Damage Control Surgery Principles (WSES 2018)

Algorithm Steps

1. ▶

   Start

   Patient in Extremis or Deteriorating in OR

   Severely injured trauma patient OR critically ill non-trauma patient (e.g., ruptured AAA, mesenteric ischemia, perforated viscus with sepsis) showing physiologic deterioration.

   1. ◆

      Decision

      Assess for Lethal Triad / DCS Indications

      LETHAL TRIAD: 1) Hypothermia: Core temp <35°C (especially <34°C). 2) Acidosis: pH <7.2, base deficit <-6 (or <-15 if age <55), lactate >5 mmol/L. 3) Coagulopathy: INR >1.5, clinical oozing, massive transfusion (>10 units pRBC). OTHER: Ongoing hemodynamic instability, prolonged surgery >90 min without control.

      1. ◆

         Decision

         Damage Control Surgery Indicated?

         Consider DCS if: Any component of lethal triad present or developing, inability to achieve hemostasis, anticipated prolonged surgery in unstable patient. Do NOT over-apply: Some patients can tolerate definitive repair. Surgeon judgment is key.

         1. ●

            Action

            Proceed with Definitive Repair

            Patient physiologically stable. No lethal triad. Complete definitive repair: vascular repair, bowel anastomosis, fascial closure. Standard postoperative care.

            1. ✓

               Outcome

               Fascia Closed - Recovery

               Definitive repair complete. Fascia closed. Continue postoperative care. Monitor for complications: Fistula, abscess, wound issues.

         2. ●

            Action

            DCS Phase 1: Abbreviated Laparotomy

            GOAL: Stop bleeding, control contamination, <90 minutes. HEMORRHAGE: Pack all four quadrants, ligate bleeding vessels, NO definitive vascular repair unless rapid. Damage control for liver/spleen (packing, no resection). CONTAMINATION: Staple transected bowel (no anastomosis), drain/ligate bile ducts, temporary ostomy if needed. DO NOT: Anastomose bowel, close fascia definitively.

            1. ●

               Action

               Temporary Abdominal Closure (TAC)

               Options: 1) NPWT with continuous fascial traction (preferred - best closure rates). 2) Bogota bag. 3) Vacuum-assisted closure. 4) Wittmann patch. KEY: Protect bowel, control fluid loss, allow fascial approximation attempts. Avoid lateral fascial retraction.

               1. ●

                  Action

                  DCS Phase 2: ICU Resuscitation

                  GOALS (24-72 hours): 1) REWARM: Core temp >35°C (active warming). 2) CORRECT ACIDOSIS: Lactate clearing, pH normalizing (bicarbonate if pH <7.1). 3) CORRECT COAGULOPATHY: FFP, platelets, cryoprecipitate, TXA. Massive transfusion protocol if ongoing hemorrhage. 4) HEMODYNAMIC OPTIMIZATION: MAP >65, adequate UOP, vasopressors as needed. 5) MONITOR IAP: Prevent ACS.

                  1. ◆

                     Decision

                     Ready for Return to OR?

                     Criteria for Phase 3: Temp >35°C, pH >7.25, INR <1.5, lactate trending down, hemodynamically stable off high-dose vasopressors. Typically 24-72 hours. Do not rush back if still physiologically deranged.

                     1. ●

                        Action

                        Continue ICU Resuscitation

                        Not yet ready. Continue warming, resuscitation, blood product administration. Reassess q6-12h. If deteriorating despite resuscitation, may need emergent return to OR for missed injury or ongoing hemorrhage.

                     2. ●

                        Action

                        DCS Phase 3: Definitive Repair

                        Return to OR when physiologically optimized. REMOVE: Packing (carefully - may restart bleeding). REPAIR: Definitive vascular repair, bowel anastomosis or ostomy formation, assess bowel viability. CLOSE: Attempt primary fascial closure if possible. If not, apply component separation or biological mesh.

                        1. ◆

                           Decision

                           Fascial Closure Achievable?

                           Attempt primary fascial closure at each OR visit. Goal: Close within 5-7 days to prevent frozen abdomen. If unable: Component separation, mesh-mediated closure, or accept planned ventral hernia.

                           1. ✓

                              Outcome

                              Planned Ventral Hernia

                              Unable to close fascia. Skin-only closure or skin graft over granulation tissue. Plan delayed hernia repair in 6-12 months.

         3. ⚠

            Warning

            ⚠️ Timing is Critical

            Early decision for DCS saves lives - don't wait until patient is moribund. But over-application leads to unnecessary morbidity from open abdomen. Surgeon must weigh benefit of abbreviated surgery vs. complications of leaving abdomen open.