Damage Control Laparotomy
Objectives
To provide guidance for surgical decision making and operative management of major abdominal injury in the context of deployed hospital healthcare.
Scope
These guidelines are for deployed clinicians managing patients who require surgery for major abdominal injuries injury.
- Indications for damage control surgery
- Preparation for and steps of the damage control laparotomy
- Post operative care in the management of severe abdominal injuries.
Audience
Surgeons, anaesthetists, critical care providers, operating theatre personnel, emergency care practitioners within the context of deployed hospital healthcare.
Initial Assessment & Management
Initial assessment and management within the deployed setting should follow BATLS or equivalent approach. The damage control laparotomy is used in conjunction with damage control resuscitation to correct physiology in the severely injured patient. It is abbreviated and expediated surgery which does not aim to definitively restore patient anatomy.
Patient Selection
Use of a damage control approach may be indicated by:
- Grossly deranged physiology due to extensive or ongoing blood loss (e.g. hypothermia, acidosis, coagulopathy, hypocalcaemia, hyperkalaemia).
- Extensive injury burden with multiple abdominal injuries and long anticipated definitive surgical time.
- Severe individual injuries (such as liver or pancreas) which cannot be definitively repaired at first surgery.
- Lack of required kit or expertise
- Mass casualty incidents requiring the use of abbreviated surgery
These indications may exist together or individually. Decision making for a damage control surgical approach should be dynamic and team based with constant communication between surgeons and anaesthetists.
Advanced Assessment & Management
Operative preparation and positioning
Patients should be positioned supine with arms out in a “cruciform” position.
The abdomen should be prepped along with the groins, and chest as high as the neck to allow for proximal control within the chest if necessary
Urinary catheter should be placed if possible and consideration of naso/oro gastric tube.
Antibiotics should be administered.
Laparotomy steps
1. The abdomen is entered through a long midline incision using a scalpel and scissors (if necessary, this incision can also be used to access the pre-peritoneal space for pelvic packing)
2. Large clots are removed manually. The small bowel is eviscerated and the abdomen is packed (multiple packs are placed systematically into the four quadrants of the abdomen starting at the point of most apparent bleeding).
3. If there is ongoing bleeding despite adequate packing, major vessel bleeding is likely and may require proximal aortic control. Proximal control may be achieved at the supra-coeliac aorta with manual pressure through the existing laparotomy incision. If not achievable, intra-thoracic aorta may be compressed or clamped through a left antero-lateral or clamshell thoracotomy.
4. A systematic exploration of the abdomen and if necessary, the retroperitoneum, is performed.
- Solid organ bleeding is controlled by packing (liver, pancreas) or organ removal (spleen, kidney) as necessary.
- Vascular injury may be managed by repair, shunting, or ligation depending upon the vessel injured. There is no role of interposition grafting within the DCL phase.
- Contamination from hollow organ injury may be managed with suture repair for small defects. Destructive injuries are managed with staple resection of injured segments. No anastomosis should be performed.
Temporary abdominal closure
No effort is made close the abdomen or to make a stoma.
Temporary abdominal closure is achieved using whichever technique is available.
The patient should have ongoing critical care physiological support and resuscitation. Documentation should state known injuries and the presence of any packs or indwelling devices or shunts. Relook laparotomy which may still not be definitive should be planned for when the patient is physiologically optimised, and preferably no later than 48 hours. Considerations of timing include physiology, evacuation timelines, and operation constraints.
Prolonged Casualty Care
There are time critical interventions that should be planned and undertaken within the same facility if the patient cannot be evacuated. Timely evacuation should be a priority for these patients.
Paediatric Considerations
No different to adult