Approach for abdominal damage control surgery

ICU: intensive care unit; SMA: superior mesenteric artery.

* Severe patterns of injury identified upon admission or intraoperatively may include the following:

• Hemorrhage likely to require internal packing for control (eg, major liver injury, pelvic fracture-related retroperitoneal bleeding).
• Severe combined organ injuries likely to need a staged approach (eg, combined chest and abdominal injuries, multiple bowel injuries, combined severe pancreatic and duodenal injury).
• Difficult-to-access major venous injury (intrahepatic, retrohepatic, retroperitoneal, pelvic).
• Significant concomitant central nervous system injury that may require immediate diagnostic evaluation, invasive monitoring, or treatment.

¶ Angioembolization can be performed intraoperatively with hybrid operating room capability, or postoperatively in an interventional radiology suite.

Δ Initial vascular control of solid organ injury may include vascular compression (eg, Pringle maneuver, sponge stick) or vascular clamping, and for vascular injury, once the affected vessel is clearly visible, balloon occlusion, vascular clamping, or placement of vascular loops.

◊ Bleeding from the liver or spleen is approached first using simple measures, then progressing to more aggressive techniques as needed. Prior to considering unilateral nephrectomy, the contralateral kidney should be palpated; an absent contralateral kidney or nonfunctioning kidney may impact this decision. Refer to UpToDate topics discussing specific injuries.

§ When necessary for damage control, most vessels can be ligated (with some risk of ischemia) with the exception of the aorta, proximal SMA, and the retrohepatic vena cava. Subsequent vascular reconstruction or resection of ischemic tissue may be required.

¥ Explore penetrating injury for active hemorrhage or expanding hematoma. Do not explore a contained, nonexpanding hematoma.

‡ Explore blunt injuries only for an expanding hematoma or one that has failed alternative methods of hemorrhage control (eg, angioembolization). Do not explore a contained, nonexpanding hematoma.