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Abdominal trauma can result in multiple different injuries affecting a number of organs. Early recognition and management of these injuries will improve patient survival and morbidity. Appropriate intervention involves the use of either definitive or damage control surgery for both haemorrhage and peritonitis. This article discusses the different mechanisms of injury, early assessment and investigations. It goes on to highlight the features of a trauma laparotomy, its preparation, management and the systematic approach for damage control surgery. The main abdominal organs are outlined in more detail to describe the individual approach to them in trauma.

Introduction Non-operative management is currently the preferred approach in blunt liver trauma, including high grade liver lesions. However, hemodynamic instability imposes the need for an emergency laparotomy, with a perihepatic packing (PHP) to control liver bleeding in most cases. Our retrospective study aimed to assess the outcomes of liver trauma patients who underwent a shortened PHP. Methods All consecutive patients who underwent PHP for blunt liver trauma from 1998 to 2019 in our Level I trauma center were included in the study. Unstable patients with severe liver trauma were transferred to the operating room without any delay, and a collective decision was made to perform abbreviated laparotomy to pack the liver. Demographics, perioperative data, postoperative outcomes, and mortality were retrospectively collected, and survivors and deceased patients were compared with a paired t-test. Results Fifty-nine patients of 206 patients admitted with severe liver injuries were treated with shortened PHP. Thirty-four (57.6%) patients died, including 26 (76.5%) within the first 24 h. Twelve (20.3%) patients had a selective hepatic embolization and eight (13.6%) had an extrahepatic embolization. Forty-eight patients had an extra abdominal associated injury. This was not a predictive factor of mortality. The removal of packing was performed in 24 patients within 72 h after laparotomy, with an 80% survival rate in these patients. Conclusion Shortened PHP is an effective strategy for controlling liver bleeding in severe hepatic trauma. The mortality rate of these patients is high, but after the removal of packing, the survival is good.

Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p

Background The damage control approach is known to reduce the mortality rate in severely injured patients and has now become a common practice. Transcatheter arterial embolization (TAE) has been shown to be useful with combining with damage control laparotomy in identifying and controlling active arterial hemorrhage. Hybrid operating room (OR) allows both damaged control surgery and TAE in the same location in minimal time. We report a case of a patient with three cardiac arrests who was saved by early intervention using damage control surgery (DCS) with interventional radiology (IVR) in the hybrid OR. Case presentation A 46-year-old woman was injured in a collision with a tree while snowboarding. She was eventually transported to hybrid operating room in our hospital with the diagnosis of significant liver laceration and hemorrhagic shock. Damage control surgery was performed with perihepatic packing (PHP) and TAE was conducted to stop active bleeding from right hepatic artery. She experienced 3 times of cardiopulmonary arrest, which was successfully resuscitated on each occasion. Although she had total of 3 times of laparotomy but tolerated well. She was discharged on day 82 of hospitalization and showed no neurological sequelae. Conclusion Saving the life of a patient with severe trauma requires a multidisciplinary approach with cooperation and early information sharing among trauma team members. Sharing treatment strategy with the trauma team and early intervention using DCS with IVR in the hybrid operating room could save the patient’s life.

The concept of damage control surgery was first introduced in the 1990s. It has great significance in the treatment for critically ill patients, which not only greatly improves survival rate, but also helps doctors avoiding misdiagnosis and mistreatment. Herein, we present a case of gastric perforation caused by neoplasm with critical condition of the patient. According to the concept of damage control surgery, the patient was subjected to perforation repair and tumor biopsy instead of conventional radical gastrectomy. Then, diffuse large B cell lymphoma was diagnosed on pathologic examination. After surgery, the patient received R-CHOP chemotherapy according to the clinical guidelines and is alive till now. Our experience might be helpful for understanding the value of damage control surgery in avoiding misdiagnosis and mistreatment for critical emergency patients. Key Words: Lymphoma, Stomach, Perforation, Damage control surgery.

BACKGROUND The management of colon injuries in damage control surgery (DCS) remains controversial. METHODS A retrospective study investigating outcomes of penetrating colonic trauma in patients who survived beyond the initial repeat laparotomy (IRL) after DCS was performed. Patients over 18 years with penetrating colon injury and who underwent DCS from 2012 to 2020 were included from our electronic trauma registry. Demographic data, admission physiology and Injury Severity Score (ISS) were reviewed. Patients were classified into three groups: primary repair of non-destructive injuries at DCL, delayed anastomosis of destructive injuries at IRL and diversion of destructive injuries at IRL. Outcomes observed included leak rates, length of intensive care unit stay, length of hospital stay, morbidities, mortality and colon-related mortality. RESULTS Out of 584 patients with penetrating colonic trauma, 89 (15%) underwent DCS. After exclusions, 74 patients were analysed. Mean age was 32.8 years (SD 12.5); 67 (91%) were male. Mechanism of injury was gunshot in 63 (85%) and stab 11 (15%) patients. Seventeen patients underwent primary repair at DCS, of which one leaked. Twenty patients underwent delayed anastomosis at IRL. Of these, five (25%) developed leaks. Mortality was significantly higher for those with an anastomotic leak compared to those without (p

Background : Damage control surgery is the practice of delaying definitive management of traumatic injuries by controlling hemorrhage in the operating room and restoring normal physiology in the intensive care unit prior to definitive therapy. Presently, damage control or “abbreviated” laparotomy is used extensively for abdominal trauma in an unstable patient. The application of a damage control approach in thoracic trauma is less established and there is a paucity of literature supporting or refuting this practice. We aimed to systematically review the current data on damage control thoracotomy (DCT), to identify gaps in the literature and techniques in temporary closure. Methods : An electronic literature search of Pubmed, MEDLINE, and the Cochrane Database of Collected Reviews from 1972-2018 was performed using the keywords “thoracic,” “damage control,” and “thoracotomy.” Studies were included if they reported the use of DCT following thoracic trauma and included survival as an outcome. Results : Of 723 studies, seven met inclusion criteria for a total of a 130 DCT operations. Gauze packing with temporary closure of the skin with suture was the most frequently reported form of closure. The overall survival rate for the seven studies was 67%. Survival rates ranged from 42-77%. Average injury severity score was 30, and 64% of injuries were penetrating in nature. The most common complications included infections (57%; pneumonia, empyema, wound infection, bacteremia), respiratory failure (21%), ARDS (8%), and renal failure (18%). Conclusion : DCT may be associated with improved survival in the critically injured patient population. Delaying definitive operation by temporarily closing the thorax in order to allow time to restore normal physiology may be considered as a strategy in the unstable thoracic trauma patient population. The impact an open chest has on respiratory physiology remains inconclusive as well as best mechanisms of temporary closure. Multi-center studies are required to elucidate these important questions.

Abdominal gunshot wounds have become a major problem globally, and it is commonly associated with liver injury. The aim of this study is to review our experience and outcomes of operative management of gunshot liver injures. A case series analysis reviewed all patients who underwent emergency laparotomy following liver gunshot injuries from January 1, 2011, to December 31, 2016. The collected data included age, gender, vital signs on admission, blood transfusion, grade of liver injury, associated intra-abdominal injuries, surgical procedures performed and re-operations, morbidity, and mortality rate. During the study period, we have done 71 operations for gunshot liver injured patients. The mean age was 28.5 years. There were 68 men and three women. There were 56 patients who had multi-organ injuries, while 64 patients were in shock. Liver injury grade I was occurred in two patients, while grades II, III, IV, and V have occurred in 10, 34, 19, and 6 patients, respectively. Liver tissue hemostasis was done in seven patients, 25 underwent liver tissue primary repair, 15 had direct blood vessel ligation, 21 were treated with perihepatic packing as part of damage control surgery, and three patients had a non-anatomical liver resection. Postoperative liver-related complications occurred in 15 patients, bleeding occurred in nine patients, the biliary leak in five, and hepatic abscess with septicemia in one patient. Despite the acceptance of selective non-operative management like hepatic angioembolization with its high success rate, expeditious exploratory laparotomy still has an effective role in the treatment of gunshot wounds of the liver with advanced grade penetrating injuries with acceptable morbidity and mortality.

Objectives Open abdomen technique with negative pressure therapy (NPT) is widely used in patients with severe abdominal sepsis. The aim of this study was to evaluate cytokine clearance in serum and peritoneal fluid during NPT. Methods This prospective pilot study included six patients with severe abdominal sepsis requiring discontinuity resection and NPT for 48 h followed by planned reoperation. Cytokines (IL6, IL8, IL10, TNFalpha, and IL1beta) were measured in the serum and peritoneal fluid during index operation, on postoperative days 0, 1, and 2. Results Concentrations of cytokines in peritoneal fluid were higher than in serum. IL10 showed a clearance both in serum (to 16.6%, p=0.019) and peritoneal fluid (to 40.9%, p=0.014). IL6 cleared only in serum (to 24.7%, p=0.001) with persistently high levels in peritoneal fluid. IL8 remained high in both serum and peritoneal fluid. TNFalpha and IL1beta were both low in serum with wide range of high peritoneal concentrations. Only TNFalpha in peritoneal fluid showed significant differences between patients with ischemia vs. perforation (p=0.006). Conclusions The present pilot study suggests that cytokines display distinct patterns of clearance or persistence in the peritoneal fluid and serum over the first 48 h of treatment in severe abdominal sepsis with NPT.

Ischemic gut or splanchnic hypoperfusion is a life-threatening emergency and it is associated with high mortality. It requires prompt diagnosis and intervention to establish the mesenteric blood flow, hence an attempt to avoid gut necrosis. Despite the understanding of pathogenesis of acute mesenteric ischemia and advanced treatment and revascularization techniques, it still remains a big diagnostic dilemma for the clinicians. Any delay in diagnosis and appropriate treatment affects the overall outcome of the patient. The high incidence of sepsis and multiorgan failure requires high-quality intensive care management. How to cite this article: Gupta S, Tomar DS. Ischemic Gut in Critically Ill (Mesenteric Ischemia and Nonocclusive Mesenteric Ischemia). Indian J Crit Care Med 2020;24(Suppl 4):S157–S161.

Purpose The likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high-grade liver injuries is a major concern. Thus, although early re-laparotomy tends to be recommended, we conducted this study to evaluate the feasibility of performing definite laparotomy within ≤ 48 h in this clinical population. Methods The subjects of this retrospective study were 65 patients (n = 24, ≤ 48-h group; n = 41, > 48-h group) who underwent DCS and perihepatic packing. The primary outcome was the rate of repacking for bleeding during re-laparotomy and the secondary outcomes were mortality and length of stay in the intensive care unit (ICU). Results The ≤ 48-h group had a higher rate of angioembolization and transfusion of red blood cells (RBCs), fresh frozen plasma, and platelets, but the rates of repacking and mortality were not significantly different between the groups. However, the incidence of pneumonia and ventilation support requirement were significantly lower in the ≤ 48-h group than in the > 48-h group. Conclusion The re-laparotomy performed within ≤ 48 h after DCS and perihepatic packing is feasible for patients with high grade liver injury, using angioembolization and aggressive transfusion, as required. Early re-laparotomy reduces the need for prolonged ventilator support and the incidence of ventilator-associated pneumonia.

With a prevalence of approximately 0.4%, distal femoral fractures are a rare entity. Nevertheless, due to the high mortality rates, which are comparable to proximal femoral fractures, these fractures are highly important. The clinical symptoms are often quite striking. In combination with preoperative computed tomography (CT) and if necessary, supplemented by CT angiography, the morphological situation can be assessed and the decision making facilitated. There are several different treatment options and the appropriate one should be selected for each individual case. The use of external fixation of the complete knee joint in the sense of damage control surgery, is useful. For definitive treatment retrograde intramedullary nailing and locking plates with angle stable screws are the main options. Modern angle stable and anatomically preformed implants enable surgical treatment using minimally invasive approaches to protect the soft tissues, with a better overall outcome.

Introduction There is evidence in the literature over the past 5 years that pelvic and acetabular fractures are increasing in prevalence with the rise of injuries sustained in road traffic accidents, the growing number and severity of trauma, significant complication rate and unsatisfactory outcomes due to untimely surgical treatment. Objective Review current trends in the selection of surgical approaches and fixation of the pelvis and acetabulum, the postoperative rehabilitation strategies and identify factors for poor outcomes of surgical treatment. Material and methods We performed searches using HAC peer-reviewed and SCOPUS indexed journals, EMBASE, MEDLINE, Сochrane library, еLibrary.ru, Wiley Online Library with search criteria of pelvic fractures, displaced acetabular fractures, open reduction of the pelvis and acetabulum, osteosynthesis, minimally invasive osteosynthesis and primary total hip arthroplasty, approaches and complications of acetabular fracture surgery. Results Indications to surgical treatment of patients with concomitant, multiple and isolated fractures of the pelvis and acetabulum were identified with the use of current strategy and principles of damage control surgery and damage control orthopaedics. Surgical approaches for two-column acetabular fractures have been shown to be extensile and traumatic. Discussion Most authors report use of the active surgical strategy for displaced fractures of the pelvis and acetabulum. Open reduction internal fixation is the standard of care for pelvic and acetabular fractures. Conclusion Postoperative complications and long term rehabilitation of patients with pelvic and acetabular fractures support further research and development of new more effective approaches to address the solution of the challenging issue.

Zusammenfassung. Es werden aktuell verschiedene Klassifikationssysteme für die Divertiukose und Divertikulitis verwendet. Die «Classification of Diverticular Disease» CDD basiert auf der heute standardmässigen Abklärung der Divertikulits mittels Schnittbildgebung und teilt in therapierelevante Gruppen ein, weshalb die Verwendung dieser Klassifikation sinnvoll ist. Die akute unkomplizierte Divertikulitis wird im Regelfall konservativ therapiert. Meist werden Patienten peroral oder intravenös antibiotisch behandelt. Mehrere über die letzten Jahre publizierten Studien zeigen, dass die alleinige symptomatische Therapie für die Mehrheit der Patienten mit unkomplizierter Divertikulitis keinen Nachteil gegenüber einer antibiotischen Therapie hat. Die akute komplizierte Divertikulitis mit einem relevanten Abszess oder einer Perforation wird interventionell oder operativ therapiert. Bei der operativen Therapie zeigt sich ein Trend weg von der klassischen Diskontinuitätsresektion nach Hartmann zur primären Anastomose oder bei schwerer Sepsis zu einem «Damage Control» Konzept. Bezüglich der elektiven Resektion im Intervall soll sich die Indikationsstellung an der Symptomatik des Patienten orientieren. Die Operationsindikation wird bei einer im Ausmass oder der Frequenz störenden Symptomatik gestellt. Die Anzahl der abgelaufenen Divertikulitisschübe ist nicht relevant. Chronische Komplikationen wie Fisteln und Stenosen stellen eine Operationsindikation dar.

Introduction: As part of the damage control surgery concept applied to the treatment of sepsis due to severe secondary peritonitis following intestinal perforation and/or in high-risk patients we describe the novel "temporary intestinal shunt" (TIS) technique with delayed intestinal anastomosis, as an alternative to primary anastomosis or enterostomy. Material and Methods: We present three patients in whom urgent laparotomy was performed due to intestinal perforation, with intestinal resection and TIS. Case reports:Case 1: A 39-year-old male presented with acute myeloid leukemia M3 and generalized peritonitis, sigmoid colon perforation and secondary jejunal loop involvement. In view of these findings, we performed 10 cm jejunal resection with TIS placement, sigmoid colon resection, and negative pressure therapy (NPT). Reoperation after 48 hours showed no evidence of peritonitis, so a manual jejuno-jejunal anastomosis and terminal colostomy were performed. Case 2: A 65-year-old woman treated with corticosteroids presented with a pneumoperitoneum secondary to a road traffic accident. Urgent laparotomy revealed a 2 cm jejunal perforation. Resection of the jejunal segment and TIS with NPT was performed. Exploration of the peritoneal cavity 96 hours later showed clinical improvement and a jejuno-ileal anastomosis was performed. Case 3: A 73-year-old male was admitted due to intestinal subocclusion. Clinical deterioration occurred rapidly and we performed an urgent laparotomy diagnosing jejunal perforation secondary to torsion and ischemia of the affected loop, and generalized peritonitis. Intestinal resection and TIS with NPT placement were thus decided. Anastomosis and closure of the abdominal appendage were deferred until 96 hours after the first surgery. Conclusion: Although the evidence we present is limited, we believe TIS to be an additional tool in damage control surgery. This staged management strategy allows definitive reconstruction with the patient in a more favorable physiological condition.

IntroductionThe objective was to report on the experience of the French Army Health Service in the management of blast injury of the hands related to warfare explosive devices.MethodsA retrospective study was conducted in the Percy Military Hospital (role 4 medical treatment facility) among French soldiers who presented with a combat-related blast injury of the hand between 2002 and 2018. The functional result was assessed by the disabilities of the arm, shoulder and hand (DASH) and the Orthotics and Prosthetics User Survey (OPUS, upper extremity functional status) scores. Proximal amputations (PAs) and distal amputations (DAs) were distinguished for the analysis.ResultsFifteen patients with a mean age of 31±8 years were included. They totalised 20 blasted hands. There were 16 traumatic amputations: 8 in each of the PA and DA groups. Twelve patients had additional injuries, four of which were polytraumatic. Skin closure time and flap use were higher in the DA group. Only one thumb reconstruction was performed. At a mean follow-up of 6.5±4 years, the number of amputees wearing a prosthesis was higher in the PA group. The mean DASH and OPUS scores were 35.5%±24.0% and 64.0%±19.0%, respectively, with no difference between the two groups.ConclusionThe severity of hand blasts related to warfare explosive devices requires the systematic application of damage control surgery. PAs are frequent and secondary reconstruction options are limited. The functional result is poor and similar between proximal and distal amputees.

Introduction Pneumatic weapons rarely cause severe trauma. However, pellet embolisation can cause severe and unexpected injuries. Report This is the case study of a 32 year old man, who was shot in the chest with a pneumatic rifle. Initially, urgent damage control surgery was performed to resolve pneumothorax and pericardial tamponade, but no projectile was found. Subsequent atypical symptomatology led to more extensive imaging that found a pellet embolised into the right carotid artery, thrombosis of the middle cerebral artery, and development of a large right hemispheric ischaemic area. After an unsuccessful endovascular intervention, the projectile was removed during an open surgical procedure. The right hemisphere oedema required decompressive hemicraniectomy, but long term intensive care and physiotherapy resulted in a satisfactory recovery with moderate neurological sequelae. Conclusion An unusual clinical presentation in combination with an absent exit wound might be symptomatic of projectile embolisation and should lead to a search for it. When the projectile position is convenient, surgical removal is the treatment of choice while an endovascular approach should be reserved for inaccessible locations or asymptomatic cases., Highlights • Projectile embolisation can lead to severe and unexpected pathologies. • Unusual clinical signs and an absent exit wound are suspicious of embolisation. • For symptomatic emboli, urgent projectile removal is necessary. • Surgical rather than endovascular removal is preferred for symptomatic emboli.

Direct peritoneal resuscitation is a validated resuscitation strategy for patients undergoing damage control surgery for hemorrhage, sepsis, or abdominal compartment syndrome with open abdomen and planned reexploration after a period of resuscitation in the intensive care unit. Direct peritoneal resuscitation can decrease visceral edema, normalize body water ratios, accelerate primary abdominal wall closure after damage control surgery, and prevent complications associated with open abdomen. This review article describes the physiological benefits of direct peritoneal resuscitation, how this technique fits within management priorities for the patient in shock, and procedural components in the care of open abdomen surgical patients receiving direct peritoneal resuscitation. Strategies for successful implementation of a novel multidisciplinary intervention in critical care practice are explored.

Abdulrahim A Rouzi, Mohammed Sulaimani Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi ArabiaCorrespondence: Abdulrahim A RouziDepartment of Obstetrics and Gynecology, King Abdulaziz University, PO Box 80215, Jeddah, 21589, Saudi ArabiaTel +966 50 5602587Email aarouzi@gmail.comPurpose: There is paucity of reports on damage control surgery use in near-miss cases associated with placenta previa, and placenta accreta spectrum. The objective is to report the outcome of damage control surgery for the obstetrical hemorrhage in near-miss cases of placenta previa and placenta accreta spectrum.Materials and Methods: The records of all women who had damage control surgery defined as abdominopelvic packing, followed by a period of medical stabilization in the intensive care unit for near-miss placenta previa and placenta accreta spectrum at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between November 1, 2007, and March 1, 2020, were identified and reviewed.Results: During the study period, seven women met the inclusion criteria. There were three women with placenta previa, three women with placenta previa accreta, and one woman with placenta accreta. Five women had cesarean section followed by laparotomy, hysterectomy, and damage control surgery, one woman had a cesarean hysterectomy and damage control surgery, and one woman had hysterectomy and damage control surgery. Estimated “near-miss” intraoperative bleeding ranged from 2 to 7 liters for the seven women (median 5 L; IQR 3.5, 6), which was managed by massive blood transfusion. Complications included disseminated intravascular coagulation (3 women), intestinal obstruction (1 woman), acute renal failure (1 woman), and vesicovaginal fistula (1 woman). Hospital stay ranged from 8 to 44 days (median 37; IQR 21, 39).Conclusion: Damage control surgery can be life-saving. It should be in the armamentarium of the health care providers managing women with placenta previa, and placenta accreta spectrum.Keywords: damage control surgery, placenta previa, placenta accreta spectrum

Background: Liver bleeding secondary to haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is uncommon, but a life-threatening peripartum condition that needs a prompt multidisciplinary approach.Case Presentation: In this study, we presented a case of 28-year-old pregnant woman, who was presented to the obstetrics department with signs of preeclampsia and foetal growth restriction. An emergency caesarean section was performed, and the patient developed a HELLP syndrome complicated by spontaneous liver rupture. After radiological and surgical procedures, liver failure became evident and liver transplantation was successfully performed. The patient and her daughter are now alive.Conclusions: Despite the rarity of this disease, liver complications due to HELLP syndrome must be properly diagnosed and treated given the gravity of the possible evolution in young women. After diagnosis, the patients must be treated in specialised centres with gynaecological, liver surgery, and transplant skills.

Trauma surgeons performing thoracic damage control surgery (TDCS) have two enemies: exsanguination and pleural space-occupying injuries with lung-compressing conditions. As a conxequence, the two primary aims of TDCS are to arrest hemorrhage thus preserving normal blood flow and to maintain gas exchange by relieving intrathoracic compression. The thoracic damage control approach follows two strategies. The first is to use procedures that are simpler and quicker and that restore a survivable physiology at the index operation. The most common procedure in this category is chest decompression and tube insertion. The second approach is an abbreviated thoracotomy such that survivable physiology is restored, but the definitive procedure is performed at the second operation after a period of recovery. Specific injuries of intrathoracic organs are managed according to the patient’s physiology and trauma surgeons should possess the technical skills for the emergency treatment of all injuries with immediate risk to survival caused by organs and structures in the chest. In fact, the trauma surgeon is often the only one present in the emergency department at all hours of the day and night.

In the last 20 years, the abdominal solid organ injuries treated definitively with non-operative management has progressively increased, including those of higher grade according to the classification of the American Association for the Surgery of Trauma Organ Injury Scale. This has led to a progressive reduction of what were considered definitive surgical treatments that currently are reserved for cases of complications of non-operative treatment or after damage control surgery procedures. Depending on the type of injury and the traumatized organ, alternative methods to surgery can be used for the definitive care of these injuries.

The lethal triad of coagulopathy, hypothermia, and acidosis is a well-known cause of severe deterioration and poor prognosis in trauma patients. The presence of this triad complicates the surgical management of a patient suffering from penetrating injury and hemorrhage. Here, we report the case and management of a 44-year-old man with multiple high-caliber gunshot wound (GSW) injuries who became severely acidotic (pH

We report a rare case of pulmonary torsion after nonpulmonary thoracotomy. A 38-year-old woman with schizophrenia committed suicide by a self-infliction of sharp force into the chest and abdomen. During emergent abdominal damage control surgery, a left-sided resuscitative thoracostomy was also performed due to hemorrhagic shock. Although abnormal shadow was detected on postoperative chest roentgenogram and computed tomography, the diagnosis of pulmonary torsion was delayed. Seven days after initial surgery, pulmonary torsion was diagnosed and managed by left upper lobectomy. To our knowledge, this is the first report of pulmonary torsion after resuscitative thoracotomy.

Introduction: Open abdomen (OA) treatment with negative-pressure therapy (NPT) was initiated for perforated diverticulitis and subsequently extended to other abdominal emergencies. The aim of this retrospective study was to analyze the indications, procedures, duration of NPT, and the outcomes of all our patients.Methods: All consecutive patients treated with intra-abdominal NPT from January 1, 2008 to December 31, 2018 were retrospectively analyzed.Results: A total of 438 patients (44% females) with a median (range) age of 66 (12–94) years, BMI of 25 (14–48) kg/m2, and ASA class I, II, III, and IV scores of 36 (13%), 239 (55%), 95 (22%), and 3(1%), respectively, were treated with NPT. The indication for surgery was primary bowel perforation in 163 (37%), mesenteric ischemia in 53 (12%), anastomotic leakage in 53 (12%), ileus in 53 (12%), postoperative bowel perforation/leakage in 32 (7%), abdominal compartment in 15 (3%), pancreatic fistula in 13 (3%), gastric perforation in 13 (3%), secondary peritonitis in 11 (3%), burst abdomen in nine (2%), biliary leakage in eight (2%), and other in 15 (3%) patients. A damage control operation without reconstruction in the initial procedure was performed in 164 (37%) patients. The duration of hospital and intensive care stay were, median (range), 28 (0–278) and 4 (0–214) days. The median (range) duration of operation was 109 (22–433) min and of NPT was 3(0–33) days. A trend to shorter duration of NPT was observed over time and in the colonic perforation group. The mean operating time was shorter when only blind ends were left in situ, namely 110 vs. 133 min (p = 0.006). The mortality rates were 14% at 30 days, 21% at 90 days, and 31% at 1 year. An entero-atmospheric fistula was observed in five (1%) cases, most recently in 2014. Direct fascia closure was possible in 417 (95%) patients at the end of NPT, but least often (67%, p = 0.00) in patients with burst abdomen. During follow-up, hernia repair was observed in 52 (24%) of the surviving patients.Conclusion: Open abdomen treatment with NPT is a promising concept for various abdominal emergencies, especially when treated outside normal working hours. A low rate of entero-atmospheric fistula formation and a high rate of direct fascia closure were achieved with dynamic approximation of the fascia edges. The authors recommend an early-in and early-out strategy as the prolongation of NPT by more than 1 week ends up in a frozen abdomen and does not improve abdominal sepsis.

Isolated duodenal injuries are not commonly seen in children who sustain abdominal trauma, and a complete pyloroduodenal disruption is quite rare. While techniques of duodenal diverticulization are employed widely in adults, the application of intubated diversion with primary repair works just as well in children. Two cases of isolated pyloroduodenal transection have been chronicled. To the best of our knowledge, one of these is the first case of successfully treated complete pyloroduodenal disjunction in pediatric literature. Case 1: A 10-year-old boy sustained multiple injuries after a road traffic accident and presented to us 48-h post-incident. Imaging suggested a duodenal injury. Exploratory laparotomy revealed a complete pyloroduodenal transection without associated pancreatic/ductal injuries. Primary repair with intubated diversions and a feeding jejunostomy was done. The child recovered completely. Case 2: A 5-year-old girl with delayed presentation following a road traffic accident required cardiopulmonary resuscitation and inotropic support prior to exploratory laparotomy. Findings included a large retroperitoneal hematoma involving zone 1 and 2, a right hepatic laceration, gastroduodenal disruption, and impending venous gangrene of the bowel. Intraoperative cardiac arrest necessitated rapid damage control surgery. Unfortunately, the child did not survive the injury. We wish to emphasize not only the need for early diagnosis and the customization of the surgery depending on the site and extent of injury but also the necessity of the rapid establishment of enteral nutrition to enhance recovery.

A 48-year-old female presented to the emergency department with chest pain and collapsed at the front desk. She was reanimated with mechanical chest compression, and after coronary angiography, a left anterior descending/diagonal bifurcation mini-crush stenting was performed. Few hours after the procedure, the patient showed severe hypotension. Abdominal ultrasound and computed tomography (CT) scan evidenced a massive subcapsular liver hematoma (Grade IV, American association for the surgery of trauma (AAST) liver injury scale) of the right lobe with extrahepatic blushing. Transhepatic embolization was attempted but without benefit, so the patient underwent emergency laparotomy for damage control surgery with perihepatic packing. After hemodynamic stabilization, right hepatectomy was performed with a favorable outcome and full recovery. The patient CT scan was retrospectively processed to obtain a virtual model visualizable through a head-mounted display. The virtual reconstruction could improve the comprehension of the injury and the liver surgical anatomy for educational purpose, and it could represent a new tool for preoperative planning.

Background An open abdomen is often necessary for survival of patients after peritonitis, compartment syndrome, or in damage control surgery. However, abdominal wall retraction relieves delays and complicates abdominal wall closure. The principle of the newly fascia preserving device (FPD) is the application of anteriorly directed traction on both fascial edges over an external support through a longitudinal beam to relieve increased abdominal pressure and prevent fascial retraction. Methods Twelve pigs were randomly divided into two groups. Both groups underwent midline laparotomy under general anesthesia. Group one was treated with the new device, group two served as controls. The tension for closing the abdominal fascia was measured immediately after laparotomy as well as at 24 and 48 h. Vital parameters and ventilation pressure were recorded. Post mortem, all fascial tissues were histologically examined. Results All pigs demonstrated increases in abdominal circumference. In both groups, forces for closing the abdomen increased over the observation period. Concerning the central closing force after 24 h we saw a significant lower force in the FPD group (14.4 ± 3 N) vs. control group (21.6 ± 5.7 N, p

This review focuses on the initial management and stabilization of complex vascular injuries for the general surgeon within the combat zone. Recent conflicts in Iraq, Afghanistan, and Syria demonstrate that general surgeons are responsible for the initial surgical management of combat-related vascular trauma in damage control scenarios. These injuries display a more complex injury pattern and often require different management strategies than seen in civilian trauma. Vascular trauma in combat settings is often accompanied by a multitude of life- and limb-threatening injuries. Definitive repair operations are often deferred for initial damage control surgery and resuscitation. Resultant strategies to restore perfusion and control bleeding are determined by the patient’s underlying physiology and frequently require the use of vascular shunts, ligation, primary anastomosis, or interposition grafting. While general surgeons in the combat zone are not typically responsible for definitive repair during initial damage control surgery, proper initial surgical management in the far-forward setting with an intimate understanding of future repair strategies remains critical aspects in assuring optimal definitive treatment.

Purpose. To evaluate the results of Damage Control Strategy (DCS) in the treatment of generalized peritonitis from perforated diverticular disease in patients with preoperative severe systemic diseases. Methods. All the patients with diffuse peritonitis (Hinchey 3 and 4) and the American Society of Anesthesiologists (ASA) score ≥3 were included and underwent DCS consisting of a 2-step procedure. The first was peritoneal lavage, perforated colon-stapled resection, and temporary abdominal closure with negative pressure wound therapy combined with instillation. The second step, 48 hours later, included the possibility of restoring intestinal continuity basing on local and general patients’ conditions. Results. Thirty patients (18 [60%] women and 12 [40%] men, median age 68.5 [range = 35-84] years) were included (18 [60%] ASA III, 11 [36.7%] ASA IV, and 1 [0.03%] ASA V). Seven patients (23.3%) showed sepsis and 1 (3.33%) septic shock. At second surgery, 24 patients (80%) received a colorectal anastomosis and 6 patients (20%) underwent a Hartmann’s procedure. Median hospital stay was 18 days (range = 12-62). Postoperative morbidity rate was 23.3% (7/30) and included 1 anastomotic leak treated with Hartmann’s procedure. Consequently, at discharge from hospital, 23 patients (76.6%) were free of stoma. Primary fascial closure was possible in all patients. Conclusions. DCS with temporary abdominal closure by negative pressure wound therapy combined with instillation in patients with diffuse peritonitis from complicated diverticulitis could represent a feasible surgical option both in hemodynamically stable and no stable patients, showing encouraging results including a low stoma rate and an acceptable morbidity rate.

IntroductionSpecialist units that assist indigenous forces (IF) in their strategic aims are supported by medical teams providing point of injury emergency care for casualties, including IF and civilians (Civ). We investigated the activities of a Coalition Forces far-forward medical facility, in order to inform medical providers about the facilities and resources required for medical support to IF and Civ during such operations.MethodsA prospective observational study (June to August 2017) undertaken at a far-forward Coalition Forces medical support unit (12 rotating personnel) recorded patient details (IF or Civ), mechanism of injury (MOI), number of blood products used, damage control resuscitation (DCR) and damage control surgery (DCS), number of mass casualty (MASCAL) scenarios, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA) and whole blood emergency donor panels (EDP).Results680 casualties included 478 IF and 202 Civ (45.5% of the Civ were paediatric). Most common MOIs were blast (n=425; 62.5%) and gunshot wound (n=200; 29.4%). Fifteen (2.2%) casualties died; 627 (92.2%) were transferred to local hospitals. DCR was used for 203 (29.9%), and DCS for 182 (26.8%) casualties. There were 23 MASCAL scenarios, 1220 transfusions and 32 EDPs. REBOA was performed eight times, and thoracotomy was performed 27 times.ConclusionsA small medical team provided high-tempo emergency resuscitative care for hundreds of IF and Civ casualties within a short space of time using state-of-the-art resuscitative modalities. DCR and DCS were undertaken with a large number of EDPs, and a high survival-to-transfer rate.

Background Urethral injury during inflatable penile prosthesis (IPP) or artificial urinary sphincter (AUS) placement is rare, and traditionally most prosthetic surgeons abort prosthetic implantation when urethral repair is necessary. Aim To report our experience with synchronous urethroplasty (SU) as a planned or damage control surgery during urologic prosthetic surgery, to evaluate the safety and outcomes of the procedure. Methods A retrospective review of our IPP and AUS database was completed to identify patients who underwent an SU between 2007 and 2018. We included patients who underwent an SU during prosthetic surgery in either a planned procedure for known stricture or diverticulum or a “damage control” procedure after intraoperative injury. Outcome Patient characteristics and surgical outcomes were assessed, with success defined as the absence of urethral stricture and revision surgery. Results From our database of 1,508 prosthetic cases, we identified 7 patients (0.46%) who had an SU in the same setting as complete prosthesis placement (4 AUS and 3 IPP [1 combined IPP/AUS], and 1 sling). Three patients underwent planned repair of a known urethral abnormality (urethral diverticulum, urethrocutaneous fistula, and urethral stricture), and 4 underwent repair of an intraoperative urethral injury. Among the patients who experienced an intraoperative urethral injury, contributing etiologies included previous anti-incontinence surgery with periurethral fibrosis (n = 2), severe corporal fibrosis from priapism, and previous urethral disruption from pelvic fracture. Nearly all of the urethroplasties (6 of 7; 86%) were completed with a primary closure. The average indwelling duration of suprapubic tube (SPT) catheters was 4.1 weeks (range, 7 to 47 days). The average duration of follow-up was 21.5 months, and all patients were continent at follow-up. No device infections or urethral complications were identified. Clinical Implications Our study illustrates the safety of concomitant urethral repair at time of prosthetic placement as an option to avoid the use of 2 anesthetics and prevent further scarring in high-risk patients. Strengths & Limitations This is the first study to address definitive urethral reconstruction during anti-incontinence procedures along with planned concomitant urethroplasty during IPP placement. This promising initial experience is relevant for surgeons who may encounter concomitant urethral pathology in the setting of complex reoperative prosthetic cases. The need for SU is rare, and thus our cohort size was limited in this retrospective, single-institution experience. Conclusion SU with prolonged SPT urinary diversion offers a safe damage control approach for men with concomitant urethral pathology during prosthetic surgery without conferring an increased risk of infection or stricture.

IntroductionWhile damage control surgery and resuscitation techniques have revolutionized the care of injured service members who sustain severe traumatic hemorrhage, the physiologic and inflammatory consequences of hemostatic resuscitation and staged abdominal surgery in the face of early aeromedical evacuation (AE) have not been investigated. We hypothesized that post-injury AE with an open abdomen would have significant physiologic and inflammatory consequences compared to AE with a closed abdomen.Materials and MethodsEvaluation of resuscitation and staged abdominal closure was performed using a murine model of hemorrhagic shock with laparotomy. Mice underwent controlled hemorrhage to a systolic blood pressure of 25 mmHg and received either no resuscitation, blood product resuscitation, or Hextend resuscitation to a systolic blood pressure of either 50 mmHg (partial resuscitation) or 80 mmHg (complete resuscitation). Laparotomies were either closed prior to AE (closed abdomens) or left open during AE (open abdomens) and subsequently closed. AE was simulated with a 1-hour exposure to a hypobaric hypoxic environment at 8,000 feet altitude. Mice were euthanized at 0, 4, or 24 hours following AE. Serum was collected and analyzed for physiologic variables and inflammatory cytokine levels. Samples of lung and small intestine were collected for tissue cytokine and myeloperoxidase analysis as indicators of intestinal inflammation. Survival curves were also performed.ResultsUnresuscitated mice sustained an 85% mortality rate from hemorrhage and laparotomy, limiting the assessment of the effect of simulated AE in these subgroups. Overall survival was similar among all resuscitated groups regardless of the presence of hypobaric hypoxia, type of resuscitation, or abdominal closure status. Simulated AE had no observed effects on acid/base imbalance or the inflammatory response as compared to ground level controls. All mice experienced both metabolic acidosis and an acute inflammatory response after hemorrhage and injury, represented by an initial increase in serum interleukin (IL)-6 levels. Furthermore, mice with open abdomens had an elevated inflammatory response with increased levels of serum IL-10, serum tumor necrosis factor alpha, intestinal IL-6, intestinal IL-10, and pulmonary myeloperoxidase.ConclusionThese results demonstrate the complex interaction of AE and temporary or definitive abdominal closure after post-injury laparotomy. Contrary to our hypothesis, we found that AE in those animals with open abdomens is relatively safe with no difference in mortality compared to those with closed abdomens. However, given the physiologic and inflammatory changes observed in animals with open abdomens, further evaluation is necessary prior to definitive recommendations regarding the safety or downstream effects of exposure to AE prior to definitive abdominal closure.

One out of 10 of military casualties and 6-9 out of 10 civilian victims of terror incidents suffer pulmonary blast injuries when the attackers use explosives as weapon. No specific therapy exists for the primary, shock-wave injury to the lung. The treatment protocols are based on mechanical ventilation, intensive therapy and supportive care. Secondary and tertiary blast structural injuries to the thorax require damage control surgery, dominated by pleural space management (drainage) and haemorrhage control (thoracotomy if needed). Parenchyma resection of irreversibly destroyed lung is rarely needed, and non-anatomical resections are to be preferred. Delayed chest wall reconstruction follows haemodynamic stabilisation and completion of demarcation process. Blast injury to the chest requires a multidisciplinary approach, where the outcome is strongly influenced by the concomitant injuries.

Thoracic damage control surgery (TDCS) is a decision making tool and derivate of the damage control concept (DCC), where physiological stabilization has a priority over anatomical reconstruction under the pressure of time. Intrathoracic haemorrhage control and pleural decompression are the two main immediate tasks of TDCS, while definitive procedures follow when the patient is stabilised in 24–48 hours. The focus of the thoracic surgeon is on the prevention of the haemorrhage induced coagulopathy, metabolic acidosis and hypothermy formed triad of death. Surgical haemorrhage control and pleural space decompression are to be performed. The individual patients benefit from TDCS procedures whose condition is too severe for a complex immediate reconstruction (polytrauma). Life threatening chest injuries in multiple/mass casualty scenarios in civilian and military environment alike are triaged and treated accordingly. Onset of acute mismatch between the resources (available hands, OP theaters, resources, hardware) and the needs (number and severity of chest trauma cases), a mindset shift should take place, where time and space the two main limiting factors. Airway obstruction, tension haemo/pneumothorax falls into the preventable death category. Chest drainage and emergency thoracotomy are the two main procedures offered by TDCS. An intervention structured organ/injury specific list of procedures is detailed. This is a mix of emergency surgery and cardiothoracic surgery, where less is more. TDSC is not the Holy Grail found to solve all complex thoracic trauma cases, but is a good tool to increase the chance for survival in challenging, and frequently quite hopeless situations.

Background and Aims:The management of duodenal trauma remains controversial. This retrospective audit of a prospectively maintained database was intended to clarify the operative management of duodenal injury at our institution and to assess the risk factors for leak following primary duodenal repair.Materials and Methods:This was a retrospective study undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. Operative techniques used for duodenal repair were recorded. Our primary outcome was duodenal leak in the postoperative period. Patients from January 2012 to December 2016 were included. All duodenal injuries were graded according to the American Association for the Surgery of Trauma (AAST) grading. Only patients who had a primary repair were included in the final analysis.Results:During the five-year data collection period, a total of 562 patients underwent a trauma laparotomy; of which 94 patients sustained a duodenal injury. A primary pyloric exclusion and gastro-jejunostomy (PEG) was performed in three patients. These three were then excluded from further analysis. Of the 91 primary duodenal repairs, seven (8%) subsequently leaked. These were managed by PEG in three and by secondary repair and para-duodenal drainage in four. The two physiological parameters most associated with subsequent leak were lactate and pH level. There was a significantly higher mortality rate for those who leaked vs those who did not leak. Chi-squared test revealed a significant difference in the leak rate between AAST I (0%), AAST-II (1.6%) and AAST-3 (66.7%) grade injuries (p Conclusion:The trend towards primary repair of duodenal injuries appears to be justified. However duodenal leak remains a significant risk in certain high risk patients and strategies to manage injuries in this subset requires further work.

Background: Abdominal trauma is a frequent indication for surgical exploration of the combat causality. Rapid transportation to trauma center, early recognition of injuries, sound surgical judgment, and timely intervention are critical for reducing mortality and morbidity. Patients and Methods: All penetrating abdominal trauma (PAT) cases admitted to a combat zone hospital from January 2014 to December 2016 were studied. Results: Forty-eight patients with PAT were evaluated and managed. Majority (66.7%) were secondary to gunshot injuries. Forty-one required operative management. Out of these, 6 (12.5%) underwent diagnostic laparoscopy and 35 (72.9%) required laparotomy. The small intestine was the most commonly injured organ which was encountered in 21 (43.7%) cases. Two (4.2%) patients succumbed to their injuries. Early resuscitation in combat zone followed by prompt evacuation to the combat hospital improved the overall outcome. Conclusion: PAT is a common cause of morbidity and mortality in combat areas. Rapid transportation, sound clinical judgment, and early surgical intervention are critical for patient survival and better outcomes.

Introduction: Traumatic kidney injury (TKI) remains a challenging element of multiorgan trauma. We present a 9-year experience of a trauma center with surgical management of multiorgan trauma patients with TKI. Materials and Methods: The inclusion criteria for this study were TKI in multiorgan trauma patients receiving surgical management. During 9 years, 10,191 patients were hospitalized to the Department of General Surgery. Forty-nine of these multiorgan trauma patients had associated TKI. Results: The severity of the kidney injury was classified on a five-point Organ Injury Scale proposed by the American Association for the Surgery of Trauma. Injuries to other organs were also evaluated. The surgical approach was either laparotomy or laparotomy with thoracotomy, depending on the severity of trauma. Discussion: Abdominal trauma may involve kidneys, especially when the injury is severe and affecting multiple organs. This may be seen in both the adult and pediatric populations. The treatment depends on the severity of organ injuries, hemodynamic stability of the patient and may be either surgical or conservative. Hemodynamically unstable patients received damage control surgery, whereas the stable ones underwent computed tomography before the decision on optimal treatment modality. The most severe vascular injuries are associated with a high mortality rate. Conclusion: TKIs usually appear in young males and predominantly follow blunt abdominal trauma. TKI is usually an element of complex multiorgan trauma with severe injuries to other organs.

Damage to the vessels remains an urgent and complicated issue of angio-surgery, both in the curative and organizational terms. In the course of the anti-terrorist operation in eastern Ukraine in 2014 — 2018, damage to major vessels requiring reconstructive interventions occurred in 2 % of the victims. In 90 % of the wounded, trauma to the vessels of the lower extremities was noted. In order to prevent the development of irreversible limb ischemia and its amputation in the trauma of major vessels in the conditions of the implementation of the surgical tactic «Damage control», the method of temporary shunting of the trunk vessels of the extremity deserves attention, which allows to restore blood flow through damaged major arteries in the short term, to prevent the development of irreversible ischemia and save the limb. Temporary bypass must be the initial stage of reconstructive surgery on the damaged major artery of the limb.The article describes the main historical stages of the inventions and improvements of temporal vascular shunts. The classification of temporal vascular shunts is given, their characteristics and detailed method of application are given. Temporary vascular shunts are effective; the possibility of their application should be considered when treating wounds of the vessels of the limbs of practically all types, in particular proximal veins. The main advantage of such shunts is to ensure early recovery of blood flow and to reduce the negative effects of arterial ischemia and venous hypertension. Unlike ligation, temporal bypass surgery is an element of multi-stage surgical treatment or damage control surgery. Despite the desire to maximize the implementation of primary reconstructive techniques at the stages of medical evacuation, for various reasons (delayed evacuation, intense combat and medical conditions) the frequency of the use of temporary prosthesis will not decrease. Therefore, in order to improve the results of treatment of injuries with damage to the main vessels, experimental and clinical testing of the use of the temporary prosthesis method in the implementation of the surgical tactic «damage control» is required.

Background Open articular fractures are an important issue due to their increasing incidence, along with the rise in motorcycle accidents. Oncology experience with allograft in orthopedics may be extended to cases of traumatic bone loss. Clinical case A 37-year-old man with an open fracture of the distal femur and proximal tibia presented a massive bone loss of the lateral femoral condyle after a motorcycle accident. Following Damage Control Surgery, a considerable lateral femoral condyle allograft was used to restore the joint anatomy. Results After an intensive rehabilitation program and two subsequent arthroscopic arthrolyses, the patient resumed walking without aids and recovered from stiffness (R.O.M. 0-130°). An MRI performed at median follow-up, revealed a favorable integration of the allograft. Discussion Allografts are a reasonable reconstructive option for young individuals with massive bone loss. An appropriately sized allograft is essential to restore an acceptable function as seen in the herein case.

Background Extracorporeal life support (ECLS) describes the use of blood perfusion devices to provide advanced cardiac or respiratory support. Advances in percutaneous vascular cannula insertion, centrifugal pump technologies, and the miniaturization of extracorporeal devices have simplified ECLS. The intention of this discussion is to review the role of ECLS as a potential rescue method for emergency department (ED) clinicians in critical clinical scenarios and to focus on the prerequisites for managing an ECLS program in an ED setting. Discussion Possible indications for ECLS cannulation in the ED include ongoing circulatory arrest, shock or refractory hypoxemia and pulmonary embolism with refractory shock. Severe trauma, foreign body obstruction, hypothermia and near drowning are situations in which patients may potentially benefit from ECLS. Early stabilization in the ED can provide a time window for a diagnostic workup and/or urgent procedures, including percutaneous coronary intervention, rewarming or damage control surgery in trauma. The use of ECLS is resource intensive and can be associated with a high risk of complications, especially when performed without previous training. Therefore, ECLS should only be used when the underlying problem is potentially reversible, and the resources are available to address the etiology of organ dysfunction. Conclusion Emergent ECLS has a role in the ED for selected indications in the face of life-threatening conditions. ECLS provides a bridge to recovery, definitive therapy, intervention or surgery. ECLS program requires an appropriately trained staff (physicians, nurses and ECLS specialists), equipment resources and logistical planning.

Urologic trauma is frequently reported in patients with penetrating trauma. Currently, the computerized tomography and vascular approach through angiography/embolization are the standard approaches for renal trauma. However, the management of renal or urinary tract trauma in a patient with hemodynamic instability and criteria for emergency laparotomy, is a topic of discussion. This article presents the consensus of the Trauma and Emergency Surgery Group (CTE) from Cali, for the management of penetrating renal and urinary tract trauma through damage control surgery. Intrasurgical perirenal hematoma characteristics, such as if it is expanding or actively bleeding, can be reference for deciding whether a conservative approach with subsequent radiological studies is possible. However, if there is evidence of severe kidney trauma, surgical exploration is mandatory and entails a high probability of requiring a nephrectomy. Urinary tract damage control should be conservative and deferred, because this type of trauma does not represent a risk in acute trauma management. Resumen El trauma renal y de las vías urinarias se presenta con relativa frecuencia en pacientes con trauma penetrante. El estándar actual de manejo es realizar una evaluación imagenológica, por medio de tomografía computarizada y un abordaje vascular, a través de técnicas de angiografía/embolización. Sin embargo, el manejo de un paciente hemodinámicamente inestable con criterios de laparotomía de emergencia, con hallazgos de trauma renal o de vías urinarias es aún tema de discusión. El siguiente articulo presenta el consenso del grupo de Cirugía de Trauma y Emergencias (CTE) de Cali respecto al manejo del trauma penetrante renal y de vías urinarias mediante cirugía de control de daños. Las características intra quirúrgicas del hematoma perirrenal tales como si es expansivo o si tiene signos de sangrado activo, son puntos de referencia para decidir entre un abordaje conservador, por estudios imagenológicos posteriores. En cambio, si existe la sospecha de un trauma renal severo, se debe realizar exploración quirúrgica con alta probabilidad de una nefrectomía. El manejo de control de daños de las vías urinarias debe ser conservador y diferido, la lesión de estos órganos no representa un riesgo en el manejo agudo del trauma.

Background Although spontaneous perforation of pyometra is very rare, it sometimes causes severe peritonitis, leading to lethal conditions. Damage control surgery reportedly improves the survival of critically ill patients; however, there has been no report describing damage control surgery for ruptured pyometra. Case presentation An 83‐year‐old postmenopausal woman with generalized peritonitis and septic shock was admitted and underwent emergency laparotomy. Abbreviated surgery was carried out because of progressing septic shock, and planned reoperation was carried out 2 days after the initial surgery. Histopathological examination revealed the perforation of pyometra with no evidence of malignancy. The patient was discharged on the 32nd postoperative day in stable condition. Conclusion We report a case of spontaneous perforation of pyometra with severe septic shock successfully treated by damage control surgery. Damage control surgery is a useful treatment option for hemodynamically unstable patients with diseases in the field of obstetrics and gynecology., We experienced a case of spontaneous perforation of pyometra successfully treated by damage control surgery. Acute care surgeons should consider damage control surgery as a useful treatment option for spontaneously ruptured pyometra in severe peritonitis.

Objective After the successful implementation in trauma patients, damage control surgery (DCS) is being increasingly used in non-traumatic abdominal emergencies, too. However, non-trauma DCS (NT-DCS) is currently a matter of debate and has not yet been comprehensively assessed. The aim of this meta-analysis was to investigate the effect of NT-DCS on mortality in patients with abdominal emergencies. Methods Systematic literature search using PubMed. Original articles addressing mortality in patients undergoing NT-DCS or non-trauma conventional surgery (NT-CS) for abdominal emergencies were included. Descriptive statistics and two meta-analyses were performed. Meta-analysis 1 compared mortality in patients undergoing NT-DCS vs. NT-CS. Meta-analysis 2 assessed the observed vs. expected mortality rate, based on APACHE, POSSUM and SAPS scores, in the NT-DCS group. Continuous and categorical variables were reported as weighted means and proportions. Effect sizes were described as risk differences (RD) with 95% confidence intervals (CI). Results Literature search revealed 1314 articles. Of these, 21 studies published 2004-2019 were included. NT-DCS was performed in 1238 and NT-CS in 936 patients. In the NT-DCS vs. NT-CS group mean age was 61.0 vs. 64.9 years and the proportion of male patients 58.6% vs. 52.9%, respectively. Most frequent indications for NT-DCS were hollow viscus perforation (28.4%), mesenteric ischemia (26.5%), anastomotic leak (19.6%), haemorrhage (18.4%), abdominal compartment syndrome (17.4%), bowel obstruction (15.5%), and pancreatitis (13.1%). In meta-analysis 1, mortality was not significantly different in the NT-DCS vs. NT-CS group (RD 0.09, 95% CI -0.06/0.24). Meta-analysis 2 revealed a significantly lower observed than the expected mortality rate in patients undergoing NT-DCS (RD -0.18, 95 % CI -0.29/-0.06). Heterogeneity of included studies was high in both meta-analyses (I2=89.0% and 79.9%, respectively). Conclusion This meta-analysis revealed no significantly different mortality in patients with abdominal emergencies undergoing NT-DCS vs. NT-CS. However, observed mortality was significantly lower than the expected mortality rate in the NT-DCS group, suggesting a benefit of the DCS approach. Based on these results, the effect of DCS in patients with non-traumatic abdominal emergencies remains unclear. Further prospective investigation into this topic is warranted.

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%. Resumen El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.

Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient’s life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity. Resumen El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients. Resumen El manejo definitivo de los pacientes hemodinámicamente estables con heridas cardíacas penetrantes continúa siendo controversial con abordajes invasivos versus manejos conservadores. Estas posiciones contrarias se extienden hasta aquellos casos de pacientes hemodinámicamente inestables donde se ha descrito y considerado la cirugía de control de daños como un procedimiento útil y efectivo. El objetivo de este artículo es presentar la experiencia en el manejo quirúrgico de heridas cardíacas penetrantes con la creación de un algoritmo práctico que incluye los principios básicos del control de daños. Se recomienda que a todos los pacientes con heridas precordiales penetrantes se les debe realizar un ultrasonido torácico como componente integral de la evaluación inicial. Aquellos que presenten un ultrasonido torácico positivo y se encuentren hemodinámicamente estables se les debe realizar una ventana pericárdica con posterior lavado. Se ha demostrado que el 25% de las ventanas pericárdicas positivas no se benefician ni requieren de posteriores abordajes quirúrgicos invasivos. Antes de este concepto, todos los pacientes con ventana pericárdica positiva terminaban en una exploración abierta del tórax y del pericárdico. Los pacientes hemodinámicamente inestables requieren de una cirugía de control de daños para un adecuado y oportuno control del sangrado. Con este propósito, se propone un algoritmo de manejo quirúrgico que incluye todos estos aspectos esenciales en el abordaje de este grupo de pacientes.

A 38-year-old man was pressed on his trunk by a heavy object weighing about 100 kg. The patient was in shock status on arrival to the hospital. Circular collapse progressed rapidly during contrast computed tomography (CT) scanning. CT images revealed exacerbation of the right lateral deviation of the heart that was earlier seen on X-ray imaging. Considering cardiac herniation based on CT findings, we immediately performed resuscitative thoracotomy and clamshell thoracotomy at the emergency department. Intraoperative findings showed a pericardial defect, and the heart had deviated to the right thoracic cavity. Immediate repositioning revealed a marked improvement in circulation. Full-thickness cardiac injury was observed in the anterior wall of the left ventricle; no active bleeding was observed. We performed temporary thoracic wall closure after cardiorraphy for damage control. After admission to the intensive care unit, he presented with respiratory failure associated with pulmonary contusion. Therefore, veno-venous extracorporeal membrane oxygenation (V V ECMO) was used from the 2nd to the 5th hospital day. After confirming no intra-thoracic events on the 6th hospital day, chest wall closure was performed. The patient subsequently developed heart failure and mitral regurgitation associated with papillary muscle rupture. On the 62nd hospital day, he underwent mitral annuloplasty at the cardiovascular surgery division; After rehabilitation till 152nd hospital day, he was discharged without any neurological abnormality. This was an extremely rare case with concomitant full-thickness myocardial injury, intracardiac injury, and cardiac herniation. Rapid resuscitative thoracotomy and damage control including V V ECMO yielded good results. Retrospectively, cardiac herniation should have been suspected earlier basis this observation. Our report highlights that cardiac herniation should be considered in case of cardiac shadow aberrations in cases of blunt chest trauma, familiarity with condition and its characteristic imaging findings are critical for the doctor overseeing initial trauma treatment.

BackgroundThe overall mortality of hemodynamically unstable pelvic fractures is high. Hemorrhage triggers off the Moore lethal triad. Hemostatic management during the golden hour is essential. Combined with pelvic stabilisation, preperitoneal pelvic packing (PPP) is proposed to control venous and bony bleeding, while arterioembolisation can stop arterial bleeding. No international consensus has yet prioritized these procedures. The aim of this study was to analyse a serie of PPP in a military level one trauma center and propose an algorithm for hemodynamically unstable pelvic traumas regardless of the military facility.MethodFrom January 2010 to December 2020, every patient from our military institution with a hemodynamically unstable pelvic fracture underwent PPP combined with pelvic stabilisation. Before 2012 data were retrospectively collected from database (PMSI), after 2012 data were prospectively recorded in our polytrauma database and retrospectively analysed. The care algorithm applied focused on hemodynamic status of polytraumatised patients on admission. Primary criteria were early hemorrhage-induced mortality (Results20 patients with a pelvic fracture had a PPP. Mean age was 49,65 +/-23,97 years and median ISS was 49 (31; 67). The decrease of blood transfusion and increase of SBP between pre- and postoperative values were statistically significant. Eight patients (40%) had postoperative arterial pelvic blush and 7 patients were embolised. The early mortality by refractory hemorrhagic shock was 25% (5/20). Overall mortality at 30 days was 50% (10/20).ConclusionPPP is a quick, easy, efficient and safe procedure. It can control venous, bony and sometimes arterial bleeding. PPP is part of damage control surgery and we propose it in first line. Angio-embolization remains complementary. Besides, PPP is the only means available in precarious conditions of practice, notably in military forward units.