Damage Control Surgery
What the Examiner Expects
An abbreviated surgical strategy for severely injured patients in physiologic extremis, prioritizing hemorrhage and contamination control over definitive repair. The examiner expects you to recognize the triggers (lethal triad), describe the three phases: Phase 1 — abbreviated surgery (pack solid organs, ligate or shunt damaged vessels, staple off bowel without anastomosis, temporary abdominal closure); Phase 2 — ICU resuscitation (warm the patient, correct coagulopathy with massive transfusion protocol and blood products, correct acidosis, optimize hemodynamics); Phase 3 — planned re-exploration at 24–48 hours for definitive repair (restore GI continuity, definitive vascular repair, remove packs).
Key Examiner Focus Points
- Three-phase approach: abbreviated surgery → ICU resuscitation → planned re-exploration
- Triggered by the lethal triad: hypothermia (< 35°C), acidosis (pH < 7.2), coagulopathy
- Surgical goals: stop hemorrhage (packing, ligation, shunting) and control contamination (staple, drain)
- Temporary abdominal closure (negative pressure wound therapy)
- Definitive repair at planned re-exploration in 24–48 hours
Common Curveballs
During re-exploration at 48 hours, removing the liver packs causes rebleeding
If the bleeding is from the pack site only, re-pack. Not all packs need to be removed at the first return. If diffuse hepatic bleeding persists, consider angiographic embolization before or after re-packing. Plan another return to OR in 48 hours. Serial operations are acceptable.
Abdominal compartment syndrome develops in the ICU after damage control — bladder pressure is 28 mmHg with oliguria
Abdominal compartment syndrome (ACS): sustained intra-abdominal pressure > 20 mmHg with new organ dysfunction. Decompressive laparotomy is required — open the temporary closure at the bedside or in the OR. This is not optional — untreated ACS leads to multi-organ failure.
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