Abstract
Damage control surgery is a true paradigm shift in the management of severely injured and physiologically compromised trauma patients. Instead of attempting definitive repair of all organ injuries in a hypothermic, acidotic, and coagulopathic patient, bleeding and enteric contamination are temporary controlled by temporary means, the abdomen is left open, and the patient is rapidly transferred to intensive care for hemodynamic stabilization, rewarming, and correction of coagulation abnormalities. The definitive repair of organ injuries is performed in a planned reoperation 48–72 h later.
But who invented damage control surgery? The first description of open abdomen probably dates back to 1897, when Andrew J. McCosh (1) published an article on the treatment of general septic peritonitis by applying some traction to the open wound edges with two to three silkworm-gut sutures and covering the intestines with a compress of gauze allowing the free exit for the escape of peritoneal secretions.
When Finland was still part of imperial Russia, Tsar Nicholas II appointed General Nikolay Bobrikov as the Governor-General of Finland. In an assassination attempt on 16 June 1904, a Finnish patriot Eugen Schauman shot Bobrikov three times with one piece of a bullet entering his abdomen. The founder of the Finish Surgical Society and veteran war surgeon Richard Faltin operated on Bobrikov, encountered large amounts of dark blood and clots, and found multiple holes in the small bowel and bleeding from a large vessel in the base of the mesentery. The vessel was ligated, 75 cm of small bowel resected, and a primary anastomosis was performed. The abdominal cavity was irrigated, and upon closing the abdomen, he left a small hole where a piece of gauze was placed in the area where bowel was resected and mesentery repaired (2). But this was still one-stage definitive surgery even if the gauze left behind (and probably would have been removed without a reoperation) was more for anticipated drainage than a true tamponade of the root of the mesentery. In any case, Bobrikov died later that night in the hospital from irreversible shock. No autopsy was performed.
The first description of perihepatic packing for severely bleeding liver injury was published by J. Hogart Pringle (3) in 1908. He reported eight patients with rupture of the liver managed at the Glasgow Royal Infirmary over 11 years. Three of them died immediately after admission and one after refusing operation. Of the four operated patients, two exsanguinated on the table, one of them after applying the Pringle maneuver, and the third immediately postoperatively after suturing and packing of the liver wound. In the fourth operated patient with injury to the right lobe of the liver and extensive rupture of the right kidney, the liver lobe was mobilized and sutured causing more bleeding. The suprahepatic space was then packed that stopped the bleeding almost completely. The right kidney was exposed from behind and packed as well with good effect. The patient showed no signs of recurrent hemorrhage postoperatively, but developed signs of consolidation of the right lung and died 4 days later. At autopsy, there were no further signs of bleeding in the abdomen, but the right lung was “in an early stage of gangrene, due, doubtless to embolism. It has been shown in the experimental work that embolism of the pulmonary vessels consequent upon thrombosis of the liver vessels is as common as it is fatal.”
William Stewart Halsted (4) modified the technique by placing rubber sheets between the liver and the packing material to protect the hepatic parenchyma. These observations were forgotten for several decades, until Lucas and Ledgerwood (5) used perihepatic packing as the primary hemostatic technique in three patients (out of 637) with severe liver injuries, and Calne et al. (6) described a series of four patients who underwent perihepatic packing before transfer to a bigger hospital for definitive repair.
A reawakening occurred in 1983 when Stone and his co-workers published a series of 17 severely injured patients who underwent damage control surgery with a survival rate of 76% when compared with 14 similar patients undergoing definitive repair with only one survivor (7%) (7). The concept was further refined by Ivatury et al. (8) in 1986 and Burch et al. (9) in 1992. The term “damage control”—originating from naval warfare, where the water leak in a ship hit by hostile fire was temporary controlled with any available means to enable the ship to keep mobile and evade further damage—was first used by Rotondo, Schwab and their co-workers (10). And the rest is history…