What is the Rotondo damage‑control surgery (DCS) concept, including its indications, operative steps, and adjunct measures?

The Rotondo Damage Control Surgery Concept

Damage control surgery (DCS), as defined by Rotondo in 1993, is a three-stage abbreviated surgical approach for severely injured patients in hemorrhagic shock that prioritizes rapid control of bleeding and contamination over definitive anatomic repair, followed by intensive care resuscitation and delayed definitive reconstruction. 1, 2

Historical Development

The concept evolved from Stone's 1983 description of abbreviated laparotomy, but Rotondo formalized it into the structured three-stage approach that revolutionized trauma surgery despite the absence of randomized controlled trials. 1 The technique has since expanded beyond abdominal trauma to thoracic, orthopedic, and neurosurgical applications. 2, 3, 4

The Three Operative Stages

Stage 1: Abbreviated Resuscitative Surgery

The initial operation must be completed as rapidly as possible, focusing exclusively on:

• Control of hemorrhage through packing, ligation, or temporary shunting of vessels 1, 2
• Restoration of blood flow where critically necessary 1, 2
• Control of contamination from hollow viscus injuries without formal repair 1, 2
• Temporary abdominal closure (typically with negative pressure therapy if open abdomen required) 5, 2

Critical principle: Avoid time-consuming traditional organ repairs that can be deferred—speed is paramount to prevent physiological exhaustion. 1

Stage 2: Intensive Care Resuscitation

The patient is transferred to ICU for aggressive physiological restoration targeting:

• Core rewarming to normothermia (36-37°C) 1, 5
• Correction of acidosis through metabolic optimization 1, 2
• Reversal of coagulopathy with hemostatic resuscitation (1:1:1 blood product ratios) 5, 2
• Hemodynamic stabilization and lactate clearance 5, 2
• Optimization of ventilation 1, 2

Additional diagnostic investigations are performed during this phase to plan definitive repair. 1

Stage 3: Definitive Surgical Repair

Return to the operating room only when target physiological parameters are achieved:

• Normothermia restored 5, 2
• pH corrected 5, 2
• Coagulopathy resolved 5, 2
• Hemodynamic stability achieved 5, 2
• Lactate clearance demonstrated 5

Specific Indications

Absolute Indications (Grade 1B)

DCS is mandated for patients presenting with: 1

• Hemorrhagic shock with signs of ongoing bleeding 1
• Coagulopathy (PT ratio >1.2, platelets <100,000/μL) 1, 5
• Combined abdominal vascular and pancreatic injuries 1

Additional Triggering Factors (Grade 1C)

DCS should be employed when any of the following are present: 1

• The "lethal triad": hypothermia, acidosis, coagulopathy 1, 2
• Inaccessible major anatomic injury 1
• Need for time-consuming procedures 1
• Concomitant major injury outside the abdomen 1, 2
• Major abdominal injury requiring adjunctive angioembolization 2
• Traumatic amputation with major abdominal injury 2

Contraindication

Primary definitive surgical management is recommended in the absence of the above factors (Grade 1C). 1 Universal application of DCS leads to unnecessary excess morbidity in patients who could undergo definitive treatment initially. 6

Essential Adjunct Measures

Damage Control Resuscitation (DCR)

Concurrent resuscitation strategies are critical to DCS success: 5, 7, 6

• Permissive hypotension: Target systolic BP 80-90 mmHg until hemorrhage controlled 5
• Hemostatic resuscitation: Balanced 1:1:1 ratio of packed RBCs:plasma:platelets 5
• Target hemoglobin: 7-9 g/dL during active bleeding 5
• Tranexamic acid: Administer within 3 hours of injury for significant bleeding 5
• Coagulopathy correction: Fresh frozen plasma, cryoprecipitate, platelets guided by laboratory values 5

Temperature Management

Aggressive prevention and treatment of hypothermia is mandatory: 1

• Remove wet clothing immediately 1
• Increase ambient temperature 1
• Forced air warming 1
• Warm fluid therapy 1
• Extracorporeal rewarming devices in extreme cases 1

Pelvic Trauma Adjuncts

For patients with pelvic fractures and hemorrhagic shock: 1

• Pelvic binder application in pre-hospital setting (Grade 1C) 1
• Early pelvic ring closure and stabilization (Grade 1B) 1
• Temporary extra-peritoneal packing when bleeding ongoing or angioembolization unavailable (Grade 1C) 1
• REBOA consideration for noncompressible life-threatening hemorrhage as bridge to hemorrhage control (Grade 2C) 1

Critical Pitfalls to Avoid

The most common error is inappropriate patient selection. DCS should be reserved for patients who cannot tolerate definitive surgery due to physiological exhaustion—not applied universally. 1, 8, 6 Overuse increases morbidity, ICU duration, and complications in patients who could undergo primary definitive repair. 8, 6

Delaying the decision to employ DCS is equally dangerous. Once the lethal triad develops, attempting definitive repair dramatically increases mortality. 1 The decision must be made early based on injury severity, physiological reserves, and anticipated surgical burden. 7

Premature return to the operating room for definitive repair before physiological parameters normalize leads to poor outcomes. 5, 2 Strict adherence to target parameters is essential before proceeding to Stage 3. 5, 2

Evidence Base and Outcomes

Despite widespread acceptance, DCS lacks randomized controlled trial evidence and is based on retrospective studies and pathophysiological principles. 2, 8 Cumulative reviews report overall mortality rates of 52% in DCS patients, reflecting the severity of injuries in this population rather than treatment failure. 1 Retrospective data consistently demonstrate survival benefit in patients who would otherwise die from the lethal triad. 1, 2 Recent advances in trauma resuscitation have reduced the frequency of DCS requirement, but it remains life-saving for appropriately selected patients. 8, 6