Damage Control and Open Abdomen in Abdominal Injury

Abstract

In the last decades, the concept of damage control surgery (DCS) has changed the way abdominal injuries are treated, modifying the surgical approach from “early definitive treatment” to “bridge surgical therapy.” The advancements in acute care medicine and antibiotic therapy and the rising comprehension of the pathophysiology of trauma and abdominal compartment syndrome (ACS) made the open abdomen (OA) a cornerstone step of damage control surgery (DCS). Currently, the advantages of OA and DCS in trauma patients are well known, but this technique brings with itself a great burden of dreadful complications, the most feared and devastating being the rise of an enteroatmospheric fistula (EAF) whose mortality can still be as high as up to 40%. The rationale of the use of OA in trauma patients is that allows to rapidly terminate the surgical procedure and to promptly admit the patient to the ICU; furthermore, it expedites any further surgical exploration and prevents the onset of the ACS. Indications for OA application in trauma patients are ACS, the need for a “second look” in case of suspected bowel ischemia, vascular injuries treated with temporary measures, post-injury grossly contaminated abdomen, and the impossibility to close the abdomen because of partial or entire loss of the abdominal wall. In every other case, patient’s physiology drives the strategy: if the patient has conserved physiological reserve, then a definitive treatment could be considered; on the other hand, if the physiological reserve is impaired, a temporized treatment is the best option. OA complication could be synthetically divided in medical and surgical, where medical complications derive from the pathophysiology of a massive open abdominal wound and surgical complications are strictly related to the surgical maneuvers performed. Every effort should be made to close the OA as soon as possible, because is demonstrated that after the first week of OA the rate of complications increases dramatically. OA patients are extremely challenging and should be managed by multidisciplinary team formed by surgeons, anesthetists and ICU attendings, nutritionists, psychologists, and specialized nurses with a specific expertise.