Timing of Return to Operating Room After Damage Control Surgery
Return to the operating room for definitive management after damage control surgery (DCS) should occur within 24-72 hours once physiological resuscitation has restored normal parameters, with the goal of closing the abdomen as early and safely as possible. 1
Physiological Optimization Before Definitive Surgery
The decision for reoperation must be individualized based on the patient's condition during resuscitation and ongoing treatment, evaluating multiple variables including: 1
- Resolution of shock - vasopressor requirements should be weaned or discontinued
- Correction of coagulopathy - normalization of clotting parameters
- Restoration of acid-base balance - correction of metabolic acidosis
- Achievement of normothermia - core temperature >35°C
- Adequate oxygenation and ventilation - improved respiratory function
Standard Timing Protocol
After DCS, patients should be transferred to the intensive care unit to continue resuscitation efforts, with definitive surgical management (bowel anastomosis if appropriate, abdominal wall closure) performed at a subsequent operation typically within this 24-72 hour window. 1
Critical Considerations for Anastomosis Timing
An anastomosis constructed in a patient requiring pressor support to treat shock is at high risk of failure. 1 Therefore, definitive reconstruction including bowel anastomosis should be deferred until hemodynamic stability is achieved without vasopressor support. 1
For patients with perforated hollow viscera managed with DCS principles, the second-look operation allows for assessment of bowel viability and consideration of primary anastomosis once physiological parameters have normalized. 1
Relaparotomy Strategy: On-Demand vs Planned
Evidence from randomized controlled trials demonstrates that relaparotomy on-demand is superior to routine planned relaparotomy, being associated with: 1
- Fewer negative laparotomies
- Fewer operations overall
- Shorter critical care stay
- Shorter total hospital stay
- No difference in mortality
This suggests that while the 24-72 hour window provides general guidance, the specific timing should be driven by clinical indicators of deterioration or failure to improve, rather than a rigid predetermined schedule.
Temporary Abdominal Closure Management
Negative pressure wound therapy (NPWT) should be initiated for temporary abdominal closure, with evidence showing benefits in mortality, complications, and time to definitive closure. 1 Combining NPWT with dynamic mesh-mediated fascial traction can achieve successful delayed fascial closure in a high proportion of patients. 1
Common Pitfalls to Avoid
- Do not attempt definitive anastomosis while the patient remains on vasopressors - this dramatically increases anastomotic failure risk 1
- Do not delay beyond 72 hours unnecessarily - prolonged open abdomen increases complications including enteroatmospheric fistula formation 1
- Do not use routine indiscriminate planned relaparotomy - this approach increases mortality risk in severe secondary peritonitis 1
- Do not proceed with definitive surgery if ongoing resuscitation requirements suggest persistent physiological derangement 1
Special Populations
In elderly patients or those with severe physiological derangement from conditions like perforated diverticulitis, DCS represents a viable option with reported bowel restoration rates of 71-83% at second-look operations. 1 However, these patients require particularly careful assessment of physiological readiness before attempting definitive reconstruction.