What is damage control surgery and its phases?

Damage Control Surgery: Definition and Phases

Damage control surgery is a life-saving surgical strategy for severely injured patients presenting with hemorrhagic shock, ongoing bleeding, and coagulopathy, consisting of three distinct phases: abbreviated resuscitative surgery, intensive care resuscitation, and delayed definitive repair. 1

What is Damage Control Surgery?

Damage control surgery represents a paradigm shift from traditional surgical management, prioritizing physiological recovery over immediate anatomical reconstruction in critically injured patients. 1 The approach was first described by Stone in 1983 as abbreviated laparotomy with packing to control hemorrhage and deferred definitive repair until coagulation was established. 1

Primary Indications

You should employ damage control surgery in patients with: 1

• Deep hemorrhagic shock with signs of ongoing bleeding
• Established coagulopathy at presentation
• The "lethal triad": hypothermia (≤34°C), acidosis (pH ≤7.2), and coagulopathy 1, 2
• Inaccessible major venous injury requiring time-consuming procedures
• Suboptimal response to resuscitation with inability to achieve hemostasis 1

Additional Triggering Factors

Consider damage control surgery when: 1

• Major abdominal injury requiring adjunctive angioembolization
• Need to evaluate other potential injuries early
• Traumatic amputation of a limb with major abdominal injury
• Concomitant major injury outside the abdomen 1

The Three Phases of Damage Control Surgery

Phase 1: Abbreviated Resuscitative Laparotomy

The first phase focuses on rapid control of bleeding and contamination without attempting definitive organ repairs. 1

Key objectives include: 1

• Control of hemorrhage through packing and temporary measures
• Restoration of blood flow where critically necessary
• Control of contamination from hollow viscus injuries
• Temporary abdominal closure (avoiding time-consuming definitive repairs)

This phase should be completed as rapidly as possible—spending unnecessary time on traditional organ repairs that can be deferred is contraindicated. 1 The abdomen is packed and temporary closure is performed to allow transition to intensive care. 1

Phase 2: Intensive Care Unit Resuscitation

The second phase occurs in the ICU and focuses on correcting the lethal triad and optimizing physiological parameters. 1

Critical interventions include: 1, 2

• Core rewarming to achieve normothermia (36-37°C)
• Correction of acid-base imbalance through adequate tissue perfusion
• Reversal of coagulopathy (recognizing that hypothermia-induced coagulopathy is primarily reversible with rewarming to 37°C) 2
• Optimization of ventilation and hemodynamic status
• Complementary angiography if needed for ongoing bleeding
• Further injury investigation as clinically indicated 1

A critical pitfall to avoid: do not rely solely on standard coagulation tests (PT, PTT) performed at 37°C, as they underestimate coagulopathy in hypothermic patients. 2

Phase 3: Definitive Surgical Repair

The third phase involves returning to the operating room for definitive anatomical reconstruction only after target physiological parameters have been achieved. 1

Prerequisites for definitive repair: 1, 2

• Normothermia achieved (core temperature 36-37°C)
• Acidosis corrected (pH normalized, base deficit improved)
• Coagulopathy reversed or significantly improved
• Hemodynamic stability maintained

Timing considerations: The definitive repair should be performed when these target parameters are met, typically after adequate resuscitation in the ICU. 1 Pack removal should preferably occur only after 48 hours to lower rebleeding risk. 1

Evidence Base and Outcomes

Important caveat: No randomized controlled trials exist to support damage control surgery—the evidence base consists of retrospective studies showing reduced morbidity and mortality in selective populations. 1 However, the concept has widespread acceptance based on pathophysiological principles and consistent retrospective data demonstrating survival benefit in patients who would otherwise die from the lethal triad. 1, 3

Extension to Other Specialties

The damage control principles have been successfully applied beyond abdominal trauma: 1

• Damage control orthopedics: Relevant fractures are stabilized with external fixators rather than definitive osteosynthesis, with definitive repair performed 4-14 days later when the patient has recovered. 1, 4
• Thoracic and neurosurgery: Similar abbreviated approaches have been described. 1
• Emergency general surgery: The strategy is increasingly used for non-trauma abdominal emergencies including uncontrolled hemorrhage and sepsis. 3, 5

Critical Decision Point

In contrast, primary definitive surgical management is recommended for hemodynamically stable patients without signs of the lethal triad, ongoing bleeding, or coagulopathy. 1 The key is recognizing which patients have exhausted their physiological reserves and require the damage control approach versus those who can tolerate immediate definitive repair.