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Part II Difficult Clinical-Based Surgical Decisions 9 Surgical Decision-Making Process and Damage Control: Current Principles and Practice Ruben Peralta, Gaby Jabbour, and Rifat Latifi Introduction Traditionally, the common surgical practice included the completion of the operation regardless of the physiologic condition of the patient. However, in trauma patients this can be challenging. Therefore, multiple strategies were developed to avoid this dilemma. While the damage control (DC) has become popular in the last few decades, this is not a new concept. Historically, the management of devastating abdominal injuries has been documented by the work of others, but the most well-known surgeon is Pringle, who described the use of packs and digital compression of the portal triad in large liver injuries more than a century ago [1]. Ogilvie during R. Peralta, M.D., F.A.C.S. (*) Department of Surgery, Division of Trauma Surgery, Hamad General Hospital and Hamad Medical Corporation, Al Rayyan Rd, PO Box 3050, Doha, Qatar e-mail: rperaltamd@gmail.com G. Jabbour, M.D. Division of Trauma Surgery, Department of Surgery, Hamad Medical Corporation, Al Rayyan Rd, PO Box 3050, Doha, Qatar e-mail: Jabbourgaby9@hotmail.com R. Latifi, M.D., F.A.C.S. Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA Department of Surgery, University of Arizona, Tucson, AZ, USA e-mail: Rifat.latifi@gmail.com World War II described the use of open abdomen technique in severely injured patients [2]. Lucas and Ledgerwood reported the management of liver injuries with temporary perihepatic packings in 1976 [3]. Stone described the modern concept of abbreviated laparotomy in 1983 [4]: hemorrhage was controlled by tamponade; bowel injuries were resected; noncritical injured vessels were ligated; and biliopancreatic injuries were drained. Later, these patients underwent definitive repairs. The term “damage control” was popularized by Rotondo in the 1990s [5], and has become a powerful tool in the management of severely injured patients. Indications and Timing of Damage Control Damage control includes the termination of the surgery after controlling bleeding and contamination, and before the patient physiological reserve is exhausted and frequently manifested by the developing of the lethal triad of acidosis, coagulopathy, and hypothermia. Definitive repair is delayed until the patient is stabilized. When a surgeon is operating in a patient with hemodynamic instability, hypothermia (<35 °C), coagulopathy, severe metabolic acidosis (pH < 7.2 or base deficit >8), multiple injuries, massive transfusion requirements (>10 units packed red blood cells), and long operative time (>90 min) for trauma or emergency, he or she should think of abbreviating the procedure [6, 7]. © Springer International Publishing Switzerland 2016 R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_9 95 96 The Damage Control Operation for Trauma While DC may be performed in any part of the body from craniotomies to orthopedic injuries, most commonly it is done in abdominal trauma, both penetrating and blunt. In general, most frequently it is done in liver injuries and vascular injuries [4, 5]. Initial hemorrhagic control is achieved by packing of the liver, and most vascular injuries can be treated by packing, simple ligation, or temporary intraluminal shunts [6, 7]. Hollow viscus injuries are treated by resection of affected areas, and anastomosis is postponed until the patient is stabilized. The majority of biliopancreatic injuries can be treated with closed suction drainage [8]. Pre-peritoneal packing has gained popularity in recent years and is performed when there is significant pelvic fracture with hemodynamic instability requiring an operation and embolization [9]. One other historical indication of DC use is the inability to close the abdomen, in order to avoid abdominal compartment syndrome due to massive fluid resuscitation. By using hemostatic resuscitation instead of massive crystalloid resuscitation, the need for leaving the abdomen open has decreased significantly, and, thus, DC, once overused, is being used less. Another new technique in the management of trauma patients that has become more popular is permissive hypotension whenever clinical conditions permit. Significantly less frequently, DC is done in isolated chest injuries, with exception for a short period of DC during emergency resuscitative thoracotomy, clamping the pulmonary hilum, or twisting the lung along its hilar axis to stop bleeding from the pulmonary parenchyma [10–12]. Occasionally, one has to pack the chest wall temporarily due to massive rib fractures associated with chest wall soft tissue destruction. Other compartments where DC may be done are extremity soft tissue injuries, particularly associated with vascular injuries, requiring revascularization. R. Peralta et al. Hemostatic Resuscitation During the initial evaluation and management, intraoperatively and following termination or abbreviated surgery, resuscitation continues. This includes resuscitation with intravenous fluids and early administration of blood products and prevention of and correction of the lethal triad. Warm room and airway circuit should be instituted in the ICU, and warmer device should be applied to the patient. A level I rewarmer device is useful at this time where all fluids and blood products should be infused warmed into the patient. In rare cases, described continuous arteriovenous rewarming can be used, a technique that permits rapid rewarming of hypothermic patients without requiring cardiopulmonary bypass or heparinization in severely hypothermic patients as described by Gentilello et al. [13, 14]. Damage control resuscitation (DCR) in brief consists of the following: (1) Avoiding or minimizing crystalloid resuscitation; (2) Treatment of acidosis requires optimization of oxygen delivery by providing optimizing cardiac output, hemoglobin, and oxygen saturation. Acute traumatic coagulopathy is a frequent occurrence in severely injured patients [15]. It is corrected by aggressive blood product replacement with fresh frozen plasma, platelets, and cryoprecipitate. A hemostatic adjuvant that has been shown effective in the correction of acquired coagulopathy of trauma is tranexamic acid (TXA) [16]. We recommend the use of TXA in bleeding trauma patients, and it is part of our MTPs. Regarding prothrombin complex concentrates (PCCs), clinical data are still lacking for use in massively bleeding trauma patients [17]. Recombinant factor VIIa has been shown to reduce the transfusion requirement [18, 19]. Definitive (Injury Repair) Operation After stabilization and the restoration of the physiological reserve, the patient is returned to the operating room for definitive management. Studies have shown that when patients are returned earlier 9 Surgical Decision-Making Process and Damage Control: Current Principles and Practice 97 than 72 h, they have a lower rate of morbidity and mortality compared with patients who return later [20]. In our practice, we return the patient to the operating room within 12–24 h. One cannot, however, wait for complete normalization of all resuscitative indicators before returning to the OR, as there may be a missed injury that is causing the patient not to have normal physiology. During the definitive procedure, a complete exploration is performed, packs are removed, and bleeding sites are controlled. This procedure in fact can be called a tertiary operative survey. Small bowel continuity is restored, and patients with colonic injuries are treated with stoma or repair. Closing the abdominal fascia is considered at this time if the patient’s clinical condition allows. Other important elements that need to be considered at this stage are long-term nutritional access, completing orthopedic repairs and even potential for tracheostomies, if one suspects long hospitalization or long ICU stay. Fig. 9.1 Intestines are covered with sterile plastic bag Management of Open Abdominal Wound and Definitive Abdominal Closure Staged abdominal reconstruction has three main functions: washout to reduce contamination, debridement of devitalized tissue, and appropriate reconstruction. This is usually done after correction of the physiological derangement or within 36 h, and helps improve the outcomes in severe injuries. Preoperative patient optimization is conducted in order to create an ideal setting for reconstruction (optimal nutritional status, resolution of sepsis, correction of acidosis, hypothermia, and coagulopathy). Delaying primary fascial closure is considered according to abdomen condition (edema, viability) [21, 22]. The surgical decision-making process on abdominal wall reconstruction has been addressed in more details in Chap. 11. In this section, we will describe temporal abdominal closure (TAC). Most commonly, the so-called “poor man VAC” is used (Figs. 9.1, 9.2, 9.3, and 9.4). In our practice, if we expect to bring the patient back to the operating room within 12 to 24 h, we do not use VAC; instead, we use Fig. 9.2 Additional cuts may be required on the plastic bag to allow better drainage of fluid the poor man technique. On occasion, the intestines are so swollen or there is continuation of intra-abdominal pathology (such as pancreatitis); thus, we are unable to close the fascia at all. In these cases, we have adopted the technique that uses temporary vicryl mesh, followed by wound VAC (Fig. 9.5) and eventually skin graft, with delayed reconstruction. Often, as in Fig. 9.6, the abdomen is covered with skin only. 98 Fig. 9.3 Most Kerlix™ (Covidien, Dublin, Ireland) gauze is placed over the plastic bag, and two drains are placed between gauzes Fig. 9.4 Finally the gauze and the drains are covered with sticky plastic R. Peralta et al. Fig. 9.5 Wound VAC, used even for smaller wounds that are left open Fig. 9.6 Closure of the skin only in a patient who had abdominal catastrophe managed with open abdomen for weeks 9 Surgical Decision-Making Process and Damage Control: Current Principles and Practice Postoperatively, patients should have good pain control (epidural anesthesia or patient controlled analgesia), antibiotic treatment until packs are removed, appropriate nutrition, and deep venous thrombosis prophylaxis. The wound should be inspected daily, and the drains left in place until there is minimum drainage. Damage Control for Abdominal Sepsis Patients with a septic abdomen have similar management focuses as the damage control trauma patient; however, the sequence differs. A longer initial resuscitation phase is used in the septic abdomen. The operative goal at the initial laparotomy is control of the infectious source. In general, a temporary abdominal closure is used at the end of the initial laparotomy. A second resuscitative phase is then performed in the ICU in preparation for further surgery. If control of the septic source is not done, then subsequent interventions are required. Common complications include enterocutaneous fistula and intra-abdominal infections (tertiary peritonitis) [23]. Complications associated with damage control can be classified as local (abscess, fistula, and intestinal necrosis) or systemic complications (ARDS and MOF). They are also divided into early (missed injuries, infections, and compartment syndrome) and late (fistula, dehiscence). Several studies have shown improved outcomes since the widespread institution of damage control techniques [24, 25]. 99 of the aorta (REBOA) has emerged as a promising alternative to packing in the setting of severe ongoing noncompressible major torso hemorrhage [27–31]. Orthopedic Interventions The damage control orthopedics (DCO) concepts refer to the initial rapid skeletal stabilization with external fixation, followed by intramedullary nailing after the systemic inflammatory response has subsided [32–36]. External fixation is also used in open book pelvic fractures and helps limit venous bleeding (Fig. 9.7). Arterial bleeding is treated by angiographic embolization. External fixation and temporary soft tissue coverage in open fractures are the standard of treatment in critically ill trauma patients. Fasciotomy is performed in vascular injuries and in ischemia reperfusion injuries [37]. Vascular Interventions The most commonly used damage control interventions in major vascular injuries are the following: TIVS (temporary intravascular shunt), where the operating surgeon can place shunts in patients with complex vascular injuries in the neck, abdomen and extremities, and proceed with the vascular anastomosis or reconstruction procedure when the patient has reached a more reasonable hemodynamic stability [26]. Most recently, the use of resuscitative endovascular balloon occlusion Fig. 9.7 External fixation for severe pelvic fractures, as part of damage control, in a patient with hemodynamic instability, bleeding perineal injury, and large sigmoid colon devascularization, requiring diversion 100 R. Peralta et al. Summary In summary, damage control is a staged approach to severely injured patients. Initially, lifethreatening injuries are managed rapidly with appropriate abbreviated procedures. The patient is then stabilized in the ICU. Later, definitive surgical management is performed. This strategy is beneficial and results in improved outcomes. This approach is still evolving, and many studies are done to implement it as a standard management approach to trauma patients. It requires a multidisciplinary team to achieve better outcomes. References 1. Pringle J. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg. 1908;48:541–9. 2. Ogilvie WH. The late complications of abdominal war-wounds. Lancet. 1940;2:253–6. 3. Lucas CE, Ledgerwood AM. Prospective evaluation of hemostatic techniques for liver injuries. J Trauma. 1976;16(6):442–51. 4. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983;197(5):532–5. 5. Rotondo MF, Schwab W, McGonigal MD, et al. Damage control: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375–83. 6. Roberts DJ, Bobrovitz N, Zygun DA. Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in trauma patients: a content analysis and expert appropriateness rating study. J Trauma Acute Care Surg. 2015;79(4):568–79. 7. Peralta R, Vijay A, El-Menyar A, et al. Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time. World J Emerg Surg. 2015 Aug 14;10:36. 8. Burch JM, Ortiz VB, Richardson RJ, et al. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg. 1992;215(5):476–84. 9. Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, Holevar M, Sabater EA, Sems SA, Vassy WM, et al. Eastern Association for the Surgery of Trauma. Practice management guidelines for hemorrhage in pelvic fracture: update and systematic review. J Trauma. 2011;71(6):1850–68. 10. Caceres M, Buechter KJ, Tillou A, Shih JA, Liu D, Steeb G. Thoracic packing for uncontrolled bleeding in penetrating thoracic injuries. South Med J. 2004;97(7):637–41. 11. Moriwaki Y, Toyoda H, Harunari N, Iwashita M, Kosuge T, Arata S, Suzuki N. Gauze packing as damage control for uncontrollable haemorrhage in severe 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. thoracic trauma. Ann R Coll Surg Engl. 2013;95(1):20–5. Rizzo AG, Sample GA. Thoracic compartment syndrome secondary to a thoracic procedure: a case report. Chest. 2003;124(3):1164–8. Gentilello LM, Rifley WJ. Continuous arteriovenous rewarming: report of a new technique for treating hypothermia. J Trauma. 1991;31:1151–4. Gentilello LM, Cobean RA, Offner PJ, et al. Continuous arteriovenous rewarming: rapid reversal of hypothermia in critically ill patients. J Trauma. 1992;32(3):316–27. Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127–30. CRASH-2 trial collaborators. Effect of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized, placebocontrolled trial. Lancet. 2010;376(9734):22–32. Al-Majzoub O, Rybak E, Reardon DP, Krause P, Connors JM. Evaluation of Warfarin Reversal with 4-Facto Prothrombin Complex Concentrate Compared to 3-Factor Prothrombin Complex Concentrate at a Tertiary Academic Medical Center. J Emerg Med 2015 Sep 30. [Epub ahead of print] Schreiber MA, Holcomb JB, Hedner U, et al. The effect of recombinant factor VIIa on coagulopathic pigs with grade V liver injuries. J Trauma. 2002;53:252–9. Martinowitz U, Kenet G, Segal E, et al. Recombinant activated factor VII for adjunctive hemorrhage control in trauma. J Trauma. 2001;51:431–9. Abikhaled JA, Granchi TS, Wall MJ, et al. Prolonged abdominal packing is associated with increased morbidity and mortality. Am Surg. 1997;63(12):1109–13. Diaz Jr JJ, Cullinane DC, Dutton WD, Jerome R, Bagdonas R, Bilaniuk JW, Collier BR, Como JJ, Cumming J, Griffen M, Gunter OL, Kirby J, Lottenburg L, Mowery N, Riordan Jr WP, Martin N, Platz J, Stassen N, Winston ES. The management of the open abdomen in trauma and emergency general surgery: part 1-damage control. J Trauma. 2010 ;68(6):1425–38. Peralta R, Latifi R. Perioperative surgical consideration of patient undergoing abdominal wall reconstruction. In: Latifi R, editor. Surgery of complex abdominal wall defects. New York: Springer; 2013. p. 173–7. Waibel BH, Rotondo M. Damage control for intraabdominal sepsis. Surg Clin North Am. 2012 Apr;92(2):243–57. viii. Johnson JW, Gracias VH, Schwab CW, et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma. 2001;51(2):261–71. Chovanes J, Cannon JW, Nunez TC. The evolution of damage control surgery. Surg Clin North Am. 2012;92(4):859–75. vii-viii. Davis TP, Feliciano DV, Rozycki GS, et al. Results with abdominal vascular trauma in the modern era. Am Surg. 2001;67:565–70. 9 Surgical Decision-Making Process and Damage Control: Current Principles and Practice 27. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71:1869–72. 28. Morrison JJ, Ross JD, Houston R, Watson JDB, Sokol KK, Rasmussen TE. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in a highly lethal model of non-compressible torso hemorrhage. Shock. 2014;41:130–7. 29. Morrison JJ, Percival TJ, Markov NP, Villamaria C, Scott DJ, Saches KA, Spencer JR, Rasmussen TE. Aortic balloon occlusion is effective in controlling pelvic hemorrhage. J Surg Res. 2012;177:341–7. 30. Brenner M, Moore L, Dubose J, Tyson G, McNutt M, Albarado R, Holcomb JB, Scalea TM, Rasmussen TE. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg. 2013;75:506–5011. 31. Morrison JJ, Ross JD, Rasmussen TE, et al. Resuscitative endovascular balloon occlusion of the aorta: a gap analysis of severely injured UK combat casualties. Shock. 2014;41:388–93. 101 32. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48(4):613–21. 33. Balogh ZJ, Reumann MK, Gruen RL, et al. Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet. 2012;380(9847):1109–19. 34. Pape HC, Tornetta 3rd P, Tarkin I, et al. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009;17:541–9. 35. Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF. Damage control: collective review. J Trauma Inj Infect Crit Care. 2000;49(5):969–78. 36. Lichte P, Kobbe P, Dombroski D, Pape HC. Damage control orthopedics: current evidence. Curr Opin Crit Care. 2012;18(6):647–50. 37. Porter JM, Ivatury RR, Nassoura ZE. Extending the horizons of “damage control” in unstable trauma patients beyond the abdomen and gastrointestinal tract. J Trauma. 1997;42:559–61. Reoperative Surgery in Acute Setting: When To Go Back? 10 Elizabeth M. Windell and Rifat Latifi Introduction Most surgical procedures done either electively or emergently go well, and, postoperatively, patients recover nicely. However, despite our best efforts and highest levels of preparation, complications can and do occur. These complications can be simple and easily remedied, but they can also be serious and life threatening, and at times patients need to be returned to the operating room at once or acutely, or in less urgent basis in a semi-planned fashion, but still need reoperation. The profiles of these patients or these procedures that are likely to undergo reoperation, that is, unplanned operation, have not been clearly defined. When the unplanned return to the operating room becomes necessary, such as in the case of early hemorrhage or profound abdominal sepsis, there are a number of issues that surgeons need to address. Discussing the plan with a patient and his/her family as well as other members of the E.M. Windell, D.O. Department of Trauma, Surgical Critical Care, and General Surgery, Legacy Emanuel Medical Center, Portland, OR, USA e-mail: ewindell@lhs.org R. Latifi, M.D., F.A.C.S. (*) Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA Department of Surgery, University of Arizona, Tucson, AZ, USA e-mail: latifi@surgery.arizona.edu; Rifat.latifi@ gmail.com surgical and anesthesia team is paramount. If the situation is clearly emergent, this conversation may not happen preoperatively, but needs to occur after the procedure. Other times, the clues are subtle, and the decision to return early to the operating room needs to be taken in a timely fashion, rather than procrastinating the inevitable, and is a matter of combination of art and scientific evidence. Unplanned trips to the operating room are not very common, some sources in the literature describe a rate of <3.5 % [1–3], but we will all encounter this at some point in our careers and knowing when and how best to perform these operations can make the difference in the survival and outcomes of our patients. The purpose of this chapter is to describe the times when a repeat operation is necessary and when the best time is for performing these operations. As there is a lack of paucity of good evidence behind this question in the literature, this chapter will focus more on this decision-making process from an anecdotal standpoint rather than from a standpoint of level one evidence. Reasons for Reoperative Surgery in the Early Postoperative Period The need to return to the operating room in the early postoperative period can be for a variety of reasons and it also depends on the surgical discipline. We will divide these reasons into the acute phase unplanned and planned return to © Springer International Publishing Switzerland 2016 R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_10 103 104 the operating room. While we will concentrate on the unplanned return, the planned return to the operating such as continuous management (damage control, burn, multiple reconstruction) will be discussed as well. Later on, the unplanned return to the operating room can also happen, such as hernia recurrence, need for revision of grafts in vascular surgery or tumor resection, but this is not a subject of this chapter. As a rule, the more common causes for reoperative surgery are ongoing management after initial damage control laparotomy, infectious complications, hemorrhage, early bowel obstructions from both adhesions and hernias, and positive margins on the initial field of resection. We will explore each of these topics in more detail. Damage Control Laparotomy Occasionally in trauma and emergency general surgery, performing a definitive operation may not be safe at the initial procedure. This is often due to physiologic instability in the patient manifested grossly as the lethal triad of coagulopathy, hypothermia, and acidosis. Damage control surgery can be used as a temporizing measure to control hemorrhage, prevent ongoing contamination, and to prevent further issues from profound systemic inflammatory response. When damage control laparotomy is utilized though, one must consider at the initial operation at what point you plan to go back for your definitive repair. While the “norm” is normalization of end point resuscitations, one cannot and should wait more than 36 h to bring back the patient for another exploration or definitive surgery [4, 5]. The major tenant of a damage control laparotomy is that the underlying problems that are leading to the lethal triad need to be corrected. The coagulopathy, acidosis, and hypothermia need to be resolving if not already corrected before a definitive operation is safe. In the instance of a damage control laparotomy, temporizing measures are applied to the abdomen, and the patient is taken to the ICU for rewarming, ongoing fluid and blood product resuscitation, and shock management [6]. E.M. Windell and R. Latifi Depending on the severity of the injury or infection, most of these issues start improving within 12–48 h of the initial operation. The best times for considering a second operation tend to be in the 24–48 h window. Prior to the 24 h window, patients may still be too unstable for an operation, and subjecting them to prolonged surgeries or anesthesia is not advisable. At the same time, waiting longer than 48 h may increase further morbidity and mortality as it can lead to organ failures, prolonged need for ventilatory support, nutritional deficits, open abdomens which are a source of fluid loses, and it puts patients at higher risk for serosal injuries, EC fistulas and anastomotic leaks. Loss of domain is also a concern with an open abdomen, and delaying closure of the abdominal wall past 48 h may lead to large hernias and need for future surgeries for abdominal wall reconstruction [5, 6]. One caveat to the 24–48 h window is when source control has not been established, such as with profound contamination or necrotizing soft tissue infections or in the case of ongoing hemorrhage. Often in these cases, patients continue to do poorly or worsen in the first 12 h after the initial operation, and they may need a second procedure sooner to establish better source control or complete disruption of infectious cascade. In these cases, the risk of a second surgery is less than the risk of death from ongoing septic shock and a second operation should be performed before 12 h. Infection Complications: Source Control Unfortunately, despite having perioperative optimization, infectious complications such as wound infection and other intra-abdominal catastrophes do occur. Anastomotic leaks range anywhere from 3–15 % of all bowel anastomoses [7–10], and the morbidity and mortality associated with this complication make appropriate management crucial. Management of this dreaded complication can range anywhere from observation to IR drainage to need for repeat surgery, and it can be difficult sometimes to