What is damage control surgery?

From the Guidelines

Damage control surgery is a life-saving surgical approach used for critically injured patients who are too unstable to undergo complete surgical repair immediately, involving a three-phase strategy to control bleeding, restore normal physiology, and perform definitive repair once the patient is stabilized. This approach is based on the most recent and highest quality study available, which emphasizes the importance of damage control surgery in improving survival rates for severely injured patients 1. The three-phase strategy includes:

• A brief initial operation to control bleeding and contamination
• Intensive care unit resuscitation to restore normal physiology
• Definitive surgical repair once the patient is stabilized. During the initial phase, surgeons focus only on controlling major hemorrhage, removing contaminated tissue, and temporarily closing the abdomen, often using techniques like vacuum-assisted closure devices. This approach prioritizes correcting the "lethal triad" of hypothermia, acidosis, and coagulopathy that often develops in trauma patients, as highlighted in the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1. The physiological rationale behind damage control surgery is that prolonged operations in unstable patients can worsen shock and increase mortality, whereas this staged approach allows time for physiological recovery before definitive repair, as supported by previous studies 1.

Key factors that should trigger a damage control approach include deep haemorrhagic shock, signs of ongoing bleeding and coagulopathy, hypothermia, acidosis, inaccessible major anatomical injury, a need for time-consuming procedures, or concomitant major injury outside the abdomen, as recommended in the management of bleeding following major trauma: an updated European guideline 1. The same "damage control" principles have been applied to orthopaedic injuries in severely injured patients, with relevant fractures primarily stabilized with external fixators rather than primary definitive osteosynthesis, as described in the management of bleeding and coagulopathy following major trauma: an updated European guideline 1.

Overall, damage control surgery is a critical approach in the management of severely injured patients, and its use should be guided by the most recent and highest quality evidence available, with the goal of improving survival rates and reducing morbidity and mortality in this high-risk population 1.

From the Research

Definition and Principles of Damage Control Surgery

• Damage control surgery (DCS) is a staged surgical approach to the treatment of critically injured trauma patients, focusing on rapid hemorrhage and contamination control with correction of physiologic derangements followed by delayed definitive reconstruction 2, 3, 4, 5, 6.
• The principles of DCS have remained consistent, but the forms of damage control intervention have evolved and proliferated dramatically 3.
• DCS is based on a limited evidence with current concerns of the variability in practice indications, rates, and adverse outcomes in poorly selected patient cohorts 5.

Indications and Applications of Damage Control Surgery

• DCS is often used in physiologically depleted patients in shock due to both traumatic and nontraumatic causes, including abdominal sepsis, intraoperative bleeding, and bowel ischemia 2, 4.
• DCS has also been shown to be safe and effective in thoracic and orthopedic injuries 3.
• The application of DCS principles in acute surgery patients may reduce mortality compared to that predicted by POSSUM or APACHE II scores 2.

Phases and Decision-Making in Damage Control Surgery

• The critical decision-making stages of DCS include patient selection, operation and intraoperative reassessment, resuscitation in the intensive care unit, definitive procedures, and abdominal wall reconstruction 4.
• Decision-making in trauma care is complex, involving precise patient assessment, treatment prioritization, and team coordination 6.
• The potential of AI-based decision support systems is noted for their ability to analyze patient data in real-time, aiding in decision-making through evidence-based recommendations 6.

Outcomes and Future Directions of Damage Control Surgery

• Despite being an accepted treatment algorithm, DCS is associated with high morbidity and mortality, but the application of DCS principles may reduce mortality compared to that predicted by POSSUM or APACHE II scores 2, 3, 5.
• Recent efforts have attempted to synthesize evidence-based indications to guide clinical practice, and significant progress in trauma-based resuscitation techniques has led to improved outcomes in injured patients and a reduction in the requirement of DCS techniques 5.
• Continued developments in early trauma care will likely result in a further decline in the required use of DCS in severely injured patients 5.