Damage control for gunshot injury. "Damage Control" in the treatment of fractures in patients with critical polytrauma. Surgical tactics “damage control”

The steady increase in injuries observed in last years, is increasingly accompanied by combined and multiple injuries to the organs and systems of the victims, which makes it impossible for them to perform large recovery operations in one stage. Success in treating such patients is largely determined not only by the availability of experienced specialists and conditions for providing specialized assistance, but also using a number of new approaches developed on the basis modern achievements surgery, anesthesiology and resuscitation. Improving care for victims with polytrauma is the most pressing task of modern traumatology, since it is the cause of mortality in young and middle-aged people. Serious damage long tubular bones are found in 70% of victims with polytrauma, which further aggravates the general condition and complicates treatment. On the other hand, these fractures do not pose an immediate threat to life, and their treatment can be divided into two or more stages using simple techniques that are safe for the victim at the first stage, and complex restorative, surgical treatment in subsequent stages, carried out in conditions of complete or partial compensation for the patient's condition with minimal risk to his life.

In the 80s, the concept of immediate total care was proposed - ETC (early total care), which allowed immediate surgery in the first 24 hours after injury of all injuries, both abdominal and orthopedic. The ETS concept has become the gold standard for providing care to victims of polytrauma. It was used universally in all groups of victims, regardless of the severity of the injuries. After osteosynthesis, patients became mobile, which reduced the number of pulmonary complications, pain impulses from the fracture zone stopped, bleeding stopped, which reduced the duration of shock. This concept also had economic effect, as it shortened the treatment time. However, in the late 1980s, with the development of trauma surgery, it turned out to be ineffective in patients with critical injuries.

Long-term surgical intervention in patients with polytrauma, especially with thoracic, abdominal and craniocerebral injuries, with unstable hemodynamic parameters, led to death, both during these operations and on the 5-7th day, from severe complications that developed - Adult RDS, multiple organ failure, pneumonia and sepsis. In foreign literature, this period is called the era of borderline states - the borderline era. To assess borderline states in 1990. The Honover school of polytraumas proposed a system damage control, damage control. This principle involves the separation surgical care in case of severe injuries in two or more stages, when the traumatic nature and duration of emergency surgical intervention exceed the functional capabilities of the body, and the immediate and final restoration of damaged structures will lead either to the death of the victim or to serious postoperative complications. Comparative characteristics tactics of ETS and DCS, carried out by G. Taeger et al., showed that with DCS, surgical blood loss is 10 times less, the traumatic effect of the operation and postoperative complications are significantly reduced.

According to P. Harwood et al., when using the damage control protocol, adult RDS and sepsis develop less frequently than when providing assistance according to the ETC principle. The term damage control surgery was proposed in 1993 by M. Rotondo et al. for surgery of abdominal injuries and consisted of three stages. First stage - stop bleeding and bacterial contamination abdominal cavity. The second is intensive anti-shock therapy in conditions intensive care unit, aimed at stabilizing vital important functions body (replenishment of circulating blood volume, correction of coagulopathy, warming the victim, hemodynamic support, ventilation support, elimination of acidosis). The third stage is final surgical treatment. In 2001, J. Johnson et al. expanded the concept of damage control by highlighting the fourth stage - ground zero, which implies the provision of pre-hospital medical care(the fastest possible transportation to a medical facility, the simplest measures to stop bleeding, prevention of hypothermia, preparation for massive transfusion therapy). This tactic significantly improved the outcomes of severe polytraumas and made it possible to save the life and health of victims who were previously considered hopeless. Separate protocols were allocated damage control for abdominal, thoracic, craniocerebral, spinal and orthopedic injuries, which received the appropriate designations - DCS (damage control surgery - damage control control of damage to the musculoskeletal system).

The main pathophysiological prerequisites for damage control tactics in severe polytrauma are metabolic acidosis, pH level less than 7.2, hypothermia, the victim’s body temperature is less than 340C, hypotension, systolic blood pressure level is less than 90 mm Hg. Art., coagulopathy, activated partial thromboplastin time more than 60 s. This triad defines the physiological limit of the body, at which even the most technically successful operation is doomed to failure. For successful application of damage control in practice, it is necessary to carefully evaluate three factors: 1) the severity of the initial injury, the first hit, 2) the biological constitution of the patient, age, body weight, accompanying illnesses, 3) number necessary operations taking into account their duration and probable blood loss (the second hit). Danger second strike stable and borderline performance of any type of osteosynthesis urgently did not lead to deterioration general condition. In the unstable group, at the first stage only low-traumatic operations are used and conservative methods. In the group, critical at the first stage are used only conservative methods fixation. Stable functional osteosynthesis in these groups is performed at the second stage, after stabilization of the general condition, on days 4-14 after injury.

Thus, the action of a traumatologist when applying damage control tactics in the case of severe polytrauma is as follows: priority is given to operations on the organs of the abdominal cavity, pelvis, chest, and brain. These operations are divided into two and sometimes three phases. First, after minimal stabilization (blood pressure at 90 mm Hg, pulse 120 per minute), drainage is performed according to indications chest, laparotomy with tamponing or clamping of bleeding vessels or organs. The damaged intestine is removed and isolated from the free abdominal cavity. The wound is being stitched up continuous seam, only skin. After stabilization, after 24-36 hours the laparotomy wound is reopened and the second phase of surgical treatment is carried out with final suturing of the wound. Depending on the severity of the condition, in unstable and critically ill patients with damage to long tubular bones, in the first phase, fixation is performed with an external fixation device (AFD), skeletal traction, or a plaster splint. At open fractures for victims in critical condition, only the wound is washed with antiseptics, visible foreign bodies, antiseptic bandage. Surgical treatment is also carried out after 24-36 hours. Immersion osteosynthesis for closed fractures postponed for 6-8 days.

Based on the above, we propose an algorithm for the treatment of fractures of long tubular bones in polytrauma. abdominal and chest cavity), DCO (damage control orthopedics - characterized by systemic inflammation in combination with microvascular damage, increasing interstitial edema, primarily of the lungs, and multiple organ failure. This explains the fact when a patient with a severe injury who has undergone several operations, blood loss is compensated by transfusion donated blood, reduced acid-base and electrolyte balance, however, after 1-2 days they develop severe complications with fatal outcome. The concept of damage control in orthopedics is used for fractures of the femur, pelvis with disruption of the anterior and posterior half-rings, multiple fractures of long tubular bones, avulsions of the femur and tibia. Great importance given to the following: damage to which areas is combined with injury to the musculoskeletal system. Most of all, the unfavorable outcome and development of complications are influenced by closed injury chest and traumatic brain injury. For effective application damage control, depending on the severity of the injury and general condition, patients with polytrauma were divided into four groups: stable, borderline, unstable, critical. The severity of the injuries received was determined using a score for the severity of polytrauma according to AIS and ISS, the severity of traumatic brain injury according to the Glasgow scale (CGS), as well as indicators of systolic blood pressure, heart rate (HR), respiratory rate (RR), hemoglobin level, hematocrit .

Thus, damage control is a tactic for treating victims with polytrauma who are in an unstable or critical condition. Damage control orthopedics applies to patients whose condition severity according to ISS is more than 20 points in combination with trauma to the skull, chest, or abdominal cavity. Treatment consists of two stages: Stage I - for victims in critical condition, in the first 24 hours from the moment of injury, a minimum of trauma care is performed, after surgery on the brain and abdominal organs; Stage II - 6-8 days after the injury, after complete stabilization, final osteosynthesis is performed.

Literature

Abakumov M.M., Bogopolsky P.M. Damage control: what's new? Surgery. Journal named after N.I. Pirogova, 2007, 11, pp. 59-62.
Voinovsky A.E., Koltovich P.I., Koltovich A.P., Kurdo S.A. Features of damage control surgical tactics for severe abdominal trauma. Surgery. Journal named after N.I. Pirogova, 2007, 11, pp.55-58.
Gumanenko E.K. Objective assessment of injury severity. St. Petersburg, 1999.
Gumanenko E.K., Shapovalov V.M., Dulaev A.K., Dadykin A.V. Modern approaches to the treatment of victims with unstable injuries of the pelvic ring. Military medical magazine 2003, 4, p. 17-24.
Eryukhin I.A. Shlyapnikov S.A. Extreme conditions of the body. St. Petersburg, 1999
Koshcheev A.G., Zavrazhnov A.A. Alisov P.G. Semenov A.V. Surgical tactics of damage control in the treatment of severe combat wounds and traumas. Military medical magazine. 2001, 10, pp.27-31.
Sokolov V.A. Damage control - modern concept treatment of victims with critical polytrauma. Bulletin of traumatology and orthopedics. 2005.1, p. 81-84.
Sokolov V.A., Byalik E.I., Ivanov P.A., Garayev D.A. Practical use damage control concepts in the treatment of fractures long bones limbs in victims with polytrauma. Bulletin of traumatology and orthopedics. 2005,1, pp.3-7.
Sokolov V.A., Byalik E.I., Ivanov P.A., Garayev D.A. Tactics of surgical treatment of fractures of long bones of the extremities in early period combined injury: Method. recommendations. M., 2000.
Charchyan A.G., Gabrielyan L.M., Bakhtamyan G.A., Harutyunyan G.R., Gyulzadyan G.G., Bdoyan G.A., Saribekyan S.A. About the concept of damage control orthopedics.
Shapot Yu.B., Seleznev S.A. Remizov V.B. Multiple and combined trauma, accompanied by shock. Chisinau, 1993
Bachicchio G.V. The management of complex liver injuries. Trauma Quart., 2002; 15; 55-76.
Boss M., Mac-Kenzie E., Reimer A. et al. J. Bone Joint Surg., 1997. Vol.79A, p.799-809.
Boss M., Tejwani N.C. Evolving trends in the care of polytrauma patients. Injury, 2004; 37; 1; 20-28.
Eppiheimer M.J., Granger D.N. Shock, 1997, Vol. 8, p.16-26.
Guerrero-Lopez F. Vazguez-Mata G. Alcazar P.P. et al. Crit. Care Med., 2000. Vol.28, p.1370-1375.
Hauser C.J., Zhou X., Joshi P. et al. J. Trauma, 1997. Vol.42, p.895-903.
Karlbauer A., Woidke R. Bulletin of Traumatology and Orthopedics, 2003, Vol.3, p. 16-19.
Mclntyre T.M., Modur V., Prescott S.M., Zimmerman G.A. Thromb. Haemost., 1997, Vol.77. p.302-309/
Pape H.C., Van-Greinsven M., Rice J. et al. J. Trauma, 2001, Vol.50, p. 989-1000.
Perl M., Gebhard F., Knofert M.W. et al. Shock, 2003, Vol.19, p. 299-304.
Przkova R., Bosch U.J. Trauma, 2002, Vol.53, p. 765-769.
Rotondo M.F., Schwab C.W., Ibid., 1993, Vol. 35, p. 375-382.
Scalea T.M., Boswekk S.A., Scott I.D. et al. Ibid, 2000, Vol. 48, p. 613-621.

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Discussion Practical application of the “damage control” concept in the treatment of fractures of long bones of the extremities in patients with polytrauma

In January there was a fracture of the tibia condyle, surgery - osteosynthesis with 3 bolts, complication of staphylococcus in knee joint. I started rehabilitation in April, everything is going according to plan, but my ankle swells in the evening, my knee has not yet returned to its size. When do you think the leg is
In April 2000, I underwent osteosynthesis surgery for fractures of the neck of the humerus and the middle third of the femur. To this day there is no complete fusion of the femur. Is this a fusion delay, if so what are the consequences? possible reasons. I am 38 years old, injured as a result of an accident.

The damage control resuscitation strategy is aimed at combating the components of the “lethal triad” - coagulopathy, hypothermia and acidosis, which arise against the background of traumatic blood loss and contribute to its continuation. Developing hypoperfusion leads to a decrease in oxygen delivery, a transition to anaerobic metabolism, lactate accumulation, and metabolic acidosis. Anaerobic metabolism limits endogenous heat production, increasing hypothermia. A vicious pathogenetic circle arises. Core body temperature less than 35 °C is an independent predictor of death in severe trauma (R.S. Martin et al., 2005).

The main components of the damage control resuscitation strategy are:

1) permissible (intentional) hypotension with limiting the volume of infusion until reliable hemostasis is formed;

2) hemostatic resuscitation strategy, including the earliest possible use of blood components as primary infusion therapy and prescription of hemostatic pharmacological agents;

3) surgical damage control.

A hypotensive resuscitation strategy (taking into account suboptimal end-organ perfusion requirements) involves delaying or limiting the volume of colloid and crystalloid infusion until reliable hemostasis is achieved and is aimed at preventing dilutional coagulopathy. Thus, the study showed that the average arterial pressure(SBP) equal to 40 mm Hg. for 2 hours, led to the development of fatal hypoperfusion, and conversely, hypertension, when SBP was more than 80% above normal, led to the development of fatal rebleeding (T. Li et al., 2011). Another study noted that systolic blood pressure (BPsyst.) at 80 mmHg. in comparison with the group of patients with ADsyst. > 100 mmHg provided effective control of bleeding. Therefore, in patients with active bleeding, it is recommended to maintain target blood pressure. less than 100 mm Hg. The effectiveness of this approach has also been confirmed by a number of other studies (R.P. Dutton et al., 2012), although it is still a subject of debate. Recommendations for acceptable hypotension are included in US military medical doctrine (T. J. Hodgetts et al., 2007) and in the 8th edition of Advanced Trauma Life Support (ATLS, 2008). Acceptable hypotension is contraindicated in TBI due to the need to maintain cerebral perfusion pressure.

The hemostatic resuscitation strategy aims to quickly and active treatment acute post-traumatic coagulopathy and is recognized as important factor improving treatment outcome (E. Kirkman et al., 2008). It includes the use of fresh frozen plasma, platelets, cryoprecipitate, fibrinogen, recombinant factor VIIa, tranexamic acid, prothrombin complex concentrate, replenishment of calcium deficiency. To monitor the state of the hemostatic system, it is not sufficient to use only publicly available diagnostic tests (prothrombin time, activated partial thromboplastin time) due to their low sensitivity and the duration of obtaining results, but the “bedside” thromboelastography technique is recommended.

Making a decision about the need for massive blood transfusion is based on clinical assessment(visually massive bleeding; bilateral proximal traumatic amputation of the extremities; bleeding in the torso area and unilateral proximal traumatic amputation), as well as the presence of such clinical signs, as a decrease in body temperature below 35 °C, BPsist. less than 90 mm Hg. and laboratory changes (INR > 1.5; base deficiency (BE > -6); hemoglobin< 110 г/л). При этом необходимо отметить, что лабораторные данные не являются обязательным требованием для активации протокола массивной трансфузии (J. Mark et al., 2011). В случае использования протокола массивной гемотрансфузии рекомендуется соблюдение соотношения свежезамороженной плазмы и эритроцитарной массы 1: 1, которое способствует снижению летальности (M.A. Borgman, 2007; J.C. Duchesne et al., 2008), а также трансфузия тромбоцитов в соотношении 1: 1 с препаратами крови (O.L. Gunter et al., 2008; J.B. Holcomb et al., 2008) или по at least one unit of platelets for every five units of packed red blood cells. The use of red blood cells with a shelf life of more than two weeks is not recommended, as this is associated with an increase in the frequency infectious complications and multiple organ failure.

Correction of metabolic acidosis requires restoration of normal organ perfusion and only occasionally the use of buffer solutions (Boyd J.H. et al., 2008).

Surgical damage control is an important component antishock therapy and involves the primary restoration of normal physiological parameters, rather than anatomical integrity: stopping bleeding, primary surgical treatment of wounds, prevention of compartment syndrome, primary (usually extrafocal) metal osteosynthesis of bone fractures. Restorative and reconstructive operations are carried out after the patient has restored normal physiological indicators(Shapiro M.B. et al., 2000).

Thus, the formation and ongoing development of the “damage control” strategy when carrying out intensive care patients with polytrauma, allows you to influence the components of the “lethal triad” and is the basis for improving treatment outcomes and increasing the survival rate of patients both in peacetime and during military operations (Holcomb J.B., 2007; Jansen J.O. et al., 2009).

CHAPTER 4 COMBAT SURGICAL PATHOLOGY. SIZE AND STRUCTURE OF SANITARY LOSSES IN THE SURGICAL PROFILE. SURGICAL TREATMENT OF WOUNDS

CHAPTER 5 OBJECTIVE ASSESSMENT OF THE SEVERITY OF COMBAT SURGICAL TRAUMA

CHAPTER 6 METHODS AND MEANS OF PAIN RELIEF AT THE STAGES OF MEDICAL EVACUATION. ANESTHETIC AND RESUSCITATIVE CARE FOR THE WOUNDED

CHAPTER 7 BLEEDING AND BLOOD LOSS. INFUSION-TRANSFUSION THERAPY. PREPARATION AND BLOOD TRANSFUSION IN WAR

CHAPTER 11 INFECTIOUS COMPLICATIONS OF COMBAT SURGICAL INJURIES

CHAPTER 20 COMBAT CHEST INJURY. THORACOABDOMINAL WOUNDS

CHAPTER 10 TACTICS OF PROGRAMMED MULTISTAGE SURGICAL TREATMENT OF WOUNDS AND INJURIES (DAMAGE CONTROL SURGERY)

The traditional approach to the treatment of combat wounds and trauma is the immediate and final elimination of all existing damage. However, in a number of wounded people, the traumatic nature and duration of emergency surgical intervention may exceed the functional capabilities of the body, and exhaustive recovery damaged organs and structures lead either to the inevitable death of the wounded person on the operating table, or to the development of severe, sometimes irreversible postoperative complications.

Another approach to the treatment of severe wounds and injuries, the proportion of which in modern local wars and armed conflicts is steadily increasing, is the use of tactics programmed multi-stage surgical treatment(ZMHL). An example of such tactics is when gunshot wounds abdomen can be a method of programmed sanitation relaparotomy, as well as second-look operations (“second look operations”). Surgical tactics have become more widely developed and used among programmed interventions. "damage control"*.

“Damage control surgery” is a programmed multi-stage surgical tactic aimed at preventing the development of unfavorable outcome wounds and injuries by reducing the scope of the first surgical intervention and shifting the final restoration of damaged organs and structures until the vital functions of the body are stabilized.

* Damage control - in literal translation from English - “damage control”. This is a naval term meaning the use of any means possible to fight to save a sinking ship.

10.1. HISTORY OF DEVELOPMENT

Before “damage control” surgical tactics began to be used as an independent approach in the treatment of wounds and injuries, its individual elements were developed. These elements were: tamponade of a liver wound with a gauze swab in case of damage ( Pringle J., 1908), abbreviated debridement gunshot wounds of the intestine by bringing the damaged area to the anterior abdominal wall, temporary prosthetics of the main arteries, therapeutic and transport immobilization.

The tactics of “damage control” were formed in the second half of the 20th century. The reasons that caused its appearance, on the one hand, were the improvement in quality prehospital care and a decrease in the duration of the prehospital stage, which in turn led to an increase in the severity of injuries in the wounded delivered to medical institutions. On the other hand, the intensive development of anesthesiology and resuscitation and the introduction of new injuries into surgery medical technologies significantly expanded the possibilities of surgical treatment of wounds and injuries.

Initially, “damage control” tactics were used exclusively for liver damage ( Lucas S., Ledgerwood A., 1976), then with multiple abdominal injuries ( Stone H., 1983). Subsequently, experience appeared in using “damage control” tactics in severe injuries and injuries to other anatomical areas.

10.2. MODERN UNDERSTANDING

SURGICAL TACTICS “DAMAGE CONTROL”

IN WOUNDS AND INJURIES

According to the classic scenario, the “damage con-trol” surgical tactics are carried out in wounded patients who, at the time of admission to the surgeon, are at the limit of their physiological capabilities or their unstable condition develops on the operating table. Within the walls of one medical institution are being carried out three stages this

tactics that consist of: temporarily or permanently stopping bleeding, preventing infection of body cavities with the contents of hollow organs and temporarily closing cavities and wounds (First step); in intensive care until the basic vital functions of the body are stabilized (second phase); in repeat surgical intervention for the purpose of final correction of all damages (third stage).

Currently, the goals and scope of application of “damage control” tactics have expanded. Thus, military surgeons of the US Army, in the difficult conditions of the war in Iraq, used this tactic on seriously wounded with compensated physiological indicators. A similar approach was used by specialists from the Department of Military Field Surgery of the Military Medical Academy named after. CM. Kirov during the hostilities in the North Caucasus, when multi-stage treatment tactics were forced to be used at the stage of providing clinical treatment with limited forces and means of the medical service.

In other words, indications for the use of MHCL tactics are established not only based on the severity of the general condition of the wounded, but also when the medical and tactical conditions for the provision of surgical care change (in case of mass admission of the wounded, shortage medical personnel, operating tables, blood products, etc.). This approach involves performing the basic techniques of ZMHL tactics at one stage medical evacuation(stage of providing CCP) with final surgical treatment at the next stage of medical evacuation (stage of providing SCP).

Thus, today the surgical tactics of “damage control” are no longer used only as a last resort measure in the surgical treatment of seriously wounded people. In this aspect, it is necessary to distinguish between the use of ZMHL tactics according to vital signs and according to medical and tactical indications. Although the technique of abbreviated operations in these groups of wounded is almost the same, the goals and methods of implementing the tactics are noticeably different.

10.3. CRITERIA FOR APPLICATION

SURGICAL TACTICS “DAMAGE CONTROL”

ACCORDING TO VITAL INDICATIONS

1. Related to the volume of damage and the complexity of surgical intervention.

A. Inability to stop bleeding directly:

Damage to the great vessels of the neck in a hard-to-reach location (internal carotid artery and internal jugular vein at the base of the skull, vertebral artery);

Damage to large vessels of the mediastinum and multiple injuries to the vessels of the chest wall;

Severe damage to the liver and vessels of the retroperitoneal space (retrohepatic inferior vena cava, abdominal aorta and its visceral branches);

Damage to the vessels of the small pelvis (including ruptured intrapelvic hematomas) and vessels of the gluteal region;

Unstable fractures of the posterior half-ring of the pelvic bones. B. Presence of combined and multiple injuries:

Multiorgan injuries to the neck, chest, abdomen, pelvis in combination with damage to the great vessels;

Combined injuries with competing sources of bleeding;

Injuries requiring complex reconstructive interventions (plasty of the trachea and larynx, pancreaticoduodenectomy, complex vascular plasty).

2. Associated with the severity of the condition and complications that have developed.

A. Physiological indications:

Unstable hemodynamics requiring inotropic support (sBP< 70 мм рт.ст.);

Severe metabolic acidosis (pH<7,2) с повышением лак-тата сыворотки крови (>5 mmol/l) and base deficiency (<-15 ммоль/л);

Hypothermia (body temperature< 35 ?C);

Electrical instability of the myocardium.

B. Increased treatment requirements:

Massive blood transfusions (more than 15 standard units of whole blood) 21 ;

Long-term surgery (more than 90 minutes).

B. Occurrence of intraoperative complications:

Coagulopathy;

Inability to close the laparotomy wound due to peritonitis and intestinal paresis.

10.4. CRITERIA FOR APPLICATION OF SURGICAL TACTICS “DAMAGE CONTROL” ACCORDING TO MEDICAL AND TACTICAL INDICATIONS

A. Mass influx of wounded. B. Insufficient qualification of the surgeon to perform complex

reconstructive surgery.

B. Limited forces and means of the medical service.

Additional, more specific criteria for the use of “damage control” surgical tactics are scales developed at the Department of Military Surgery of the Military Medical Academy for predicting the likelihood of a lethal outcome (VPH-CT scale - neck and VPH-CT scale - abdomen). In these scales, the most informative and easy-to-identify signs (such as the value of SBP on admission, the presence of multi-organ damage, the estimated amount of blood loss, unstable hemodynamics during surgery, etc.) are assigned a point gradation. The calculation of the mortality probability index is made by sequentially determining the value of each of the signs and summing them up. At certain values of this index, the probability of death in the wounded may exceed 95%, which is an indication for the use of programmed multi-stage surgical tactics.

21 1 standard unit of whole blood is equal to 400 ml with a hemoglobin concentration of 150 g/L.

10.5. STAGES AND ELEMENTS OF SURGICAL TACTICS “DAMAGE CONTROL”

Surgical tactics “damage control” are carried out in 3 stages. Stage 1 - primary emergency operation in a reduced volume. Stage 2 - intensive therapy until the vital functions of the body are stabilized (or, when using “damage control” tactics according to medical and tactical indications - plus - urgent evacuation of the wounded in a forward medical center).

Stage 3 - repeated planned surgical intervention to correct all damage.

Stage 1 tasks“damage control” tactics are: temporary or permanent stop of bleeding; prevention of further infection of body cavities and tissues with the contents of hollow organs (intestinal contents, bile, urine, saliva); temporary sealing of cavities, closure of wounds and immobilization of bone fractures. Temporary or permanent stop of bleeding is done: by ligating minor or restoring large damaged blood vessels (Fig. 10.1, 10.2, color illustration); applying soft clamps to the vascular pedicles of parenchymal organs (lungs, kidneys, spleen) or removing them when destroyed (Fig. 10.3, color illustration); temporary vascular prosthetics of the main arteries (Fig. 10.4, color illustration); applying a hemostatic tourniquet (for separations and destruction of limbs); tight tamponade of the damaged area, for example, the nasal cavity, sites of multiple rib fractures, liver wounds, retroperitoneal space and pelvic cavity, muscle masses of the gluteal and lumbar regions (Fig. 10.5, color illustration); the use of balloon catheters (for wounds of the heart, liver, large cavitary vessels), which can be used both endovascularly (Fig. 10.6, color illustration) and by introducing and inflating a balloon into the wound canal (Fig. 10.7);

Rice. 10.7. Balloon occlusion of the through canal of the right lobe of the liver

Application of a Ganz frame (for unstable fractures of the posterior half-ring of the pelvic bones with ongoing intrapelvic bleeding). The technique of performing these methods has its own characteristics. For example, before liver tamponade, the damaged lobe must be mobilized and compressed, tampons must be inserted above and below (or in front and behind) the damaged lobe, and the pressure vectors of the tampons must recreate the tissue planes. Temporary replacement of the iliac and femoral arteries should be accompanied by fasciotomy of the four muscle compartments of the leg. Removal of destroyed parts of parenchymal organs is best done using stitching devices.

Preventing further infection of cavities and tissues with the contents of hollow organs achieved:

Suturing small wounds of hollow organs (esophagus, small intestine, colon, bladder) with a continuous single-row suture;

Obstructive resection of destroyed sections of hollow organs without restoring their integrity with plugging of the ends (Fig. 10.8) (suturing with a purse-string or single-row suture, ligation with a thick thread, application of a clamp) or with the application of fistulas;

Rice. 10.8. Obstructive small bowel resection

The application of temporary suspended stomas in case of damage to the common bile duct, pancreatic duct, gallbladder, ureter, esophagus (Fig. 10.9, color illustration) or delimiting the area of damage with ointment tampons with drainage directly to the wound of these structures. In addition, extensive damage to the trachea can be temporarily eliminated by introducing an endotracheal tube (or tracheostomy cannula) through the wound (atypical tracheostomy), and large bronchi - by hardware resection of a lobe or the entire lung.

Temporary sealing of cavities and closure of wounds produced: for a thoracotomy wound - with a single continuous suture through all layers

Chest wall; for a laparotomy wound - by applying temporary interrupted sutures to the skin or bringing the skin together with linen tweezers, and the edges of the wound with subcutaneous Kirschner needles or suturing a sterile plastic bag to the edges of the wound (Fig. 10.10, color illustration). When sealing a laparotomy wound, it is very important to install a thick drainage into the pelvic cavity to control hemostasis, and to prevent abdominal compartment syndrome - not to suture the aponeurosis;

For bleeding soft tissue wounds - by applying rare skin sutures over tampons inserted into the wound canal (according to A. Beer). In case of injuries to the extremities, the first stage of the “damage control” surgical tactics ends with the immobilization of bone fractures with rod or pin devices in the fixation mode. The duration of the first stage should not exceed 90 minutes. Upon completion, the wounded are transferred to the intensive care unit.

Stage 2 tasks“damage control” tactics: replenishment of blood volume; correction of coagulopathy; elimination of acidosis; long-term respiratory support; preventive antibacterial therapy; warming the wounded.

Replenishment of blood volume must be carried out with large-volume infusions and transfusions, preferably through the systemic circulation (intra-aortic). Particular importance should be given to blood reinfusion in those wounded in the chest and abdomen. Correction of coagulopathy is carried out by transfusion of fresh frozen plasma, cryoprecipitate, platelet mass, administration of large doses of protease inhibitors and glucocorticoids. In case of massive reinfusions, it is necessary to promptly inactivate excess heparin by administering protamine sulfate.

All wounded people should be warmed by available methods (by wrapping them in blankets, heating pads, warming infusion media). Central hemodynamics are supported by inotropic drugs (dopamine, adrenaline). Preventive antibacterial therapy is carried out with cephalosporins of the II-III generations in combination with aminoglycosides and metrogyl.

During intensive therapy, monitoring of basic vital parameters (pulse, blood pressure, red blood cell count, hemoglobin, urine, respiration and coagulation parameters, biochemical blood parameters) should be carried out. The duration of the second stage of the “damage control” tactic (in the treatment of wounded in an extremely serious unstable condition) is 25–4 hours.

Criteria for stabilizing the condition of the wounded considered: SBP≥100 mm Hg, heart rate≤100 per minute, hematocrit ≥30%, condition severity index

wounded on the VPH-SG scale≤40 points, on the VPH-SS scale<70 баллов (состояние субкомпенсации).

Upon reaching these indicators, the 3rd stage surgical tactics “damage control”, the purpose of which is definitive surgical correction of all damage .

Priority surgical interventions are: final restoration of large vessels of the neck, cavities,

Pelvis and limbs; repeated revision of tamponed areas with replacement of tampons with hemostatic drugs (hemostatic sponges or films) or with reconstructive hemostatic operations on parenchymal organs; reconstructive interventions on hollow organs (suturing, resection, restoration of continuity, ostomy, probe decompression); sanitation and drainage of cavities and cellular spaces (thoracic and abdominal cavities, paravesical and pararectal spaces of extensive soft tissue wounds); delayed (or late) PST of gunshot wounds. When using the tactics of programmed multi-stage surgical treatment according to medical and tactical indications, repeated surgical intervention is performed at the next stage of medical evacuation. In this case, the timing of repeated operations can be determined by the time of transportation of the wounded, the stability of the general condition or the development of other emergency situations (repeated bleeding, abdominal compartment syndrome, peritonitis, uncompensated ischemia of the muscles of the extremities, etc.).

A feature of the 3rd stage of the “damage control” surgical tactics for those wounded in the abdomen is not only the performance of reconstructive operations, but also the subsequent programmed sanitation relaparotomies. Final reduction and fixation of fractures of the pelvic bones and extremities can be performed on days 3-7 after the initial emergency intervention ( “orthopedic damage control” tactics), and stabilizing operations on the spine are performed as planned - against the background of compensation for the condition of the wounded.

The experience of using the tactics of programmed multi-stage surgical treatment of severe wounds and injuries in local wars and armed conflicts in recent years has shown its significant advantages over the traditional approach. Opportunity

DAMAGE CONTROL SURGERY

"Modern surgery is safe for the patient. A modern surgeon must make the patient safe for modern surgery." -Lord Moynihan

INTRODUCTION Surgical tactics - one of the great improvements in surgery over the past 20 years. Principles are accepted by surgeons around the world slowly, because they violate standard surgical practice—that a single, definitive operation is best for the patient. However, it is now well established that a patient with multiple trauma is more likely to die from intraoperative metabolic derangements than from failure to completely repair the injuries. Patients with large injuries accompanied by massive blood loss do not tolerate large complex operations, such as anatomical liver resection or pancreaticoduodenectomy. The operating room team must completely change their thinking in order for the patient to survive a major, devastating injury.

Standard surgical approach: Resuscitation - Surgery - Death

Damage control: Resuscitation - Operation - IT - Operation - IT

The central principle of tactics is that the patient dies from the triad<Коагулопатия + Гипотермия + Метаболический ацидоз>.

If metabolic insufficiency has already been established, then it is extremely difficult to stop bleeding and correct disorders. In order for the patient to survive, the operation must be planned so that the patient can be transferred to the ICU, where he can be warmed and hypothermia and acidosis corrected. Only after this correction can the necessary definitive surgery be performed, i.e.<этапная операция>.

STAGED LAPAROTOMY.

Principles of the first operation are: 1) stopping bleeding, 2) preventing infection, and 3) protecting against further damage.

Surgery is the most technically demanding and stressful surgery encountered by the trauma surgeon. There is no room for mistakes or frivolous surgery. METABOLIC INSUFFICIENCY.

Three disorders—hypothermia, acidosis, and coagulopathy—develop rapidly in a patient with massive traumatic blood loss and create a vicious circle that is sometimes impossible to break. 1. HYPOTHERMIA

Most patients with massive trauma are hypothermic upon admission to the emergency room due to weather conditions at the scene. Inadequate protection, intravenous fluid therapy, and ongoing blood loss worsen hypothermia. Hemorrhagic shock leads to decreased cellular perfusion and oxygenation and inadequate heat production. Hypothermia has impressive systemic effects on body function, but most importantly in our context, it increases coagulopathy and affects hemostasis mechanisms.

Uncorrected hemorrhagic shock results in inadequate cell perfusion, anaerobic metabolism, and lactic acid production. This leads to profound metabolic acidosis, which affects the coagulation mechanisms and increases coagulopathy and blood loss. 3. COAGULOPATHY

Hypothermia, acidosis and the consequences of massive blood transfusion lead to the development of coagulopathy. Even if mechanical control of bleeding is achieved, the patient may continue to bleed from all incision surfaces. This leads to increased hemorrhagic shock, worsening hypothermia and acidosis, reinforcing the vicious circle.

Some works have attempted to determine<пороговые уровни>parameters for switching to the "damage control" operation. Criteria such as pH are mentioned<7.2, температура <ядра>less than 32C, transfusion to the patient of a volume exceeding the bcc. However, if these levels are reached, it is already too late. The trauma surgeon must decide to switch to tactics within 5 minutes from the start of the operation. This decision is based on the patient's initial physiological status and a rapid initial assessment of internal injuries. You can't wait for metabolic disorders to start. This early decision is essential for the patient's survival. LAPAROTOMY .

So, the principles of the primary operation are:

1. Stop bleeding

2. Prevention of infection

3. Protection from further damage

PREPARATION. The time of delivery of such patients to the hospital and stay in the intensive care unit should be minimal. All unnecessary and unnecessary studies that will not immediately change the patient's treatment strategy should be postponed. Cyclic fluid therapy before surgery is useless and only worsens hypothermia and coagulopathy. Colloidal solutions also affect the quality of the blood clot. The patient should be quickly taken to the operating room without attempts to restore the volume of blood flow. Surgical control of bleeding and simultaneous vigorous therapy with blood and coagulation factors are required. Induction of anesthesia is performed on the operating table while the patient is prepped and dressed and the surgeons are cleaned. The patient in shock usually requires minimal analgesia and a gentle, hemodynamically neutral method of induction should be used. The use of arterial catheterization for intraoperative monitoring is valuable, but a small bore venous central catheter is of little benefit. Blood, fresh frozen plasma, cryoprecipitate, and platelets should be available, but clotting factors should be administered promptly only after bleeding has stopped. All solutions must be warm, the patient must be covered and, if possible, intensively heated. GENERAL ISSUES AND PHILOSOPHY.

The patient is quickly swabbed from neck to knees with large swabs soaked in an antiseptic skin solution. The incision should be from the xiphoid process to the pubis. This incision may require extension into either the right side of the chest or a median sternotomy depending on the injury. The decrease in intra-abdominal pressure by paralyzing the muscles and opening the abdominal cavity can lead to severe bleeding and hypotension. Immediate stop of bleeding is necessary. Initially, tamponing of 4 quadrants is performed with large tampons. At this stage, cross-clamping of the aorta may be necessary. It is usually best performed at the level of the aortic hiatus by blunt digital dissection, pressure with an assistant's finger, followed by application of a clamp (dc1). It is sometimes difficult to locate the aorta in severe hypovolemia and direct visualization may be required after dividing the right crus of the diaphragm. Some surgeons prefer to perform a left anterolateral thoracotomy to clamp the descending thoracic aorta into the pleural cavity. However, this requires opening a second body cavity, involves additional heat loss, and is rarely necessary. The next step is to find the main source of bleeding. A thorough inspection of the 4 quadrants of the abdomen is performed. A moment of silence can help to hear the bleeding. Emergency bleeding control is performed with direct blunt pressure using the surgeon's hand, a tampon or a tampon. The proximal and distal control technique is rarely used in urgent settings. Bleeding from the liver, spleen, or kidney can usually be stopped by applying pressure with several large tampons. Abdominal examination should be complete. If necessary, it includes mobilization of retroperitoneal structures using some techniques of rotation of internal organs (Fig. dc2 - right medial rotation, dc3 - left medial rotation according to Mattox). All intra-abdominal and most retroperitoneal hematomas require exploration and evacuation. Even a small paracolic or parapancreatic hematoma can mask vascular or intestinal injury. Revision should be performed regardless of whether the hematoma is pulsating, enlarging or not, due to blunt trauma or wound. Non-expanding perirenal and retrohepatic hematomas, as well as pelvic hematomas due to blunt trauma, should not be revised and can be tamponed. Occasionally, simultaneous angiographic embolization may be required. Prevention of infection is achieved by rapid suturing of injuries to hollow organs. This may be the definitive intervention when there are only a few small bowel wounds requiring primary closure. More complex procedures such as resection with primary anastomosis should be delayed and the bowel ends stapled, sutured or ligated (dc4). End evaluation and anastomosis are performed in the second operation.

CLOSURE OF THE ABDOMEN.

A rapid temporary closure of the abdomen is performed. If possible, only the skin is sutured with a quick continuous suture or even clipping. Abdominal compartment syndrome is common in these patients and, if in any doubt, the abdomen should be left open as for laparostomy. or technology.

FEATURES IN CASE OF DAMAGE TO INTERNAL ORGANS.

LIVER. Main A technique to stop bleeding from the liver is perihepatic packing. This technique, when performed correctly, stops most bleeding, with the exception of bleeding from the main arteries. Massive bleeding from the liver can be temporarily stopped by applying a soft vascular clamp to the portal triad (Pringle maneuver). Further vascular isolation (inferior vena cava above and below the liver) may be risky and is usually unnecessary in the setting of . This may require complete mobilization of the liver and extension of the incision into the chest through a median sternotomy or left thoracotomy. The liver parenchyma is first compressed by hand and then tamponed in an orderly manner. For adequate packing of the liver, compression in the anteroposterior direction is necessary. This can only be achieved by mobilizing the right hepatic ligament and alternating packing posterior and anterior to it, as well as packing the hepatorenal space. This technique can even stop retrohepatic venous bleeding and bleeding from the inferior vena cava. Only intense arterial bleeding from the liver parenchyma requires further action. In this case, the liver damage must be expanded using<пальцевую>technique with identification of the bleeding vessel, its ligation or clipping. In some cases, with a shallow injury, rapid resection of the edges is possible by applying large clamps along the edges of the wound and stitching the entire wound surface under the clamp. The hepatic packing patient should be taken to the angiography unit immediately after surgery to identify any ongoing arterial bleeding that is controlled by selective angiographic embolization.

SPLEEN. For large splenic injuries, the treatment of choice is splenectomy, with the exception of small injuries that can be sutured. Attempts to preserve the spleen usually take a long time and are prone to failure, so that they are recommended for .

VESSELS OF THE ABDOMINAL CAVITY.

Access to the abdominal aorta is best achieved using the Mattox full medial left splanchnic rotation technique (Figure dc5). The left half of the colon, spleen and kidney are mobilized and rotated medially, exposing the entire length of the abdominal aorta. In the hands of an experienced vascular surgeon, the aorta should be quickly sutured or replaced with PTFE. However, in extreme cases, or when such experience is not available, intravascular bypass may be considered. For the abdominal aorta, a large piece of chest tube is used. Shunts can also be used for injury to the iliac vessels and superior mesenteric artery. Injuries to the inferior vena cava in accessible areas are sutured; in case of injury in the retrohepatic space, packing is performed. Temporary stoppage of bleeding is best accomplished by direct pressure with blunt pads above and below the site of injury. All other venous injuries in conditions must be bandaged. The opening of a pelvic retroperitoneal hematoma in the presence of a pelvic fracture is almost always fatal, even when the internal iliac arteries are successfully ligated. In this case, the retroperitoneal space is not opened; the pelvis is tamponed with large tampons. Before this, the pelvis must be stabilized (a sheet tightly tied around the large trochanteres and pubis is sufficient) to prevent the opening of a pelvic fracture due to packing with increased bleeding. GASTROINTESTINAL TRACT.

Once the bleeding has stopped, attention shifts to preventing subsequent infection by stopping the flow of intestinal contents. Small wounds of the stomach and small intestine can be quickly sutured with a single-row continuous suture. In case of extensive damage, bowel resection with primary anastomosis is required. This may take time, and the integrity of the anastomosis is compromised by generalized hypoperfusion. In addition, under these conditions it is often difficult to determine the margins of resection. In this case, especially if there is trauma to the colon or multiple wounds to the small bowel, it is wiser to resect the nonviable bowel and close the ends, leaving them in the abdomen for anastomosis in a second operation. This involves using a linear stapler or a continuous suture, or even an umbilical tie. Ileostomies and colostomies should not be performed when , especially if the stomach remains open.

PANCREAS.

RV trauma rarely requires or allows definitive intervention in the setting of . Minor injuries that do not affect the duct (AAST I, II, IV) do not require treatment. If possible, a suction drain may be placed at the injury site, but this should not be done if the abdomen is packed and left open. For distal pancreatic injury (distal to the superior mesenteric vein - AAST III) with extensive tissue destruction, including the pancreatic duct, it is possible to quickly perform distal resection of the pancreas. Massive injury of the pancreaticoduodenal complex (AAST V) is almost always accompanied by injury to surrounding structures. Patients cannot tolerate major surgeries such as PDR. Only necrectomy should be performed. Small lesions of the duodenum are sutured with a single-row suture, but large lesions should be resected and the edges closed temporarily with sutures or tape with restoration in a second operation. LUNG. Lung resection may be necessary to stop bleeding or in cases of massive air loss and to remove nonviable tissue. A typical lobectomy or segmentectomy is difficult and unnecessary in a patient with multiple trauma. The simplest possible method should be used. Typically this is the use of a linear stapler, both for vascular and bronchial trauma. This non-anatomical approach also preserves the maximum amount of functioning lung tissue. If necessary, the stapler line can be reinforced with a continuous seam. Care must be taken when suturing superficial injuries with a simple suture. Often this only stops external bleeding, while bleeding continues into the deeper tissues. In case of injury to the root of the lung, the bleeding is initially best stopped by applying pressure with the fingers. In most cases, the damage is then more distal to the root and can be repaired accordingly. To compress the root of the lung, you can use a Satinsky vascular clamp or an umbilical cord tape in emergency conditions. Up to 50% of patients die from acute right ventricular failure after hilar clamping, so this decision must be based on absolute necessity. Pulmonary tractotomy may be useful for deep lung injuries. Two long clamps are passed through the wound tract. The canal wall is opened, the exposure of the inner surface is revealed, all bleeding vessels and bronchi are ligated, the edges under the clamps are sheathed.

INTENSIVE THERAPY.

The purpose of the intensive therapy phase is the rapid and complete correction of metabolic disorders. Operation only deals with a life-threatening injury, and then the patient requires follow-up surgery to remove the packings and/or permanent surgery. The next 24-48 hours are decisive for the patient in terms of preparation for the second operation. After this time, multiple organ failure, especially ARDS and cardiovascular failure, may make a second operation inadequate. The ICU must act aggressively to correct metabolic failure. The patient must be intensively warmed using blankets, air heaters, or even an arteriovenous technique. This is necessary to ensure correction of coagulopathy and acidosis. Acidosis is a reflection of impaired transport and utilization of oxygen. Tissue perfusion should be restored with an intravenous infusion of warm crystalloid and, if necessary, blood. Massive tissue and intestinal edema may occur due to the activation and release of inflammatory mediators, requiring large volumes of infusion. Right heart catheterization should be used as needed to monitor cardiac filling pressures and determine oxygen delivery. Vasodilators such as dobutamine or phosphodiesterase inhibitors may be necessary to open the vasculature. In the absence of equipment to monitor muscle and intestinal perfusion, base deficiency and lactate levels should be used to guide intensive care. Coagulopathy is treated with fresh frozen plasma, cryoprecipitate and, if necessary, platelets, as well as correction of hypothermia and acidosis. To successfully correct metabolic failure, all three disorders must be corrected simultaneously and aggressively. We must not miss a patient who has started to actively bleed again. Large chest drain losses, abdominal distension, loss of control over the open abdomen, and repeated episodes of hypotension suggest recurrent bleeding, which requires surgical control. ABDOMINAL COMPARTMENT SYNDROME.

Massive intestinal edema is often observed after laparotomy for massive trauma, especially when there has been prolonged shock. This tissue edema is caused by the use of crystalloids, capillary disorders due to the activation of inflammatory mediators, and reperfusion injury. When combined with abdominal packing or retroperitoneal hematoma, it may be difficult or impossible to close the abdomen. If the abdomen is closed, then intra-abdominal pressure can exceed 25 cm of water column, which leads to significant cardiovascular, respiratory, renal and cerebral disorders.

CARDIOVASCULAR DISORDERS

An increase in IAP leads to a decrease in cardiac output, mainly due to compression of the inferior vena cava and a decrease in venous return to the heart. Cardiac output decreases despite apparent increases in central venous pressure, pulmonary artery wedge pressure, and systemic vascular resistance. This distortion of standard monitoring parameters makes adequate intensive care difficult.

RESPIRATORY DISORDERS.

Increasing IAP effectively immobilizes the diaphragm, leading to increased peak airway pressure and intrapleural pressure, which also reduces venous return to the heart. Increased airway pressure can also provoke barotrauma and lead to the development of acute ARDS.

RENAL DISORDERS

An acute increase in IAP leads to oliguria and anuria, probably due to compression of the renal vein and renal parenchyma. Renal blood flow and glomerular filtration decrease, and renal vascular resistance increases.

CEREBRAL DISORDERS.

An increase in IAP and intrathoracic pressure leads to an increase in central venous pressure, which interferes with adequate venous outflow from the brain, leading to an increase in ICP and increased cerebral edema. DIAGNOSTICS

ACS should be suspected and sought in any multiple trauma patient who has suffered a period of profound shock. Clinically, ACS is characterized by a decrease in diuresis combined with an increase in central venous pressure. The diagnosis is confirmed by measuring IAP. This is done with either a Foley catheter in the bladder or a nasogastric tube in the stomach. Simple water column manometry is used at 2-4 hour intervals, although it is possible to connect a pressure transducer to a catheter. Normal IAP is 0 or subatmospheric. Pressure above 25 cm water column. suspicious, but above 30 cm water column. definitely talking about AKC.

TREATMENT OF ACS.

It is better to prevent the development of ACS and use an alternative technique for abdominal closure. If the abdomen is difficult to close, an alternative technique must be used. A good rule of thumb is that if the abdomen is viewed horizontally and the intestines are visible above the level of the wound, the abdomen should always be left open and a temporary closure used. The simplest method of opening the abdomen is to close it . The three-liter plastic irrigation bag is opened and cut. The edges are trimmed and sutured to the leather, away from the edge of the leather, using a continuous silk-1 stitch. It is helpful to place a sterile absorbent cloth in the abdomen to absorb some of the fluid and make it easier to monitor the laparostomy. An alternative technique is method. In this case, a three-liter bag is cut and placed under the aponeurosis in the stomach, protecting the intestines. Two large diameter suction drains are placed on it and a large adhesive steridrape is placed on the entire abdomen. Drains are connected to the suction system to control fluid loss and create effect. There is no need to sew the material to the aponeurosis. Repeated suturing of the aponeurosis damages it and makes final closure impossible. If the aponeurosis cannot be reduced at a subsequent operation, the defect can be closed using an absorbable mesh. Sudden resolution of ACS can lead to ischemia-reperfusion injury, causing acidosis, vasodilation, cardiac dysfunction, and even cardiac arrest. Before ACS is resolved, the patient must be prepared with crystalloid solutions. Mannitol, vasodilators (dobutamine) or phosphodiesterase inhibitors may be needed.

REPEATED OPERATION.

The principles of reoperation are removal of tampons and blood clots, complete exploration of the abdomen to identify missed lesions, hemostasis, restoration of intestinal continuity, and closure of the abdomen. The timing of the operation is decisive. There is usually a convenient<окно>between correction of metabolic failure and the onset of systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF). This window is usually observed within 24-48 hours after the first surgery. A choice must be made between early reoperation, when the patient may be less stable and swelling of the intestinal wall is still severe, and late reoperation, when cardiovascular, respiratory and renal failure make the operation risky. Vascular shunts should be removed and prosthetics performed as soon as possible, because they may become dislodged or thrombosed when the coagulopathy is corrected. If tampons are left in the abdomen, it is usually recommended to remove them within 48-72 hours, although there is no evidence that leaving them in for longer is harmful. Tampons, especially those from the liver and spleen, must be removed carefully, as they can stick to the parenchyma and removal can lead to bleeding. Wetting the tampons can help with this. Bleeding, however, is rarely severe and is controlled with argon diathermy or fibrin glue. Repeat packing is rarely necessary. All intestinal closures performed during the first operation should be checked to determine their viability. The ends of the intestine that have been stapled or ligated are inspected, resected if necessary, and a primary end-to-end anastomosis is performed. In a hemodynamically stable patient without hypothermia, a colostomy is rarely necessary. The abdominal cavity is extensively washed and the abdomen is closed using standard suturing through all layers, and the skin is sutured. If the aponeurosis cannot be matched, use or absorbable PDS or vicryl mesh, which can later undergo skin grafting. An incisional hernia can be closed later.

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5. Carvillo C, Fogler RJ, Shafton GW. "Delayed gastrointestinal reconstruction following massive abdominal trauma" J Trauma 1993;34:233-235 6. Richardson JD; Bergamini TM; Spain DA et al. "Operative strategies for management of abdominal aortic gunshot wounds" Surgery 1996; 120:667–671 7. Reilly PM, Rotondo MF, Carpenter JP et al. "Temporary vascular continuity during damage control - intraluminal shunting for proximal superior mesenteric artery injury" J Trauma 1995;39:757-760

8. Velmahos GC; Baker C; Demetriades D et al. "Lung-sparing surgery after penetrating trauma using tractotomy, partial lobectomy, and pneumonorrhaphy" Arch Surg 1999;134:86-9

9. Wall MJ Jr; Villavicencio RT; Miller CC et al. "Pulmonary tractotomy as an abbreviated thoracotomy technique" J Trauma 1998;45:1015-23 10. Schein M, Wittman DH, Aprahamian CC, Condon RE. The abdominal compartment syndrome - the physiological and clinical consequences of raised intra-abdominal pressure J Am Coll Surg 1995;180:745-753

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