinal tract before the patient is transferred to the intensive care unit (ICU). Although early papers described a three step process, this has been expanded to include prehospital management and closure of the abdominal incision.

Stages

Prehospital (“Ground Zero”)

The initial evaluation by prehospital personnel often initiates the damage control process. Early notification of the trauma center about the level of hemodynamic instability and magnitude of injuries can prompt mobilization of operative and/or interventional teams. Permissive hypotension will be appropriate in patients without traumatic brain injuries, and blood transfusion during transport is available in some prehospital systems.

Abbreviated Initial Operation

As noted above there are certain subsets of patients who can be identified in the prehospital phase as likely to need damage control operations. Most decisions to initiate damage control operations, however, are based on the intraoperative physiology of the patient, the operative findings and amount of transfusion (Table 38-1).²⁸ Common historic indications have been for abdominal (56.5%) or vascular injuries (12.7%), especially in patients with unresolved metabolic failure despite control of hemorrhage in combination with damage control resuscitation.^{6,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44} The major recent evolution in the decision for damage control has been in recognizing patients at risk and early implementation of the strategies described herein, rather than waiting till traditional approaches have failed.²⁸

In addition to the control of hemorrhage and contamination in the abdomen described above, the concept of damage control now includes the following operative procedures in a number of locations in the body: packing of oozing spaces and organs including the pleural cavity, liver, spleen, retroperitoneum, abdominal cavity; temporary intravascular shunting rather than ligation of named arteries or veins in the abdomen and proximal extremities; and temporary closure (skin staples, skin sutures, towel clips only) or coverage (silo, vacuum-assisted device) of incisions in the neck, chest, abdomen, or an extremity.

Resuscitation in the ICU

Any postoperative hypothermia, metabolic acidosis, and/or a coagulopathy (metabolic failure or physiologic exhaustion) is treated during the IUC phase. Newer concepts such as “damage control resuscitation” (whole blood or high ratio blood components and limited infusion of crystalloid solutions) and goal-directed resuscitation may decrease the incidence of known complications such as the adult respiratory distress syndrome and the primary or secondary abdominal compartment syndrome.

Reoperation

Once the patient’s metabolic failure has been corrected and there are limited numbers of major organ failures, reoperation is performed from 12 to 72 hours after the original damage control operation. In a patient with a prior damage control laparotomy, the goals at reoperation are as follows: removal of packs, comprehensive examination to find missed injuries, reestablish intestinal continuity, create stomas, and insertion of drains and feeding access (nasojejunal feeding tube, feeding jejunostomy).

Closure of Abdominal Wall

Factors influencing the decision on whether to formally close the midline incision versus cover the open abdomen at the end of the reoperation include the following: the patient’s cardiovascular, respiratory, and renal status; the continuing need to complete organ repairs or gastrointestinal reconstruction; distension of the midgut; and the distance separating the two sides of the linea alba.⁴⁵ Also, it is recognized that an inappropriately timed midline aponeurotic closure may cause an abdominal compartment syndrome that negates all the advantages of the damage control process.^46,47,48

Operative Techniques in Thoracic Trauma

Heart

Surgical access to the heart is attained by a left anterolateral thoracotomy (the most rapid approach), bilateral anterolateral thoracotomy with transverse sternotomy, or a median sternotomy (see Chapter 26). Once the pericardium is opened, a number of techniques are available to obtain temporary or permanent control of hemorrhage from the heart by a general surgeon. Digital compression is one of the quickest ways, but may be inadequate for blunt ruptures or multiple penetrating injuries. Skin staples (6 mm) have been shown to be quick and effective for temporary or permanent control of hemorrhage from penetrating wounds.^49,50,51,52 Formal cardiac repair in the operating room with a nonabsorbable monofilament suture and Teflon pledgets can then be performed in between or overlying the staples, which can be sequentially removed if so desired by the surgeon.

Larger wounds or ruptures may be temporarily controlled by the insertion of a Foley balloon catheter directly into the injury.^53,54 Once the balloon is within the heart, it is inflated and traction gently applied to plug the hole. Teflon-pledgeted sutures are then passed through the atrium or ventricle over the balloon, recognizing that the balloon can be easily punctured. One technique to avoid this complication is to remove the traction on the balloon and push the catheter slightly into the cardiac chamber while the suture is being placed, although this results in significant blood loss.

If the above measures are insufficient, such as with a longitudinal perforation or significant rupture of a ventricle, inflow occlusion is a time-honored technique that is useful in avoiding cardiopulmonary bypass.⁵⁵ Inflow occlusion involves placing curved aortic or angled vascular clamps on the superior and inferior vena cavae. As the heart slows, horizontal sutures are inserted rapidly on either side of the defect and then crossed to control hemorrhage. A continuous suture or staples are placed to close the defect and, before completion, air is vented out of the elevated ventricle by releasing the clamps on the cavae.

Although cardiopulmonary bypass is rarely required (2% of the time acutely) in penetrating cardiac injuries, it is appropriate for larger wounds not amenable to simple suture repair or for wounds in which repair has failed.^55,56,57,58

Lung

In the rare patient who arrives with signs of life after sustaining an injury to the pulmonary hilum just at the border of the pericardium, intrapericardial control of the pulmonary artery may be necessary (see Chapter 25). The previously performed ipsilateral thoracotomy should be extended across the sternum and into the contralateral thorax to allow for wide exposure of the pericardial contents. The intrapericardial right pulmonary artery is exposed by retracting the superior vena cava to the right and the ascending thoracic aorta to the left. The right pulmonary artery passes transversely and posterior to these structures and can be clamped between them. The intrapericardial left pulmonary artery passes transversely, inferior and posterior to the transverse aortic arch and is exposed by retracting the ascending thoracic aorta to the right and superiorly.

Exsanguinating hemorrhage more laterally from the hilum or from the pulmonary parenchyma is controlled by cross-clamping or temporary hand control of the hilum, the hilar twist, or application of a hilar snare. Cross-clamping is the application of a DeBakey aortic clamp from superior to inferior if the inferior pulmonary ligament has not been divided.⁵⁹ If there is time to divide the inferior pulmonary ligament, the cross-clamp can be placed in an anterior-to-posterior direction. Hand control of the pulmonary hilum has been described, as well. Left hand control of the right pulmonary hilum by the surgeon will allow for the assistant to evacuate blood from the pleural cavity, divide the inferior pulmonary ligament, and replace the surgeon’s manual control with his or her own hand. The surgeon then applies an aortic cross-clamp across the hilum in the most appropriate direction.⁶⁰ The surgeon’s right hand is used for manual control of the left pulmonary hilum. The “hilar twist” as described by the group at Ben Taub General Hospital includes division of the inferior pulmonary ligament and then rotating or twisting the lung 180° to control exsanguinating parenchymal hemorrhage.^61,62 The hilar snare is an experimental technique in which an umbilical tape is passed around the pulmonary hilum and pulled tight through a 36 French plastic tube acting as a Rumel tourniquet.⁶³

A definitive technique to expose the source of bleeding from deep parenchymal stab wounds or missile tracks is pulmonotomy or pulmonary “tractotomy.”^64,65 The pulmonary parenchyma overlying the area of bleeding is divided between noncrushing vascular clamps or a linear stapler. This exposes injured parenchymal vessels, which can be selectively ligated. The pulmonotomy can then be closed used a continuous 0 or 2-0 absorbable suture or left open if the injured lung is too edematous.

It is now commonly accepted that “lung-sparing” operative techniques have improved outcomes in patients undergoing either urgent or damage control procedures on parenchymal injuries.⁶⁶

Thoracic Damage Control

Packing with or without closure of the incision is now used in patients with an intraoperative coagulopathy and oozing from the lung or pleural cavity.^67,68 Garcia et al have recently reviewed damage-control techniques in the management of severe trauma to the lung, while Phelan et al had previously summarized multiple techniques used in injuries to the heart, great vessels, and lungs (Table 38-2).^69,70

Esophagus

Primary closure without an overlying buttress is appropriate management of the perforated esophagus in a damage control situation (see Chapter 25).^71,72,73 At a reoperation, reinforcement of the repair is appropriate with one of the following: (1) cervical esophagus—sternal head (detached) of the sternocleidomastoid muscle; (2) thoracic esophagus—rhomboid muscle, intercostal muscle, three-sided pleural flap; (3) abdominal esophagus—fundoplication or 3-sided diaphragmatic flap. If primary repair is not possible because of a large defect in the cervical esophagus, creation of a lateral loop esophagostomy at this site over a Robinson catheter as a rod is appropriate.⁷⁴ With a similar large defect in the thoracic esophagus, insertion of a surgeon-created large T-tube (Abbott-Mansour tube) into the defect is a time-honored technique.^75,76

Operative Techniques in Abdominal Trauma

Gastrointestinal Tract

Most duodenal injuries are caused by penetrating trauma and are commonly associated with injuries to the pancreas and/or upper abdominal vessels (see Chapters 32, 33). A Kocher maneuver should be performed to allow for complete visualization of an injury to D₁, D₂, or D₃. In patients who are hemodynamically unstable, the perforation should be quickly oversewn in a transverse direction, if possible, with a continuous full-thickness suture of 3-0 or 4-0 polypropylene or side stapled with a TA-stapler. A No. 10 Jackson-Pratt drain is then placed inferior to the repair. At an early reoperation, the suture or staple line is inspected and repaired or replaced, if necessary. Techniques that have been used to protect a narrowed, complex, or tenuous repair of the duodenum are duodenal “diverticulization,” triple tube drainage or pyloric exclusion with antecolic gastrojejunostomy. Duodenal diverticulization is mentioned for historical interest only. The sacrifice of a normal gastric antrum and need to insert a T-tube into a normal-sized common bile duct have always limited enthusiasm for this procedure.⁷⁷ The triple-tube approach (gastrostomy, transjejunal retrograde duodenostomy, antegrade jejunostomy) described in 1978 is an effective decompressive procedure, but has the disadvantage of making three new holes in the upper gastrointestinal tract to insert the tubes.⁷⁸ Pyloric exclusion and antecolic gastrojejunostomy were used extensively at Ben Taub General Hospital/Baylor College of Medicine in the 1970s and 1980s.^79,80 Many urban centers, however, have abandoned the technique over the past 20 years or more as no improvements in the rate of postoperative sepsis and mortality could be demonstrated with this adjunctive procedure.^{81,82,83,84,85}

Rapid control of contamination from the small bowel and colon is one of the main goals of damage control laparotomy as previously noted. Noncircumferential injuries are closed with a 3-0 suture in a transverse direction similar to duodenal perforations. Multiple or large perforations within a short segment of small bowel or colon are best treated with segmental resection, utilizing large metal clips to control mesenteric bleeders and linear staplers to divide the bowel. Reestablishing intestinal continuity with an anastomosis or forming an ostomy is not performed until the reoperation in 12–72 hours. While there is still controversy, most authors currently favor performing an anastomosis of the colon at a reoperation when resection was performed at the damage control procedure.^86,87 In one recent article favoring this approach, contraindications to a delayed colon anastomosis included “severe acidosis, bowel wall edema, and/or persistent intra-abdominal infections.”⁸⁷

Liver

As the liver receives 1500 mL of blood per minute, rapid control of hemorrhage is the primary goal (see Chapter 29). Hemostasis for American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) grade I or II injuries is by temporary compression with laparotomy pad packs, electrocautery and/or topical hemostatic agents.

With grade III to V injuries and the need for a damage control procedure, bimanual compression to close a deep laceration or to compress a stab or missile tract followed by the insertion of perihepatic packing with dry laparotomy pads will control the hemorrhage in many patients.^9,10 Any raw hepatic surface should be covered with a plastic drape prior to insertion of the laparotomy pads to decrease the risk of rebleeding when the packs are removed at a reoperation (Fig. 38-1). Also, it should be noted that there have been refinements in the operative placement of perihepatic packs in recent years.^88,89 The acute disadvantages of tight perihepatic packing are now well known and include compression of the retrohepatic vena cava with secondary oliguria and contributing to the development of an abdominal compartment syndrome. And, the surgeon should be mindful of the possible need for postoperative hepatic arteriography with therapeutic embolization as an adjunct to laparotomy. If the radiopaque markers of the laparotomy pads are not cut off, they may obscure the visualization of bleeding intrahepatic arteries during the subsequent arteriogram.

If perihepatic packing successfully tamponades hepatic hemorrhage, the perihepatic packs are left in place and a skin closure only of the upper one-third of the midline incision with towel clips is performed to maintain perihepatic tamponade with the packs. A temporary silo or vacuum-assisted coverage is used over the remaining two-thirds of the open abdomen until the reoperation for removal of the packs is performed.

If perihepatic packing is not successful in controlling hemorrhage, a Pringle maneuver is performed. Although the exact length of time that this maneuver can be applied in the hypothermic patient is unknown, one hour in the absence of cirrhosis is acceptable to most senior surgeons with experience in operative hepatic trauma.^90,91 If the Pringle maneuver controls hepatic hemorrhage, the falciform ligament and the triangular and coronary ligaments of the injured lobe are divided to allow for its mobilization into the midline.

Advanced indirect methods of control for hepatic hemorrhage in damage control situations include balloon catheter tamponade, absorbable mesh tamponade, and extensive compressive suture hepatorrhaphy.^54,92 Balloon catheter tamponade can be used in long transhepatic stab or missile tracks. A Foley catheter, Fogarty catheter, or Penrose drain over red rubber catheter (tied down at either end) is sequentially advanced into the track, and the balloon is inflated. Successful control of hemorrhage mandates continued inflation until a reoperation. Absorbable mesh tamponade is a time-honored technique for control of hemorrhage from any disrupted solid organ in the abdomen. Either a disrupted lobe with viable fragments attached to the hilum is encircled with a large piece of mesh with the edges sutured together or a piece of mesh is used to replace a disrupted Glisson’s capsule after rupture of a subcapsular hematoma. Extensive hepatorrhaphy with zero absorbable continuous or interrupted sutures (figure of 8) is a historical technique that is still useful in damage control operations on the liver. This technique can lead to significant hepatic necrosis when the “Pringle time” is prolonged and the sutures are tied tight enough to compress intraparenchymal injured vessels.⁹²

Advanced direct methods of control for hepatic hemorrhage include hepatotomy with selective vascular ligation and resectional debridement. A rapid hepatotomy or entrance into the liver is performed using the electrocautery or finger fracture in damage control situations and allows for exposure of injured vessels and bile ducts in deep lacerations or in stab or missile tracks. Either clips or ties can be used on these structures when they are small. On occasion, a laceration in a large intrahepatic vein can be repaired with a 5-0 polypropylene suture. Resectional debridement is indicated for partial avulsions of hepatic segments II/III or VI/VII. With a Pringle maneuver in place, the electrocautery is used to mark a line on the uninjured hepatic capsule medial to the frayed and partially avulsed segments. A combination of the electrocautery and multiple metal clips placed on uninjured vessels and ducts in the line of resection will allow for rapid resection of all injured parenchyma, vessels, and ducts laterally. In a patient with an intraoperative coagulopathy, deep horizontal mattress sutures placed circumferentially around the raw edge of the remaining injured liver may help control hemorrhage. Approximating the anterior and posterior edges of the remaining uninjured liver with large compressive horizontal mattress sutures is another option.⁹³

Other advanced damage control techniques of hepatic hemostasis used in the past have been abandoned (selective hepatic artery ligation) or are used in less than 2–4% of patients (formal hepatic resection).

If hepatic hemorrhage is not temporarily controlled by packing or by applying a Pringle maneuver, an injury to the retrohepatic vena cava or a hepatic vein should be suspected. Mobilization and elevation of the overlying injured hepatic lobe after warning the anesthesiologist about the increased blood loss will allow for visualization of the area of venous injury. Another attempt at perihepatic packing of the overlying lobe is worthwhile as this is venous hemorrhage, but failure of packing to control hemorrhage will lead to a significant mortality regardless of subsequent operative management.⁹⁴ Operative and endovascular options include the following: (1) direct temporary control of the laceration in the vein with Judd-Allis clamps followed by suture repair,⁹⁵ (2) direct transhepatic approach,⁹⁶ (3) total hepatic vascular occlusion (clamping of the portal triad and suprahepatic and infrahepatic inferior vena cavae),⁹⁷ (4) insertion of a No. 36 French thoracostomy tube or a No. 8 endotracheal tube as an atriocaval shunt after loop control of the suprarenal and intrapericardial inferior vena cava,⁹⁸ (5) venovenous bypass (from the common femoral to axillary or internal jugular vein),⁹⁹ and (6) use of an endovascular stent.^100,101,102

Spleen

Under damage control conditions splenectomy is the safest choice for an AAST OIS grade III, IV, or V injury (see Chapter 30). Should an AAST OIS grade I or II injury be present, splenorrhaphy after rapid mobilization may be faster than splenectomy and will avoid leaving a denuded retroperitoneal bed in the coagulopathic patient (Fig. 38-2). Options for rapid splenorrhaphy with grade I or II injuries include application of topical hemostatic agents or repair with a 3-0 chromic or polypropylene suture.¹⁰³ On occasion, after application of topical hemostatic agents or absorbable mesh to replace part of the splenic capsule, perisplenic packing with laparotomy pads may ensure hemostasis.

Pancreas

Parenchymal defects not involving the duct and ductal injuries are treated with closed suction drainage once hemorrhage from the gland or underlying mesenteric-portal vessels is controlled at the damage control operation (Fig. 38-3) (see Chapter 32). At reoperation, parenchymal defects are filled with a viable omental plug, while ductal transections to the left of the mesenteric vessels are treated with a distal pancreatectomy and splenectomy in adults.^104,105 Ductal defects in the head of the pancreas or an AAST OIS grade V injury of the pancreas (“massive disruption of pancreatic head”) mandate pancreatoduodenectomy at the reoperation. Depending on the patient’s condition the Whipple resection and subsequent reconstruction may have to be performed at two separate reoperations.^106,107

Abdominal Arteries

Major named abdominal arteries are managed with repair, insertion of a temporary intravascular shunt, or, on rare occasions, ligation at the damage control laparotomy (see Chapter 34). With segmental loss or need for resection of the suprarenal or infrarenal abdominal aorta, a large intraluminal shunt (thoracostomy tube) may be used if the surgeon is uncomfortable in inserting an interposition graft (12-, 14-, or 16-mm-woven Dacron, albumin-coated Dacron, or PTTE). A significant injury to the celiac axis or one of its branches is treated with ligation, though the hepatic artery proper or common hepatic artery may be amenable to repair, on occasion. An extensive injury to a renal artery is treated with ligation and ipsilateral nephrectomy at the reoperation in the presence of a palpably normal contralateral kidney. The superior mesenteric, common iliac and external iliac arteries are never ligated by experienced trauma surgeons. A better choice is insertion of an intraluminal Argyle (Sherwood Medical Co., St. Louis MO.), Javid (C.R. Bard, Inc., Murray Hill, NJ), or Pruitt-Inahara (LeMaitre Vascular, Inc., Burlington, MA) shunt to maintain arterial inflow to the midgut or lower extremity (Fig. 38-4).^{108,109,110,111} If the surgeon lacks the experience to insert a shunt into the superior mesenteric artery and chooses ligation, an early reoperation for vascular reconstruction is mandatory to avoid loss of the midgut. In similar fashion, ligation instead of shunting of the common or external iliac artery mandates performing a four compartment fasciotomy of the ipsilateral leg at the damage control operation.¹¹²

Abdominal Veins

Ligation is the treatment of choice in a damage control situation if there are multiple abdominal injuries and a significant injury to one of the following veins: infrarenal inferior vena cava; superior mesenteric vein; renal vein; common, external, or internal iliac vein; or portal vein (see Chapter 34).¹¹² Ligation of the infrarenal inferior vena cava in a patient with hemorrhagic shock and the need for massive transfusion mandates measuring a compartment pressure in the bilateral below knee anterior muscle compartments at the damage control operation. A pressure of 30–35 mm Hg mandates immediate bilateral below knee two-skin incision four-compartment fasciotomies. In addition, serial monitoring of the pressures in the anterior compartments of the thighs should be performed in the ICU postoperatively. Significant infusion of crystalloid solutions will be necessary in the postoperative period, as well.

Lateral repair or ligation is the treatment for an injury to the renal vein. Ligation of the right renal vein mandates a right nephrectomy at a reoperation. If the left renal vein is ligated medial to the entrance of the left adrenal and gonadal veins, nephrectomy may not be necessary. Long-term follow-up of left renal function is necessary in such a patient.

Ligation of the superior mesenteric or portal vein causes splanchnic hypervolemia as described by Stone et al in 1982.¹¹³ The associated systemic hypovolemia that results will, once again, be treated with significant infusions of crystalloid solutions.

Pelvic Trauma

Closure of an “open book” (anterior-posterior compression) closed pelvic fracture with a compressive sheet wrap or binder or external fixation by the orthopedic service will control hemorrhage in 90–92% in-patients (see Chapter 35). Patients who remain hypotensive while waiting for angiography with embolization may benefit from the interim placement of extraperitoneal pelvic packing.^{114,115,116,117} After an 8-cm longitudinal incision from the umbilicus to the pubis is made, the extraperitoneal paravesical spaces are packed with three laparotomy pads on either side. In order not to obscure extravasation on subsequent pelvic arteriography, the tails of the laparotomy pads should be removed before insertion into the pelvis. When a laparotomy has been performed for other abdominal injuries and a pelvic hematoma is noted to be expanding without pulsations, intrapelvic packing with laparotomy pads without tails is performed.

Selective embolization of branches of the internal iliac artery for hemorrhage after pelvic fractures has been available since 1971.¹¹⁸ Many centers continue to perform bilateral embolization of the main internal iliac arteries when exsanguinating hemorrhage is occurring, though there continue to be reports of buttock necrosis when a crush injury has occurred.^{119,120,121,122} For these reasons, surgical ligation of the internal iliac arteries for pelvic hemorrhage has fallen into disfavor until recently. In 2010, DuBose et al demonstrated that temporary or permanent occlusion of the bilateral internal iliac arteries at surgery was worthwhile in a small subset of patients in a damage control situation who would “not survive to reach angiography.”¹²³

Transpelvic gunshot wounds can cause exsanguinating hemorrhage from the presacral veins. Ligation of injured presacral veins is very difficult as they are intimately adherent to the periosteum of the sacrum. One option for control during a damage control procedure is the insertion of (preferably) sterile tacks into or around the defect in a vein with an orthopedic hammer. Another option is to sew a free piece of omentum into the venous defect with sutures into the periosteum of the sacrum. Failure of either option to control venous hemorrhage should be followed by the insertion of intrapelvic laparotomy pad packs without tails.

Resuscitative Thoracotomy Versus Retrograde Endovascular Balloon Occlusion of the Aorta

Resuscitative thoracotomy and retrograde endovascular balloon occlusion of the aorta (REBOA) are two damage control techniques used in the management of patients with noncompressible bleeding in the chest, abdomen, or pelvis (see Chapter 34). Resuscitative thoracotomy has been used in the United States since the late 1800s, but did not become widespread until the 1960s and 1970s.¹²⁴ Since that time, numerous studies have examined this technique, the timing of its application, and its use in a variety of thoracic and abdominal injuries, both from blunt and penetrating trauma.^125,126,127 Concerns have been raised about the increased exposure risk to health care providers, the revival of patients with residual severe anoxic encephalopathy, and an overall low survival rate.^128,129 From the numerous writings on the subject, certain patient factors have been shown to impact the success of this technique, including the following: mechanism of injury, initial vital signs, cardiac rhythm, and presence or absence of signs of life on presentation.^129,130 For patients arriving in shock, current data reflect a 15% survival for patients presenting after penetrating trauma (primarily patients with stab wounds of the heart) and 2% for patients after blunt trauma.¹²⁷

First described during the Korean War, balloon occlusion of the aorta has recently been the subject of renewed interest and research.^{131,132,133,134,135,136} There are no current studies comparing this technique to that of resuscitative thoracotomy in humans, and the role of REBOA has not been clearly defined. The American Association for the Surgery of Trauma, however, is collecting data on all approaches to aortic occlusion (resuscitative thoracotomy, REBOA, and laparotomy).¹³⁵ Limitations of REBOA include complications such as paraplegia and femoral artery thrombosis, the need for radiologic guidance, and, formerly, a large deployment device requiring a closure of the arteriotomy.^{135,136,137,138} The size of the deployment device has decreased, but further study and testing of FDA approved devices are needed before widespread use.

Intra-Abdominal Packing

Diffuse intra-abdominal packing as described by Stone in 1983 is rarely indicated in the modern era of damage control resuscitation and massive transfusion protocols.¹ The current indications are oozing in the retroperitoneum (splenic bed, renal bed, bed of pancreas, paraspinal or spinal area) or pelvis secondary to an intraoperative coagulopathy. As with perihepatic packing, dry folded laparotomy pads are preferred as is a temporary closure of the abdominal wall (skin closure with towel clips or sutures). Reoperation for removal of the packs should be performed as soon as the patient is hemodynamically stable and the coagulopathy is resolved (see below). Part of the reason for this is the known contamination that occurs with the presence of intra-abdominal packs.^139,140

Operative Techniques for Temporary Closure of the Abdominal Wall or Coverage of the Open Abdomen

General

Damage control operations often end with a temporary closure of the abdominal wall or with a temporary cover of an open abdomen. The three main reasons have been consistent over the past 30 years and include the following: (1) unable to close the midline incision over an enlarged midgut (avoid abdominal compartment syndrome—to be described); (2) need to perform an early reoperation as a damage control operation has been performed; and (3) loss of or severe injury to abdominal wall (Table 38-3).

Management of the open abdomen can be divided into two phases. The first phase in the acute setting is to provide temporary closure or coverage. The temporary closure or cover should not add significant time to the initial damage control operation and will allow the patient to be taken from the operating room to the intensive care unit for additional resuscitation and stabilization. Once the patient’s physiology has normalized, the patient then enters the second phase, that is, managing the open abdomen. The goal of this phase is not only continued protection of intra-abdominal contents, but also progression towards definitive closure. Closure of the abdomen within 8 days is preferred to reduce complications from the open abdominal wound.^{45,141,142,143,144,145}

Towel Clip or Continuous Suture Closure of the Skin Only of the Incision

The towel clip or continuous suture closure of the skin only is a simple and rapid technique used for temporary closure of cervical, thoracic, abdominal, or extremity incisions. The towel clips or suture bites are placed at approximately 1.5 cm intervals to prevent evisceration of underlying viscera.

With the towel clip closure, 25–30 will usually be applied to close a midline abdominal incision in 2 minutes. Suture closure is performed with a 2-0 nylon or thicker suture. To prevent manipulation of either closure, decrease cross-contamination, and decrease fluid leakage from the underlying body cavity, a plastic adhesive drape is applied over the clips of sutures.

With ongoing concerns about contributing to a postoperative abdominal compartment syndrome, these temporary skin closures are rarely performed in the modern era.

Temporary Silos

The technique of using a large piece of nonadherent material over the open abdomen was first described in Bogota, Colombia by Dr Oswaldo Borraez G. at the San Juan de Dios Hospital in 1984. Therefore, the silo is commonly referred to as a “Bogota bag.” As the technique of complete silo coverage has evolved, a variety of materials and methods have been used, including the following: large sterile intravenous or irrigation bags, Silastic sheeting, parachute silk, polytetrafluoroethylene patch, and x-ray cassette covers.^{141,142,145,146} When a small- or moderate-sized silo is needed, an adherent plastic wound drape (Steri-Drape, 3M Healthcare, St. Paul, Minnesota) is applied to the skin around the open abdomen. In patients with significant distention of the intra-abdominal contents, a stronger silo can be made with a sterile x-ray cassette cover, Silastic sheeting (DowCorning Corp, Midland, Michigan) or a sterile 2.5 L genitourinary irrigation bag size by cutting three seams of the bag open. The silos are sewn to the skin edges of the abdominal wound with 2-0 nylon or polypropylene suture. Advantages of this technique include its low cost, nonadherence of the silo to the bowel, ease of removal, and low incidence of postoperative abdominal compartment syndrome. In addition, some materials allow for visual inspection of the bowel at the bedside for patients in whom bowel ischemia is suspected. The disadvantages, however, are that this technique does not allow for effective fluid removal from the abdomen or prevent retraction of fascial edges. Although temporary silos are still used as the first cover of the open abdomen after a damage control operation by some senior surgeons, they are usually replaced by a negative pressure device at the first reoperation.

Zippers, Slide Fasteners, Velcro Analogue

Originally described by Leguit in 1982, the zipper closure of the abdominal wall was popularized by Stone et al in the United States in their open treatment of patients with pancreatic abscesses.^147,148 Either a conventional zipper is sutured to the skin or fascia with a continuous suture of 0 or 2-0 nylon or polypropylene, or a commercial zipper with adhesive sidepieces is applied to the skin edges. The major advantage of using the skin is that it preserves the fascia for formal wound closure at an appropriate time.

Another commercial device is the Wittmann Patch (Starsurgical, Burlington, Wisconsin). It is a device that consists of two adherent Velcro sheets, one consisting of loops, the other of hooks. The sheets are cut to the length of the incision and sewn to the fascia. The sheets are then pulled from either side allowing them to overlap and be pressed together. This provides continuous fascial tension along the length of the incision in an effort to prevent loss of abdominal domain. This process is then repeated with serial trimming of the sheets, thereby gradually pulling the fascial edges closer together until closure of the midline incision can be safely performed. The major advantages of this system are the ease of access for reoperations and the tension on the aponeurotic edges that prevents the usual lateral retraction. Good success in achieving definitive closure has been documented in the literature with this device. Tieu et al reported an 82% closure rate using the Wittmann Patch in a mixed population of trauma and critically ill surgical patients.¹⁴⁹ In a study by Weinberg et al, delayed primary fascial closure was achieved in 78% of trauma patients treated with the Wittmann Patch.¹⁵⁰ A “modified Wittmann” technique has been described with good closure rates, as well. Fantus et al described placing a nonadherent layer, such as the previously mentioned sterile x-ray cassette cover, under the abdominal wall and over the viscera to decrease the formation of adhesions between the two that would make delayed fascial closure more difficult.¹⁵¹ Despite the high closure rate, this system is not without its disadvantages. This device is contraindicated in patients with intra-abdominal sepsis because it does not allow for an efficient egress of fluid. In addition, the serial tightening can result in damaged and ischemic fascia which could make primary abdominal closure more difficult. Despite these concerns, the abdominal complication rates associated with the use of the Wittmann Patch are comparable to other temporary abdominal serial tightening techniques.¹⁵²

Visceral Packing

This older technique placing nylon cloth material over the midgut has been used at Detroit Receiving Hospital for almost 40 years.^153,154 The cloth is covered with “generous” gauze packs, and several widely spaced retention sutures are placed through the abdominal wall above the packs. Every effort is made to keep the midgut below the fascial edges to lessen dilation and thinning of the wall.

As midgut edema resolves, the retention sutures are gradually tightened at each reoperation until the linea alba can be reapproximated and definitive primary closure achieved. In the report by Bender et al, 15 or 17 patients surviving longer than 24 hours had successful closure of the midline incision using the technique described.¹⁵³ There were no enterocutaneous fistulas nor incisional hernias in the 14 long-term survivors. One significant advantage of this technique is that it serves not only as a temporary closure, but also as a method to achieve primary closure by placing progressive amounts of tension on the abdominal wall.

Vacuum-Assisted Wound Closure

Schein et al first reported the negative pressure dressing as a temporary abdominal wound closure in 1986.¹⁵⁵ The dressing they described consisted of Marlex mesh applied directly on top of the bowel with suction drains overlying the mesh. An Op-Site adhesive drape was then placed over both the mesh and drains.

Over the past 19 years, this technique has been modified by several groups, but typically consists of a nonadherent perforated subfascial drape with blue towel, laparotomy pad, or sponge with or without sutures to provide constant fascial tension.^{156,157,158,159,160,161,162} At the present time, a commercially available negative pressure dressing, the AbThera (Kinetic Concepts, Inc., San Antonio, TX) is most commonly used. Approved by the United States Food and Drug Administration in 2009, it consists of two layers. The innermost layer is made of nonadherent fenestrated plastic with six pieces of foam arranged in a radial pattern. It is placed directly on top of the viscera and extends widely into the paracolic gutters and pelvis. The second layer is a foam sponge cut to accommodate the abdominal wound and is placed directly on top of the first layer. An adhesive drape is then applied over this polyurethane foam to keep the dressing in place and provide an airtight seal to the system. A small section of the adhesive drape and foam underneath are removed, allowing for the suction tubing system to be applied. Another commercially available device is the ABRA Abdominal Wall Closure System (Canica, Ontario, Canada). This product integrates a silicone traction component with a skin fixation component. The combination is used to provide gentle elastic traction on the tissues theoretically preventing loss of abdominal domain and facilitating primary wound closure. This device is less commonly used than the AbThera, and more clinical data are still needed to determine its role.

There are many advantages to this type of closure. The dressing can be used as a temporary abdominal closure and will aid in completing primary fascial closure. On a cellular level, studies have shown that the application of micromechanical forces created by the negative suction promotes cell division, angiogenesis, the growth of granulation tissue, and the local elaboration of growth factors—all without increasing apoptosis.^163,164 Practically speaking, applying suction to the open wound over the midgut allows for the rapid removal of peritoneal fluid and collapses space between the viscera. As both of these results will make the contents of the abdominal cavity smaller, there is a greater chance of definitive aponeurotic closure of the midline incision. In fact, primary fascial closure rates with this technique over the years have approached or been 100% and with few complications.^{156,158,165,166}

Combination Closure

In patients with significant hepatic injuries requiring perihepatic packing, a combination of closures may be appropriate and beneficial as previously noted. In such a patient, it is sometimes desirable to have a “tight” closure of the upper abdomen to maintain pack tamponade of the injured liver. Partial fascial closure limited to the upper abdomen or partial towel clip closure of the same area may be used in conjunction with a silo or vacuum-assisted dressing placed over the lower abdomen. This arrangement maintains a tamponade effect on the injured liver while allowing ample room for expansion of the midgut to avert development of an abdominal compartment syndrome. A number of similar approaches have been described in the literature, as well.^167,168