Damage Control Surgery Principles (WSES 2018): Adult in extremis or deteriorating in theatre → Before you start: child, head or spinal injury, TXA timin...
Pathway Overview
16 steps
16 total
Severely injured adult trauma patient, or critically ill adult non-trauma patient (for example ruptured AAA, acute mesenteric ischaemia, severe peritonitis with septic shock), with physiological deterioration.
These patients need a different approach before any step below. Pregnant: call the obstetric team early; if 20 weeks or more, displace the uterus to the left. The SBP 80-90 mmHg target comes from non-pregnant patients: agree the BP target with the obstetric team. Rh D negative: anti-D immunoglobulin within 72 h. Fetal monitoring once the mother is stable.
Trauma triggers: haemorrhagic shock, ongoing bleeding, coagulopathy, combined abdominal vascular and pancreatic injury, hypothermia, acidosis, inaccessible major injury, or a long repair needed. Risk thresholds: pH 7.2 or less; lactate 5 mmol/L or more; base deficit 6 mmol/L or more (age over 55 years) or 15 mmol/L or more (age 55 years or less); core temperature 34 °C or less; SBP 70 mmHg or less; blood loss 4 L or more, or 10 units of red cells or more; INR or PT more than 1.5 x normal. Non-trauma: severe peritonitis with septic shock and physiological derangement, ruptured AAA, acute mesenteric ischaemia, abdominal compartment syndrome if medical treatment has failed (repeated, reliable bladder pressure measurements).
Decide before the patient is in extremis. Do not over-use it: an open abdomen has its own harms (fistula, frozen abdomen, ventral hernia).
Yes: any trigger above is present or developing, or bleeding or contamination cannot be controlled quickly. No: no triggers; do the definitive operation.
Aim: stop bleeding and control contamination, then leave theatre. Bleeding: pack, ligate or shunt. Liver: perihepatic packing; avoid major resection. Spleen (adult): splenectomy; do not try to save it. Contamination: staple off injured bowel, no anastomosis; control bile or urine leaks. Peritonitis or sepsis: broad-spectrum IV antibiotics now (ideally within 1 h); follow the local sepsis pathway. Do not close the fascia. At the same time: major haemorrhage protocol, active warming, and reversal of any anticoagulant. Trauma without TBI or spinal cord injury: restrict fluids and target SBP 80-90 mmHg until major bleeding is controlled.
Preferred: negative pressure wound therapy with continuous fascial traction. Low-resource setting: Bogota bag (lower fascial closure rate, more fistulas). Protect the bowel: no NPWT or synthetic mesh directly on the bowel. Coagulopathy or high bleeding risk: reduce the negative pressure.
1) Rewarm actively to normothermia (core temperature 36-37 °C). 2) Restore perfusion; follow lactate or base deficit until normal. 3) Correct coagulopathy: major haemorrhage protocol while bleeding continues, then targeted blood products guided by lab or viscoelastic tests. Keep ionised calcium in the normal range. Do not start tranexamic acid more than 3 h after injury. 4) Blood pressure: once bleeding is controlled, usual ICU perfusion targets; severe TBI: MAP 80 mmHg or more. 5) Measure bladder (intra-abdominal) pressure often. 6) Start early enteral feeding if the bowel is in continuity. 7) Thromboprophylaxis: intermittent pneumatic compression early; add pharmacological prophylaxis within 24 h after bleeding is controlled. Intracranial bleed: start it only after a repeat head CT shows the bleed is stable.
Plan the re-look no later than 24-48 h after each operation, and sooner if the patient does not improve. Ready: warm, acidosis and lactate improving, coagulopathy corrected, vasopressor need falling.
Remove packs carefully (bleeding may restart). Check bowel viability. Definitive repair: vessels; bowel anastomosis or stoma. Keep the abdomen open if resuscitation is still needed, contamination persists, a further second look is needed, or compartment syndrome is a concern. Try primary fascial closure at every re-look.
Close the fascia as soon as possible, ideally within 4-7 days of the first operation. Delay increases the risk of fistula and frozen abdomen.
Monitor for fistula, abscess, wound failure and abdominal compartment syndrome. After splenectomy: vaccinate against pneumococcus, Hib and meningococcus from 14 days, or before discharge if that is earlier.
Keep NPWT with fascial traction and try closure at each re-look. Component separation only for definitive closure, never during the open abdomen. Large defect or contamination: biologic mesh. Avoid synthetic mesh as a fascial bridge. Planned ventral hernia (skin closure or skin graft) if entero-atmospheric fistula, protracted open abdomen, or no other option. Repair the abdominal wall after recovery. After splenectomy: vaccinate against pneumococcus, Hib and meningococcus from 14 days, or before discharge if that is earlier.
Continue rewarming, resuscitation and targeted blood products. Go back to theatre now for ongoing bleeding, abdominal compartment syndrome or failure to improve. Do not delay the re-look beyond 48 h.
Physiology stable. Do the definitive repair (vascular repair, bowel anastomosis) and close the fascia. Do not close under tension: leave the abdomen open if there is massive visceral or retroperitoneal swelling, or high bladder pressure when you try to close. If the patient deteriorates during the operation, change to damage control (phase 1 steps above).
Yes: fascia closed, patient stable. No: abdomen left open or changed to damage control: temporary abdominal closure, ICU resuscitation and re-look within 24-48 h, as in the DCS steps.
WSES 2018 Guidelines: The Open Abdomen in Trauma and Non-Trauma Patients
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
Contraindicated Populations
Applicable Regions
AU: Use the local major haemorrhage protocol based on the National Blood Authority critical bleeding guideline (2023).
Global: WSES open abdomen (2018) and European trauma bleeding guideline (6th ed, 2023) principles.
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The Damage Control Surgery Principles (WSES 2018) is a emergency clinical algorithm for General Surgery. It provides a structured decision tree to guide clinical decision-making, based on WSES 2018 Guidelines: The Open Abdomen in Trauma and Non-Trauma Patients.
This algorithm is based on WSES 2018 Guidelines: The Open Abdomen in Trauma and Non-Trauma Patients (DOI: 10.1186/s13017-018-0167-4).
Known limitations include: Adults only. Thresholds, drug doses and splenic management differ in children.; Covers damage control laparotomy only. Pelvic, thoracic and limb haemorrhage control are not covered.; DCS is a surgeon's decision; triggers support, not replace, judgement. Non-trauma indications have weaker evidence.; Pregnancy: trauma BP targets and DCS evidence come from non-pregnant patients.; Follow the local major haemorrhage protocol for blood product ratios and doses.; Open abdomen care needs specialist surgical and ICU resources.. Individual patient factors may require deviation from these recommendations.
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