Bishwajit Bhattacharya, Department of surgery, Yale school of medicine, New Haven, Connecticut, USA, Tel: (203) 785-2572; E-mail:
DCL was also not only being applied to trauma patients but its use was extended to emergency general surgery cases where the indications and outcomes were less clear . During this time resuscitation of surgical patients involved liberal use of crystalloids and a non-evidenced based use of blood product ratios. It was accepted among surgeon's a patient would 'swell to get well'. During this time overlapped the recognition of abdominal compartment syndrome physiology and the need for surgical decompression. This perhaps provided another catalyst to the embracing of DCL and increasing the number of open abdomens.
But is there too much of a good thing? The liberal use of DCL was not without its drawbacks. The improved survival was associated with open abdomens, complex ventral hernias and enterocutaneous fistulas. The repair of these complex hernias posed its own set of unique challenges and associated morbidity. Survivors experienced multiple repeat admissions and interventions and longer ICU stay [11,12]. In the midst of the widespread use of DCL were many instances of using DCL when not indicated, by some measures one in five patients did not meet criteria . The philosophy of correcting the physiological derangements that warranted DCL were diluted and the window of opportunity to close the abdomen were lost.
The last decade also witnessed a massive shift in the approach to hemorrhagic resuscitation. The military's experience in Iraq and Afghanistan brought new understanding about a tighter transfusion ratio of RBC's plasma and platelets in a 1:1:1 ratio. The military experience showed improved survival . The experience was soon adopted in the civilian world with trauma centers adopting a massive transfusion protocol. Also the war experience brought back the use of tourniquets, the application of topical hemostatic agents and a revisit to the use of permissive hypotension thereby decreasing crystalloid exposure . Any fluid that does not carry oxygen or clot should be viewed with suspicion.
With improved resuscitation strategies resulting in less crystalloid infusion potentially avoiding the development of abdominal compartment syndrome  and move away from the DCL. When employed the physiological basis for DCL has to be kept in mind. The patient must return to the OR as soon as the physiological parameters that warranted DCL are corrected. Patient physiology must be the dictating factor in deciding the time to take back, arbitrarily selected times diminish the physiological rational behind DCL. The greater the duration of the open abdomen the less likelihood of primary closure .
Over the past few decades the pendulum has swung form definitive surgery all at once to the liberal use of DCL to a more conservative use of DCL with the use of damage control resuscitation. Trauma centers have shown a decrease in DCL use without compromising outcomes . The result has been a shift to less open abdomens and a focus of avoiding this powerful adjunct unnecessarily.
Many questions remain unanswered. What is an appropriate massive transfusion protocol is yet to be clearly defined with great variability among centers . The role of adjuncts such as TXA remains controversial [20,21]. The search for the ideal endpoint of resuscitation continues. There may be more opportunity for the pendulum to swing in the coming years. The last decade demonstrated that the widespread use of DCL was itself in need of damage control.
- Pringle JH. V. Notes on the arrest of hepatic hemorrhage due to trauma. Ann Surg. 1908; 48(4):541-9.
- Halsted WS. The employment of fine silk in preference to catgut and the advantages of transfixing tissues and vessels in controlling hemorrhage. Also an account of the introduction of gloves, guttapercha tissue and silver foil. JAMA 1913; 60:1119.
- Schroeder WE. The process of liver hemostasis: reports of cases. SurgGynecolObstet 1906; 2:52.
- Rotondo MF, Schwab CW, McGonigal MD, Phillips GR, Fruchterman TM, Kauder DR, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993; 35(3):375-82.
- Feliciano DV, Mattox KL, Jordan GL Jr, Burch JM, Bitondo CG, Cruse PA. Management of 1000 consecutive cases of hepatic trauma (1979- 1984). Ann Surg. 1986; 204(4):438-45.
- Feliciano DV, Mattox KL, Burch JM, Bitondo CG, Jordan GL Jr. Packing for control of hepatic hemorrhage. J Trauma. 1986; 26(8):738-43.
- Wall MJ Jr, Soltero E. Damage control for thoracic injuries. Surg Clin North Am. 1997; 77(4):863-78.
- Rotondo MF, Bard MR. Damage control surgery for thoracic injuries. Injury. 2004; 35(7):649-54.
- D'Alleyrand JC, O'Toole RV. The evolution of damage control orthopedics: current evidence and practical applications of early appropriate care. Orthop Clin North Am. 2013; 44(4):499-507. doi: 10.1016/j.ocl.2013.06.004.
- Weber DG, Bendinelli C, Balogh ZJ. Damage control surgery for abdominal emergencies. Br J Surg. 2014; 101(1):e109-18. doi: 10.1002/bjs.9360.
- Sutton E, Bochicchio GV, Bochicchio K, Rodriguez ED, Henry S, Joshi M, et al. Long term impact of damage control surgery: a preliminary prospective study. J Trauma. 2006; 61(4):831-4; discussion 835-6.
- Brenner M, Bochicchio G, Bochicchio K, Ilahi O, Rodriguez E,Henry S, et al. Long-term impact of damage control laparotomy: a prospective study. Arch Surg. 2011; 146(4):395-9. doi: 10.1001/ archsurg.2010.284
- Hatch QM, Osterhout LM, Podbielski J, Kozar RA, Wade CE, Holcomb JB, et al. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma. 2011; 71(6):1503-11. doi: 10.1097/TA.0b013e31823cd78d.
- Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007; 63(4):805-13.
- Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern military surgery. Surg Clin North Am. 2007; 87(1):157-84, vii.
- Huang Q, Zhao R, Yue C, Wang W, Zhao Y, Ren J, et al . Fluid volume overload negatively influences delayed primary facial closure in open abdomen management. J Surg Res. 2014; 187(1):122-7. doi: 10.1016/j.jss.2013.09.032.
- Fox N, Crutchfield M, LaChant M, Ross SE, Seamon MJ. Early abdominal closure improves long-term outcomes after damage-control laparotomy. J Trauma Acute Care Surg. 2013; 75(5):854-8. doi: 10.1097/TA.0b013e3182a8fe6b.
- Higa G, Friese R, O'Keeffe T, Wynne J, Bowlby P, Ziemba M, et al. Damage control laparotomy: a vital tool once overused. J Trauma. 2010; 69(1):53-9. doi: 10.1097/TA.0b013e3181e293b4.
- Schuster KM, Davis KA, Lui FY, Maerz LL, Kaplan LJ. The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion?. Transfusion. 2010; 50(7):1545-51. doi: 10.1111/j.1537-2995.2010.02587.
- Valle EJ, Allen CJ, Van Haren RM, Jouria JM, Li H, Livingstone AS, Namias N, Schulman CI, Proctor KG. Do all trauma patients benefit from tranexamic acid? J Trauma Acute Care Surg. 2014; 76(6):1373-8. doi: 10.1097/TA.0000000000000242.
- Ausset S, Glassberg E, Nadler R, Sunde G, Cap AP, Hoffmann C, et al. Tranexamic acid as part of remote damage-control resuscitation in the prehospital setting: A critical appraisal of the medical literature and available alternatives. J Trauma Acute Care Surg. 2015; 78(6 Suppl 1):S70-5. doi: 10.1097/TA.0000000000000640.