Trauma Laparotomy and Damage Control Surgery

Damage control surgery (DCS) is a three-stage approach for trauma laparotomy in patients with severe physiologic derangement. Stage I (initial operation) prioritizes hemorrhage control via packing, ligation, balloon occlusion, or selective embolization, gastrointestinal contamination control with stapler resection without anastomosis, and temporary abdominal closure with negative-pressure dressing or Bogota bag.

Stage II (ICU resuscitation) corrects the lethal triad: rewarming to >36 degrees C, correction of metabolic acidosis with crystalloids and bicarbonate guided by lactate, and reversal of coagulopathy with massive transfusion protocol (1:1:1 RBC:FFP:platelets), tranexamic acid, and viscoelastic-guided component therapy. Optimization of oxygenation, hemodynamics, and identification of missed injuries by tertiary survey is performed during 24-72 hours.

Stage III (definitive operation) is performed when the patient is hemodynamically stable, normothermic, with normal coagulation and lactate clearance. Procedures include bowel reconstruction with primary or staged anastomosis, definitive vascular repair, hollow-viscus injury revision, bile duct reconstruction, and abdominal wall closure with mesh or component separation. Open abdomen complications include enterocutaneous fistula, ventral hernia, and intra-abdominal hypertension. Indications include shock with pH <7.2, temperature <34 degrees C, INR >1.5, transfusion >10 units, prolonged operation, and complex multi-system injury.