Damage control surgery

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Damage control surgery (DCS) is surgical intervention to keep the patient alive rather than correct the anatomy. [1] [2] It addresses the "lethal triad" for critically ill patients with severe hemorrhage affecting homeostasis leading to metabolic acidosis, hypothermia, and increased coagulopathy. [3]

Contents

This lifesaving method has significantly decreased the morbidity and mortality of critically ill patients, though complications can result. It stabilizes patients for clinicians to subsequently reverse the physiologic insult prior to completing a definitive repair. While the temptation to perform a definitive operation exists, surgeons should avoid this practice because the deleterious effects on patients can result in them succumbing to the physiologic effects of the injury, despite the anatomical correction. The leading cause of death among trauma patients remains uncontrolled hemorrhage and accounts for approximately 30–40% of trauma-related deaths. [4]

While typically trauma surgeons are heavily involved in treating such patients, the concept has evolved to other sub-specialty services. A multi-disciplinary group of individuals is required: nurses, respiratory therapist, surgical-medicine intensivists, blood bank personnel and others.

Technique

Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. Each of these phases has defined timing and objectives to ensure best outcomes. The following goes through the different phases to illustrate, step by step, how one might approach this. There are clearly different approaches throughout the country, and no one way is necessarily correct. However, the ability to evaluate objectively the differences and then choose the one that fits your team is important.[ citation needed ]

Initial laparotomy

This is the first part of the damage control process whereby there are some clear-cut goals surgeons should achieve. The first is controlling hemorrhage followed by contamination control, abdominal packing, and placement of a temporary closure device. [5] Minimizing the length of time spent in this phase is essential. For groups (i.e., trauma centers) to be effective in damage control surgery, a multi-disciplinary team is critical. The approach to caring for such critically ill patients is dependent on nurses, surgeons, critical care physicians, operating room staff, blood bank personnel, and administrative support. In addition to having the right team in place is having a prepared team. The more facile the team is enhances the ability for centers to effectively implement damage control surgery. This is referred to by some as damage control ground zero (DC0). [6] The ability to mobilize personnel, equipment, and other resources is bolstered by preparation; however, standardized protocols ensure that team members from various entities within the health care system are all speaking the same language. This has been seen during implementation of complex processes such as the massive transfusion protocol (MTP). Controlling of hemorrhage as discussed above is the most important step in this phase. Eviscerating the intra-abdominal small bowel and packing all four abdominal quadrants usually helps surgeons establish initial hemorrhagic control. Depending up on the source of hemorrhage a number of different maneuvers might need to be performed allowing for control of aortic inflow. Solid organ injury (i.e., spleen, kidney) should be dealt with by resection. When dealing with hepatic hemorrhage a number of different options exist such as performing a Pringle maneuver that would allow for control of hepatic inflow. [7] Surgeons can also apply manual pressure, perform hepatic packing, or even plugging penetrating wounds. Certain situations might require leaving the liver packed and taking the patient for angio-embolization or if operating in a hybrid operating room having perform an on table angio-embolization. Vessels that are able to be ligated should, and one should consider shunting other vessels that do not fall into this category. This has been described by Reilly and colleagues when they shunted the superior mesenteric artery to decrease the length of time in the operating room. [8] Once hemorrhage control is achieved one should quickly proceed to controlling intra-abdominal contamination from hollow-viscus organs. The perception might be that one could quickly perform an anastomosis. This should not be attempted in the damage control setting. The key is to simply prevent continued intra-abdominal contamination, and to leave patients in discontinuity. A number of different techniques can be employed such as using staplers to come across the bowel, or primary suture closure in small perforations. Once this is complete the abdomen should be packed. Many of these patients become coagulopathic and can develop diffuse oozing. It is important to not only pack areas of injury but also pack areas of surgical dissection. There are various methods that can be used to pack the abdomen. Packing with radiopaque laparotomy pads allow for the benefit of being able to detect them via x-ray prior to definitive closure. As a rule abdomens should not be definitively closed until there has been radiologic confirmation that no retained objects are present in the abdomen. The final step of this phase is applying a temporary closure device. Numerous methods of temporary closure exist, with the most common technique being a negative-vacuum type device. Regardless of which method one decides to use it is important that the abdominal fascia is not reapproximated. The ability to develop Abdominal Compartment Syndrome is a real concern and described by Schwab. [9]

ICU resuscitation

On completion of the initial phase of damage control, the key is to reverse the physiologic insult that took place. This specifically relates to factors such as acidosis, coagulopathy, and hypothermia (lethal triad) that many of these critically ill patients develop. When developing a strategy to best care for these patients, the same principles of having a multi-disciplinary team that work together in parallel for the same result apply. The intensivist is critical in working with the staff to ensure that the physiologic abnormalities are treated. This typically requires close monitoring in the intensive care unit, ventilator support, laboratory monitoring of resuscitation parameters (i.e., lactate). In using a number of different resuscitation parameters, the critical care team can have a better idea as to which direction is progressing. The first 24 hours often require a significant amount of resources (i.e., blood products) and investment of time from personnel within the critical care team. In many circumstances, especially trauma patients, require that other specialties address a variety of injuries. Moving the patient early on, unless absolutely necessary, can be detrimental. Certain circumstances might require this, and the patients should continue to receive care from the critical care team during the entire transport period. As the literature begins to grow within the field of damage control surgery, the medical community is continuously learning how to improve the process. Certain pitfalls have also become evident, one of which is the potential to develop abdominal compartment syndrome (ACS). While it might sound counterintuitive since the fascia is left open during the placement of these temporary closure devices, they can create a similar type process that leads to ACS. If this occurs the temporary closure device should be taken down immediately.[ citation needed ]

Definitive reconstruction

The third step in damage control surgery is addressing closure of the abdomen. Definitive reconstruction occurs only when the patient is improving. At this point in process the critical care team has been able to correct the physiologic derangements. The optimization typically takes 24 to 48 hours, depending on how severe the initial insult is. Prior to being taken back to the operating room it is paramount that the resolution of acidosis, hypothermia, and coagulopathy has occurred.[ citation needed ]

The first step after removing the temporary closure device is to ensure that all abdominal packs are removed. Typically the number of packs has been documented in the initial laparotomy; however, an abdominal radiograph should be taken prior to definitive closure of the fascia to ensure that no retained sponges are left in the abdomen. Once the abdominal packs are removed the next step is to re-explore the abdomen allowing for the identification of potentially missed injuries during the initial laparotomy and re-evaluating the prior injuries. Attention is then turned to performing the necessary bowel anastomosis or other definitive repairs (i.e., vascular injuries).[ citation needed ]

An attempt should be made to close the abdominal fascia at the first take back, to prevent complications that can result from having an open abdomen. The concern for early closure of the abdomen with development of compartment syndrome is a real one. A method to pre-emptively evaluate whether fascial closure is appropriate would be to determine the difference in peak airway pressure (PAP) prior to closure and the right after closure. An increase of over 10 would suggest that the abdomen be left open. [9] As mentioned above, it is important to obtain an abdominal radiograph to ensure that no retained sponges are left intra-operatively.

Considering that not all patients can undergo definitive reconstruction at first return, there are other options that surgeons can consider. Data would suggest that the longer the abdomen is left open from initial laparotomy the higher the rate of complications. [10] After about one week, if surgeons can't close the abdomen, they should consider placing a Vicryl mesh to cover the abdominal contents. This lets granulation occur over a few weeks, with the subsequent ability to place a split-thickness skin graft (STSG) on top for coverage. These patients clearly have a hernia that must be fixed 9 to 12 months later.

Resuscitation

Damage control resuscitation has had a dramatic impact on how care for critically ill patients is administered.[ citation needed ]. The core principles of resuscitation involve permissive hypotension, transfusion ratios, and massive transfusion protocol. The resuscitation period lets any physiologic derangements be reversed to give the best outcome for patient care.

Permissive hypotension

Typical resuscitation strategies have used an approach where aggressive crystalloid and/or blood product resuscitation is performed to restore blood volume. The term permissive hypotension refers to maintaining a low blood pressure to mitigate hemorrhage; however, continue providing adequate end-organ perfusion [Duchesene, 2010]. The key is to prevent exacerbation of hemorrhaging until definitive vascular control can be achieved, the theory being that if clots have formed within a vessel then increasing the patient's blood pressure might dislodge those established clots resulting in more significant bleeding. Permissive hypotension is not a new concept, and had been described in penetrating thoracic trauma patients during World War I by Bickell and colleagues demonstrating an improvement in both survival and complications. [11]

Subsequent animal studies have shown equivalent outcomes with no real benefit in mortality [4] Recently there has been further data in trauma patients that has demonstrated increased survival rates [Morrison, 2011]. Cotton and colleagues found that the use of a permissive hypotension resuscitation strategy resulted in better outcomes (increased 30-day survival) in those undergoing damage control laparotomy. This would not be used in situations where patients might have injuries such as a traumatic brain injury considering that such patients are excluded from the studies.

Transfusion ratios

For over a century the casualties of war have provided valuable lessons that can be applied within the civilian sector. Specifically the past decade has seen a paradigm shift in early resuscitation of critically injured patients. Instead of replacing blood volume with high volumes of crystalloid and packed red blood cells with the sporadic use of fresh frozen plasma and platelets, we have now learned that maintaining a transfusion ratio of 1:1:1 of plasma to red blood cells to platelets in patients requiring massive transfusion results in improved outcomes [Borgman 2007] [4] While this was initially demonstrated in the military setting, Holcomb and colleagues extrapolated this to the civilian trauma center showing improved results as well [12] [13] Broad implementation across both the military and civilian sector has demonstrated a decreased mortality in critically injured patients. [4] Debate has gone back and forth as to the correct ratio that should be used; however, recently Holcomb and colleagues published the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study. [13] [14] They compared administration a higher ratio of plasma and platelets (1:1:1) compared to a lower ratio (1:1:2). The patients that received a higher ratio had an associated three to four-fold decrease in mortality. To help mitigate confounding variables a randomized control trial called the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) has been performed to evaluate the transfusion requirement. There was no difference in 24 hour or 30 day mortality between the 1:1:1 group and the 1:1:2 group - https://jamanetwork.com/journals/jama/fullarticle/2107789. [12]

Massive transfusion protocol

Initial resuscitation of trauma patients continues to evolve. Massive transfusion (defined as receiving greater than or equal to 10 units of packed red blood cells with a 24-hour period) is required in up to 5% of civilian trauma patients that arrive severely injured. [15] Patients who are arriving severely injured to trauma centers can be coagulopathic. In fact, data suggests that around 25% of patients arrive having coagulopathy. [16] New ways of measuring coagulopathy such at thromboelstography (TEG) and rotational thromboelastometry (ROTEM) have allowed for a more robust assessment of the coagulation cascade compared to traditional methods of measuring international normalized ratio (INR) allowing clinicians to better target areas of deficiency. [4] For trauma teams to systematically and efficiently deliver blood products institutions have created protocols that allow for this. The protocols allow for clear communication between the trauma center, blood bank, nurses, and other ancillary staff. They also allow for the quick delivery of certain set of blood products depending upon the institution. One example might be that a “cooler” would contain 10 units of packed red blood cells, 10 units of plasma, and 2 packs of platelets. The idea is that the coolers would continue to be delivered to the location where the patient is being treated until the trauma team leader (typically the trauma surgeon) would discontinue the order [15] Certain factors have been looked at by Callcut and colleagues to determine the predictive ability of patients arriving at trauma centers. The different variables were systolic blood pressure below 90, hemoglobin <11 g/dL, temperature <35.5, INR > 1.5, base deficit >=6, heart rate >= 120 bpm, presence of penetrating trauma, and positive Focused Abdominal Sonography Trauma (FAST) exam. All the variables were found to be predictive of the need of massive transfusion protocol except for temperature (Callcut 2013).

History

Surgeons have used the concept of damage control surgery for years, and controlling hemorrhage with packing is over a century old. Pringle described this technique in patients with substantial hepatic trauma in the early twentieth century. [7] The U.S. military did not encourage this technique during World War II and the Vietnam War. Lucas and Ledgerwood described the principle in a series of patients. [17] Subsequent studies were repeated by Feliciano and colleagues, [18] and they found that hepatic packing increased survival by 90%. This technique was then specifically linked to patients who were hemorrhaging, hypothermic, and coagulopathic. [19] This extrapolation allowed for the first article in 1993 by Rotondo and Schwab specifically adapting the term “damage control”. [20] This term was taken from the United States Navy who initially used the term as “the capacity of a ship to absorb damage and maintain mission integrity” (DOD 1996). This was the first article that brought together the concept of limiting operative time in these critically ill patients to allow for reversal of physiologic insults to improve survival. In addition, the description illustrated how the three phases of damage control surgery can be implemented. Since this description the development of this concept has grown both within the trauma community and beyond.

Outcomes

The data that have been published regarding definitive laparotomy versus damage control surgery demonstrate a decrease in mortality when performed in the critically ill patient. [19] [6] Subsequent studies by Rotondo and colleagues in a group of 961 patients that had undergone damage control surgery demonstrate an overall mortality of 50% and a 40% morbidity rate. [21]

There are four main complications. The first is development of an intra-abdominal abscess. This has been reported as high as 83%. [18] [19] Next is the development of an entero-atmospheric fistula, which ranges from 2 to 25%. [5] [22] The third is abdominal compartment syndrome that has been reported anywhere from 10 to 40% of the time. [23] [24] Finally fascial dehiscence has been shown to result in 9–25% of patients that have undergone damage control surgery. [25] [26]

Related Research Articles

<span class="mw-page-title-main">Bleeding</span> Loss of blood escaping from the circulatory system

Bleeding, hemorrhage, haemorrhage or blood loss is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vagina or anus, or through a puncture in the skin. Hypovolemia is a massive decrease in blood volume, and death by excessive loss of blood is referred to as exsanguination. Typically, a healthy person can endure a loss of 10–15% of the total blood volume without serious medical difficulties. The stopping or controlling of bleeding is called hemostasis and is an important part of both first aid and surgery.

<span class="mw-page-title-main">Internal bleeding</span> Medical condition

Internal bleeding is a loss of blood from a blood vessel that collects inside the body, and is not usually visible from the outside. It can be a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding. Severe internal bleeding into the chest, abdomen, pelvis, or thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

<span class="mw-page-title-main">Major trauma</span> Injury that could cause prolonged disability or death

Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Depending on the severity of injury, quickness of management, and transportation to an appropriate medical facility may be necessary to prevent loss of life or limb. The initial assessment is critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of injuries accurately and to formulate a course of treatment.

<span class="mw-page-title-main">Hypovolemic shock</span> Medical condition

Hypovolemic shock is a form of shock caused by severe hypovolemia. It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock is a medical emergency; if left untreated, the insufficient blood flow can cause damage to organs, leading to multiple organ failure.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, sports-related injuries, and are notably common among the elderly who experience falls.

<span class="mw-page-title-main">Focused assessment with sonography for trauma</span> Fluid accumulation screening

Focused assessment with sonography in trauma is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart or abdominal organs (hemoperitoneum) after trauma. There is also the extended FAST (eFAST) which includes some additional ultrasound views to assess for pneumothorax.

Hemoperitoneum is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemoperitoneum is generally classified as a surgical emergency; in most cases, urgent laparotomy is needed to identify and control the source of the bleeding. In selected cases, careful observation may be permissible. The abdominal cavity is highly distensible and may easily hold greater than five liters of blood, or more than the entire circulating blood volume for an average-sized individual. Therefore, large-scale or rapid blood loss into the abdomen will reliably induce hemorrhagic shock and, if untreated, may rapidly lead to death.

<span class="mw-page-title-main">Blunt splenic trauma</span>

Blunt splenic trauma occurs when a significant impact to the spleen from some outside source damages or ruptures the spleen. Treatment varies depending on severity, but often consists of embolism or splenectomy.

<span class="mw-page-title-main">Penetrating trauma</span> Type of injury

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.

Abdominal compartment syndrome (ACS) occurs when the abdomen becomes subject to increased pressure reaching past the point of intra-abdominal hypertension (IAH). ACS is present when intra-abdominal pressure rises and is sustained at > 20 mmHg and there is new organ dysfunction or failure. ACS is classified into three groups: Primary, secondary and recurrent ACS. It is not a disease and as such it occurs in conjunction with many disease processes, either due to the primary illness or in association with treatment interventions. Specific cause of abdominal compartment syndrome is not known, although some causes can be sepsis and severe abdominal trauma. Increasing pressure reduces blood flow to abdominal organs and impairs pulmonary, cardiovascular, renal, and gastro-intestinal (GI) function, causing obstructive shock, multiple organ dysfunction syndrome and death.

An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the staging of some cancers.

The Wittmann Patch is a temporary abdominal fascia prosthesis for the planned open abdomen to ease the management of cases where the abdomen cannot be closed due to abdominal compartment syndrome or because multiple further operations are planned. It consists of a sterile hook and a sterile loop sheet made from propylene and nylon.

<span class="mw-page-title-main">Peter M. Rhee</span> American surgeon

Peter Meong Rhee is an American surgeon, medical professor, and military veteran. During his 24 years in the United States Navy, Rhee served as a battlefield casualty physician in Afghanistan and Iraq.

Permissive hypotension or hypotensive resuscitation is the use of restrictive fluid therapy, specifically in the trauma patient, that increases systemic blood pressure without reaching normotension. The goal blood pressure for these patients is a mean arterial pressure of 40-50 mmHg or systolic blood pressure of less than or equal to 80. This goes along with certain clinical criteria. Following traumatic injury, some patients experience hypotension that is usually due to blood loss (hemorrhage) but can be due to other causes as well. In the past, physicians were very aggressive with fluid resuscitation to try to bring the blood pressure to normal values. Recent studies have found that there is some benefit to allowing specific patients to experience some degree of hypotension in certain settings. This concept does not exclude therapy by means of i.v. fluid, inotropes or vasopressors, the only restriction is to avoid completely normalizing blood pressure in a context where blood loss may be enhanced. When a person starts to bleed the body starts a natural coagulation process that eventually stops the bleed. Issues with fluid resuscitation without control of bleeding are thought to be secondary to dislodgement of the thrombus that is helping to control further bleeding. Thrombus dislodgement was found to occur at a systolic pressure greater than 80mm Hg. In addition, fluid resuscitation will dilute coagulation factors that help form and stabilize a clot, hence making it harder for the body to use its natural mechanisms to stop the bleeding. These factors are aggravated by hypothermia.

Trauma surgery is a surgical specialty that utilizes both operative and non-operative management to treat traumatic injuries, typically in an acute setting. Trauma surgeons generally complete residency training in general surgery and often fellowship training in trauma or surgical critical care. The trauma surgeon is responsible for initially resuscitating and stabilizing and later evaluating and managing the patient. The attending trauma surgeon also leads the trauma team, which typically includes nurses and support staff, as well as resident physicians in teaching hospitals.

<span class="mw-page-title-main">Stab wound</span> Medical condition

A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.

<span class="mw-page-title-main">Liver injury</span> Form of trauma sustained to the liver

A liver injury, also known as liver laceration, is some form of trauma sustained to the liver. This can occur through either a blunt force such as a car accident, or a penetrating foreign object such as a knife. Liver injuries constitute 5% of all traumas, making it the most common abdominal injury. Generally nonoperative management and observation is all that is required for a full recovery.

Early appropriate care (EAC) is a system in orthopaedic trauma surgery aiming to identify serious major trauma patients and treat the most time-critical injuries without adding to their physiological burden.

Endovascular and hybrid trauma and bleeding management is a new and rapidly evolving concept within medical healthcare and endovascular resuscitation. It involves early multidisciplinary evaluation and management of hemodynamically unstable patients with traumatic injuries as well as being a bridge to definitive treatment. It has recently been shown that the EVTM concept may also be applied to non-traumatic hemodynamically unstable patients.

<span class="mw-page-title-main">Resuscitative endovascular balloon occlusion of the aorta</span> Temporary procedure to support blood pressure and stem blood loss

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure performed during resuscitation of critically injured trauma patients. Originally developed as a less invasive alternative to emergency thoracotomy with aortic cross clamping, REBOA is performed to gain rapid control of non-compressible truncal or junctional hemorrhage. REBOA is performed first by achieving access to the common femoral artery (CFA) and advancing a catheter within the aorta. Upon successful catheter placement, an occluding balloon may be inflated either within the descending thoracic aorta (Zone 1) or infrarenal abdominal aorta (Zone 3). REBOA stanches downstream hemorrhage and improves cardiac index, cerebral perfusion, and coronary perfusion. Although REBOA does not eliminate the need for definitive hemorrhage control, it may serve as a temporizing measure during initial resuscitation. Despite the benefits of REBOA, there are significant local and systemic ischemic risks. Establishing standardized REBOA procedural indications and mitigating the risk of ischemic injury are topics of ongoing investigation. Although this technique has been successfully deployed in adult patients, it has not yet been studied in children.

References

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  3. ↑ Garth Meckler; Cline, David; Cydulka, Rita K.; Thomas, Stephen R.; Dan Handel (2012). Tintinalli's Emergency Medicine Manual 7/E. McGraw-Hill Professional. ISBN   978-0-07-178184-8.
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  14. ↑ Callcut, Rachael A.; Cotton, Bryan A.; Muskat, Peter; Fox, Erin E.; Wade, Charles E.; Holcomb, John B.; Schreiber, Martin A.; Rahbar, Mohammad H.; Cohen, Mitchell J.; Knudson, M. Margaret; Brasel, Karen J.; Bulger, Eileen M.; del Junco, Deborah J.; Myers, John G.; Alarcon, Louis H.; Robinson, Bryce R.H. (January 2013). "Defining when to initiate massive transfusion". Journal of Trauma and Acute Care Surgery. 74 (1): 59–68. doi:10.1097/TA.0b013e3182788b34. PMC   3771339 . PMID   23271078.
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  16. ↑ Brohi 2008
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  20. ↑ Rotondo MF, Schwab CW, McGonigal MD, et al. (September 1993). "'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury". The Journal of Trauma. 35 (3): 375–82, discussion 382–3. doi: 10.1097/00005373-199309000-00008 . PMID   8371295.
  21. ↑ Rotondo, Michael F.; Zonies, David H. (August 1997). "The damage control sequence and underlying logic". Surgical Clinics of North America. 77 (4): 761–777. doi: 10.1016/S0039-6109(05)70582-X . PMID   9291979.
  22. ↑ Moore, Ernest E.; Burch, Jon M.; Franciose, Reginald J.; Offner, Patrick J.; Biffl, Walter L. (14 March 2014). "Staged Physiologic Restoration and Damage Control Surgery". World Journal of Surgery. 22 (12): 1184–1191. doi: 10.1007/s002689900542 . PMID   9841741. S2CID   10040060.
  23. ↑ Hirshberg, Asher; Wall, Matthew J.; Mattox, Kenneth L. (September 1994). "Planned Reoperation for Trauma". The Journal of Trauma: Injury, Infection, and Critical Care. 37 (3): 365–369. doi:10.1097/00005373-199409000-00005. PMID   8083894.
  24. ↑ Barker, Donald E.; Green, John M.; Maxwell, Robert A.; Smith, Philip W.; Mejia, Vicente A.; Dart, Benjamin W.; Cofer, Joseph B.; Roe, S. Michael; Burns, R. Phillip (May 2007). "Experience with Vacuum-Pack Temporary Abdominal Wound Closure in 258 Trauma and General and Vascular Surgical Patients". Journal of the American College of Surgeons. 204 (5): 784–792. doi:10.1016/j.jamcollsurg.2006.12.039. PMID   17481484.
  25. ↑ Finlay, I. G.; Edwards, T. J.; Lambert, A. W. (January 2004). "Damage control laparotomy". British Journal of Surgery. 91 (1): 83–85. doi: 10.1002/bjs.4434 . PMID   14716799. S2CID   6509240.
  26. ↑ Ekeh, Akpofure Peter; McCarthy, Mary C.; Woods, Randy J.; Walusimbi, Mbaga; Saxe, Jonathan M.; Patterson, Lisa A. (March 2006). "Delayed closure of ventral abdominal hernias after severe trauma". The American Journal of Surgery. 191 (3): 391–395. doi:10.1016/j.amjsurg.2005.10.045. PMID   16490553.

Bibliography

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