Traditional surgical operations include access, visualization, hemostasis, resection, reconstruction, drainage, etc. Surgeons should strictly abide by the operating principles to achieve ideal perfection.
However, in modern critical surgery, due to the neglect of the patient’s physiological state, often the operation is successful, but the patient still dies eventually. Therefore, in the treatment of critically ill surgical patients, especially those with severe injuries, the surgeon’s philosophy should be free from the traditional surgical treatment model, and the survival rate of the patient, rather than the success rate of the operation, should be given primary importance. The resulting concept of “damage control surgery” has evolved considerably in recent years, expanding from a surgical technique applicable only to patients with near-death injuries to a new concept of surgical treatment for critically ill patients. The purpose of this paper is to review the literature and to introduce it in the context of our own treatment experience.
1. Historical review
The origin of the concept of injury-controlled surgery can be traced back to the early 20th century, when bungee ngle, Halsted, schmeder, etc. After 1955, with the advancement of surgical techniques and the literature reporting complications such as tissue necrosis, infection and rebleeding after tamponade, “tamponade” was no longer used as a mainstream surgical technique. After the 1970s, the use of perihepatic tamponade was gradually abandoned.
After the 1970s, the perihepatic gauze tamponade technique gradually gained acceptance again and achieved better results in patients with certain strict indications. In 1993, the trauma team of the University of Pennsylvania developed a protocol for “damage control” in patients with abdominal penetrating injuries, including rapid termination of surgery after controlling bleeding, continuous aggressive Icu This was the first report of “damage control surgery” in the literature.
In 1997, Rotondo et al. reviewed the literature on the use of the “damage control” principle in the treatment of liver injury over the past 20 years and found a mortality rate of 44% and a complication rate of 39% in 495 patients; in patients with combined extrahepatic trauma, the mortality rate increased to 60% and the complication rate increased to 43%. 43%; combined, the total mortality rate was 52% and the complication rate was 40%. Since the survival rate of this group of extremely critically ill patients was almost zero in previous clinical practice, the principle of “damage control surgery” is gradually gaining acceptance despite its high complication and mortality rates.
2.Pathophysiological changes after serious injury
The basis of pathophysiological changes in the body after severe injury is massive blood loss, so Kashuk et al. proposed “blood vicious cycle (b100dy vicious cycle)”
This vicious cycle is characterized by a triad of hypothermia, coagulation disorders and metabolic acidosis, which eventually leads to physiological depletion of the body. A correct understanding of the pathophysiological changes of the body after severe injury is the basis for understanding damage control surgery.
2.1, hypothermia due to reduced production capacity of the damaged organism, a large amount of heat energy escape after opening, a large number of blood transfusion, fluid transfusion and other rescue treatment, coupled with most surgeons tend to ignore the operating room warming, patient torso insulation, infusion of fluids and abdominal irrigation fluid warming and other links, so the prevalence of hypothermia in patients with severe injuries. Hypothermia will lead to (1), impairment of systemic cellular metabolism; (2), cardiac arrhythmia; (3), reduction of cardiac output; (4), reduction of intertissue oxygen release by prompting a leftward shift in the oxygen dissociation curve; and (5), affect coagulation and other old 1. Jurkouich et al. reported that the mortality rate would increase from 40% to 100% if the patient’s central temperature dropped from 34°C to below 32°C. Burch et al. quantitatively monitored the loss of body temperature of patients during post-traumatic cesarean surgery and found that even with warming of intravenous fluids, anesthetic inhalation gas and air convection blankets, the patient’s temperature loss per hour during cesarean surgery was at least 4.6°C. Therefore, they believe that the main role of rapid termination of cesarean surgery is to limit heat loss and restore temperature-sensitive coagulation.
2.2, coagulation disorders of a variety of factors can affect the coagulation function of patients with severe injuries, especially in patients with hypothermia, all aspects of the coagulation process of the body are adversely affected. 37 ℃ when the standard coagulation function measurement, can not reflect the actual coagulation status of patients with hypothermia. The coagulation prothrombin time (Prr) and activated partial coagulation prothrombin time (APTT) are significantly prolonged for every 1°C drop in body temperature. It was found that plasma thromboxane levels were reduced at low temperature; temperature-sensitive serine lipase activity was reduced, platelet dysfunction and endothelial function were abnormal, thus affecting coagulation; low temperature also had an effect on the fibrinolytic process. In addition, the dilution reaction after a large number of blood transfusions causes a decrease in platelets and factors V, VII and VIII, which acts synergistically with hypothermia and aggravates coagulation disorders.
2.3, metabolic acidosis after severe injury with massive bleeding and extensive inter-tissue exudate leads to severe and sustained hypoperfusion and secondary to systemic tissue.
“Oxygen debt”, cellular metabolism from the aerobic state to the anaerobic state transition, producing a large number of acidic metabolites resulting in metabolic acidosis. This “cell hypoxia” is different from “ceIIdysoxia”, which is a condition in which the mitochondria are still in an oxygen-rich environment, but the microcirculatory oxygen shunt at the cellular level is inadequate and there is not enough oxygen supply to maintain aerobic metabolism. The latter is manifested by the fact that the mitochondria remain in an oxygen-rich environment, but the microcirculatory oxygen shunt at the cellular level is insufficient to maintain aerobic metabolism. Lactate clearance is now commonly used as an indicator of successful resuscitation. Studies have demonstrated that in patients with hemorrhagic shock, blood lactate clearance can be used as a prognostic indicator of oxygen delivery, mortality, and complication rates, and Abr锄son’s data showed that patients who were able to clear blood lactate within 24 h had a 100% survival rate, whereas those who cleared within 48 h had a 14% survival rate. Over the past 5 years, as many as 13 studies in more than 600 patients with injuries have shown that lactate clearance can be an extremely valuable prognostic indicator.
3. Indications for Damage Control Surgery
Most patients with injuries can be managed with conventional surgery, but only a few patients who are approaching or reaching the limits of their physiological potential should be managed with damage control surgery. The determination of the indications requires the surgeon to be able to judge the patient’s injury and physiological condition as soon as possible, and to make a judgment in advance rather than being forced to perform when the patient is physiologically exhausted. Therefore, proper and proficient knowledge of the indications for damage control surgery is critical to the successful use of this technique. Patients with the risk factors shown in Table 1 should be considered for damage control surgery, with emphasis on controlling bleeding and reducing the time consumed in dealing with unbleeding organs. o Some authors suggest that damage control surgery should be used in patients under 55 years of age with a base residual (BE) >18 mmoL/L, and in patients over 55 years of age or any age with head injury with a BE >8 mmoL/L.
Damage control surgery should also be considered in patients over 55 years of age or with head injury of any age, if BE is >8 mmoL/L. Patients who are required to undergo cesarean surgery, if blood lactate level is >5 mmL, are also indicated. If the patient is > 70 years of age
If the patient is >70 years old and has had cardiac arrest or fatal head injury due to blunt contusion before admission, the mortality rate is usually 100%, so damage control surgery is also worth trying.
4. Damage control surgery procedures
The procedure usually consists of three parts, including an initial brief dissection, ICu resuscitation, and later definitive surgery, sometimes with the addition of an “unplanned reoperation”. Since patients undergoing “damage control” are usually on the verge of physiologic exhaustion, the hospital where the critical care team is located must develop an effective coordinated treatment plan in advance, including the emergency room, operating room, Icu, blood bank, laboratory, and radiology interventional unit, with the surgeon as the leader and core of the treatment team.
4.1, Damage Control Surgery Part 1 – Initial Surgery. Before leading the patient to the operating room, members of the treatment team must identify the surgical room, prepare the resuscitation equipment and instruments needed for the dissection, and also raise the room temperature and preheat the organism heating device.
Surgery is usually performed using a median incision, and hemostasis is quickly achieved after opening the abdomen using tamponade, ligation, clamping, or balloon catheter compression. After hemorrhage is controlled, the GI tract is quickly explored and contamination is controlled by simple suturing or clamping of the broken organ site. Do not attempt reconstructive surgery at this point and close the abdomen quickly. The first surgery has an extremely important impact on the overall outcome of the patient, and the surgeon must be aware of the following questions during the procedure: (1), Is all bleeding due to mechanical injury under control? (2) Is tamponade necessary? (3), What is the expected therapeutic effect?
There are various methods to rapidly close the abdomen: (1), multiple towel clamp arrangement clamps; (2), continuous suturing of the skin and subcutaneous tissue with 2-decade nylon thread; (3) suturing of the sterile infusion bag to the skin; (4), negative pressure dressing (vacuum pack dressing) covering, etc.
If the abdominal wall can be buttressed, it is recommended to close the abdomen with a continuous layer of thick nylon sutures, which has the advantage of maintaining the integrity of the abdominal wall tissues, and closing the abdomen is simpler and faster, and can avoid imaging interference caused by metal instruments when performing angiography and other imaging examinations. The disadvantage is that the lack of expansion of the abdominal wall can lead to increased intra-abdominal pressure, and although this is beneficial for the efficacy of filling and arrest, the possible resulting inter-abdominal compartment syndrome must be fully considered. If the abdominal wall cannot be closed, it can usually be covered with a negative pressure dressing. The recent disadvantage of this method is the significant loss of body fluids at the incision, which should also be fully considered during resuscitation if solid organ bleeding is still suspected after the initial surgery, radiological interventions can be performed. Patient transport is challenging and requires careful consideration, as the patient is usually surrounded by a large number of devices: assisted ventilator, intravenous fluids and blood transfusion, fluid warmers, monitors, and possibly vasoactive drug infusion devices, requiring the cooperation of several members of the treatment team to transfer the patient to the Icu (angiography suite). Resuscitation and warming of the patient should not be interrupted during the intervention. Proximal embolization may increase the risk of tissue ischemia and lactic acidosis, so the embolization site should be as close to the distal end of the vessel as possible. After embolization patients may experience muscle ischemia and even rhabdomyolysis secondary to embolization. The risk of renal failure should also be considered during resuscitation.
4.2, Damage control surgery part II – Icu resuscitation, once the abdominal cavity is temporarily closed, Icu resuscitation should be started immediately, focusing on fluid resuscitation, mechanical ventilation, rewarming, correction of acidosis and coagulation disorders. This phase of treatment is primarily undertaken by the critical care physician and usually requires significant medical and nursing resources.
(1) A large caliber intravenous catheter should be used for fluid resuscitation, preferably a transjugular or subclavian central venous line. The degree of fluid resuscitation needs to be judged by the level of end-organ perfusion, including adequate urine output, recovery of vital signs, and clearance of lactic acidosis. In addition to routine testing, blood lactate levels need to be monitored every 4 h until 2 consecutive monitoring values ≤ 2. If lactate clearance is poor or elevated after resuscitation, warm lactate Ringer’s solution can be used for high volume resuscitation. If the patient has decreased urine output, decreased mixed venous oxygen saturation (sv0:), or pulmonary artery monitoring indicators suggesting hypovolemia, the amount of intravenous rehydration is generally increased in a gradient of 1,000 mL each time. If the blood lactate level continues to increase, the amount of intravenous rehydration must be adjusted. A pulmonary artery catheter, which is consistent with the direction of pulmonary blood flow, can be placed to monitor blood oxygen and blood volume to maintain hemodynamic stability and to bring the systemic blood volume to a level where oxygen consumption is independent of blood flow rate. Dynamic changes in blood lactate levels are an important indicator of the progress of resuscitation, and the recovery of vital patient signs signifies successful resuscitation.
As concerns about the potential complications of pulmonary artery placement and other invasive monitoring methods have increased, more and more new minimally invasive techniques have been applied to monitor cardiac indices in critically ill patients. It is important to note that the majority of these monitoring data are from patients undergoing cardiac surgery, and no data are currently available for patients undergoing damage control surgery. In addition, the inability to monitor cardiac output only dynamically by these methods also limits their use in patients undergoing damage control surgery.
(2), Patients undergoing damage control surgery with mechanical ventilation are at risk for acute lung injury (Au) and acute respiratory distress syndromes (ARDs). In addition to interstitial lung injury and shock, which are common in trauma patients, massive fluid rehydration at the beginning of resuscitation is a unique trigger for injury control patients to be prone to ALI or ARDs, and massive fluid rehydration will decrease chest wall compliance and lead to pulmonary edema. In addition, abdominal tamponade and intra-abdominal hypertension force the diaphragm to elevate, increasing thoracic pressure and decreasing compliance. Therefore, patients need mechanical ventilation at the beginning of resuscitation, and the inhaled gas needs to be warmed to 40°C. The purpose is to maintain good oxygenation and ventilation and to prevent the occurrence of volumetric injury.
(3), rewarming quickly end surgery and temporary closure of the abdominal cavity is the first step of active rewarming, successful rewarming will restore the normal function of cofactors in the coagulation process, to control bleeding and remove lactic acidosis, which has an important role in the resuscitation process. During the transfer of the patient from the operating room to the Icu, the patient’s body temperature should be maintained with an insulating device. the room temperature in the ICU should exceed 29°C. Upon arrival at the Icu, the patient should be quickly removed from wet clothing and dried, covered with an air convection blanket heated to 40°C. All infusion lines should be connected to a precise heating and temperature control device, and the ventilator tubing should be heated. The patient must be rewarmed to 37°C within 4 hours of entering the ICu. If the patient’s temperature is unresponsive and remains below 35°C, chest irrigation with warm saline through multiple chest tubes may be considered. If the temperature remains below 33°C, continuous arteriovenous warming with a special device must be considered. A temperature probe should be placed inside the patient for temperature monitoring during resuscitation, and the target temperature should be set at 37℃.
(4), correction of coagulation disorders during the resuscitation process, the patient needs a large number of blood transfusions and fluids, usually need 24-48h to restore the “normal” physiological state. During the first 24 h, transfusions can be performed on a 10-unit basis, i.e., 10 units each of concentrated red blood cell suspension (PRBcs), fresh frozen plasma (FPP), and platelets. However, if prothrombin time ≥15s or platelet count ≤100×109/L, blood products must still be continued. If fibrinogen <1 000m∥L, cold precipitation must be given every 4h until the fibrinogen level >1 000mg/L. As an effective hemostatic factor for the treatment of coagulation disorders after hemorrhage, recombinant activated coagulation factor VIIa (rFⅦa trade name Novo seven) has been increasingly used.
Once the patient is adequately resuscitated and warmed, the acidosis will mostly resolve on its own.
Oxygen debt will also be eliminated, the body from anaerobic metabolism back to aerobic metabolic state. During resuscitation, sodium bicarbonate is generally not required unless pH < 7.2, especially when positive inotropic drugs are used, as they work better in a low-acid environment.
(5) Unplanned reoperation In “damage control surgery”, reoperation is usually considered only after the patient is hemodynamically stable, with complete recovery of body temperature and basic physiological parameters. However, unplanned reoperation may be required in the following three situations: (i) progressive bleeding; (ii) residual gastrointestinal injury leading to systemic inflammatory response syndrome and shock; and (iii) abdominal compartment syndrome (Acs). The aim of surgery at this time is to control bleeding and contamination, and abdominal decompression must be performed if necessary.
Emergency reoperation at this time is often risky because of the unstable physiological status of the patient and the difficulty of moving the patient with a large amount of equipment attached to the patient’s periphery. After the first operation, the patient may often show partial bleeding, which generally does not require special treatment, but if 3b in a row require more than 2 units/h of Bc, or if the bleeding exceeds the surgeon’s expectations (especially in patients with normal body temperature and no coagulopathy), reoperation must be considered. The bleeding at this point is usually mechanical bleeding due to failure of the initial procedure, such as failure of liver tamponade or rebleeding from an embolized vessel. If bleeding from a substantial organ is suspected, angiography of the suspected organ and embolization of the bleeding site is preferred. If the patient presents with volume-distributed shock, it may be due to missed injury sites, or failed injury repair, or organ ischemia, etc., resulting in leakage of digestive fluid. If it is true that the patient cannot be moved and open surgery at the bedside is required, careful consideration should be given because adequate lighting, good suction devices, and adequate instruments and apparatus are critical to the success of the procedure. These conditions are lacking at the bedside in the vast majority of cases. The addition of an anesthesiologist to the treatment team is very important at this time.
Acs can cause physiologic changes in multiple organ systems, and in patients undergoing damage control surgery, it is important to be on high alert for the development of Acs. Abdominal pressure can be monitored using the method provided by Chealhalll et al IIIo, and bladder pressure can be measured every 4 h.
Bedside decompression should be considered if bladder pressure is >25 mmHg (1 mmHg = 0.133 kPa) with symptoms of Acs. Mos et u scraped reported that decompression in some patients may cause reperfusion syndrome leading to cardiac arrest, which must be taken seriously.
This is because a sudden decrease in abdominal pressure is followed by a decrease in inferior vena cava pressure, which may lead to irreversible hypotension. If AcS is detected late, a large amount of acid, potassium and hypoxic metabolites in the otherwise hypoperfused abdominal organs and lower extremities are released into the circulation after reperfusion, which may lead to reperfusion metabolic acidosis. This can be prevented by appropriate infusion of lactated Ringer’s solution, sodium bicarbonate, and mannitol prior to decompression.
During abdominal decompression, changes in maximal peak inspiratory pressure (PIP) need to be monitored and ventilation reduced immediately after decompression to prevent alveolar hyperinflation and air pressure injury. Instantaneous release of abdominal pressure should be avoided if possible, and slow decompression over a period of l to 2 min is recommended. After the abdominal cavity has been opened to aspirate the fluid, it can be covered with a negative pressure dressing. In a few cases, AcS may still occur even with a negative pressure dressing, so continued monitoring of bladder pressure is still required.
4.3. Damage control surgery part III – definitive surgical stretching.
Patients who are hemodynamically stable, have recovered body temperature, and have no coagulation dysfunction can be considered for definitive surgery, which is usually performed 24-48 h after the initial procedure. The surgical objectives include removal of the tamponade, adequate abdominal exploration and re-evaluation of the extent of injury, extensive irrigation and placement of drainage, restoration of gastrointestinal continuity, and establishment of enteral nutrition access. If the patient becomes physiologically unstable again during the procedure, the surgeon must maintain a damage control I surgical mindset, reperform the tamponade, shorten the operative time, and temporarily close the abdomen.
Tension-free suturing of the fascia may not be possible at the end of definitive surgery.
Increased PIP levels at the time of closure suggest that the patient is not a candidate for a routine closure procedure. An attempt to close the skin without suturing the subcutaneous tissues can be made at this time, which is consistent with the physiological state of the body, although it may result in a ventral hernia and require reoperative repair in 3-4 months. If skin closure is also not possible, a mesh or absorbable patch can be used to suture to the fascial tissue, which partially prevents visceral bulging and provides a matrix for granulation tissue formation. Once the granulation tissue bed can support the graft, a skin graft can be performed. Patients treated with this method will still require ventral hernia repair at a later stage. If none of the above methods are appropriate for patients undergoing damage control stage III surgery, the abdomen may still be closed using negative pressure dressing coverage. Regardless of the technique used, it is important to allow distension of the abdominal contents to limit the possibility of AcS occurring and to allow continuous removal of third interstitial fluid. Once the patient has recovered physiologically and the organ and peritoneal edema has subsided, the negative pressure dressing may be changed at the bedside until the patient’s abdominal cavity can be closed properly.
Residual foci of abdominal infection or abdominal abscesses after damage control surgery are a concern. Patients present primarily with sepsis, and unexplained hyperglycemia may serve as an early warning sign of potential infection, at which point a CT scan of the abdomen should be performed to detect the source of infection. Smaller abscesses may be drained by cT-guided puncture, or require reoperation if drainage is not possible. Patients undergoing damage control surgery are highly susceptible to complications of gastrointestinal fistulae, and timely and adequate drainage is the key to treatment. Early tracheotomy is recommended because patients are often on a ventilator for 1 week or even 1 month or more. Early tracheotomy facilitates pulmonary physiotherapy, bronchoscopic aspiration and bronchoalveolar lavage, and can shorten the duration of ventilator use and increase patient comfort.
5. Understanding of damage control surgery
The term “dage contml suery” can be translated as “damage control surgery” or “damage control surgery”. The former is a kind of salvage surgery plan for serious trauma patients, the latter can be understood as a kind of salvage concept for serious surgical diseases, that is, according to the patient’s general condition, the scope of the disease, the operator’s technology, follow-up treatment conditions, etc., the best surgical treatment plan for the patient. The goal is the survival of the patient and the quality of life after surgery, rather than the pursuit of the “ideal and perfect surgical operation” on the operating table. The concept of damage control surgery is applicable to all specialties of surgery and even to all invasive medical treatments.
Freeman et al IIIo applied this concept in the management of acute mesenteric ischemia. This concept is particularly important in abdominal surgery because of the large volume and compensatory function of the digestive organs (especially the gastrointestinal tract), the relatively small impact of partial resection on patient survival, the relative simplicity of the surgical operation, and the relatively low technical difficulty of reconstruction, which can easily lead to arbitrary surgery and excessive or even unbelievable operations.
Over the years, we have admitted many patients with short bowel syndrome transferred from various places and found that performing extensive bowel resection along the traditional bowel resection rather than damage control surgical concept is one of the important causes of certain short bowel syndrome. In order to avoid the serious complication of anastomotic fistula after surgery, traditional bowel resection emphasizes the importance of a good blood supply to the anastomosis, i.e., “the necrotic intestine is removed and the intestine with suspected necrosis or impaired blood supply is also removed, and the anastomosis is established on a viable intestine with good blood supply. Because the normal adult small intestine has a large functional reserve, patients can tolerate partial small bowel resection without clinical symptoms.
However, in conditions such as mesenteric vascular obstruction, intestinal torsion, intra-abdominal hernia, and injury, extensive ischemia of the intestinal canal is sometimes difficult to determine viability during surgery, especially when combined with conditions of shock. According to the concept of damage control surgery, the principle of surgery in this case should be “resection of the necrotic intestine, preservation of the intestine with suspected blood supply obstruction, and external stoma at both sides of the incision”. If the stoma continues to show necrosis, it can be resected by dissection again. If the stoma gradually regains normal vitality, a suitable time can be selected for second-stage surgery to restore intestinal continuity. More than ten years ago, the author consulted a patient with severe hemorrhagic necrotizing small bowel inflammation complicated by shock, and a large amount of bloody fluid was seen in the abdominal cavity during emergency surgery, and the whole small intestine mesenteric vascular pulsation disappeared, showing necrotic changes. If the conventional surgical concept is followed, the entire small intestine must be resected and it is still difficult to avoid postoperative anastomotic fistula.
However, on closer examination, the proximal 1m of small intestine showed dark gray changes, which were colorfully different from the distal necrotic small intestine with black appearance, and the intestinal wall still had some elasticity.
Therefore, the author removed the patient’s necrotic small intestine, preserved the proximal lm jejunum and terminal Ocm ileum, and externalized the stoma day at both ends, and gave active treatment after surgery. At that time, we only considered how to maintain the patient’s postoperative quality of life, but now we realize that this is the clinical application of the concept of damage control surgery.