Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center

  • Wu Seong Kang
  • Young Goun JoEmail author
  • Yun Chul Park
Original Scientific Report



Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center.


The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011–2013) and trauma center (TC) (2014–2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality.


Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80 min, p = 0.022), time from admission to operation (125 vs. 112 min, p = 0.010), time from admission to first treatment (119 vs. 99 min, p = 0.004), and time from admission to first transfusion (70 vs. 52 min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24 h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period.


After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.



We would like to thank Chang Hyun Kim and In-Soo Shin for their useful advice on statistical analysis.

Compliance with ethical standards

Conflict of interest

The authors declare that there is no conflict of interest.


  1. 1.
    Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF (2000) Damage control: collective review. J Trauma Acute Care Surg 49(5):969–978CrossRefGoogle Scholar
  2. 2.
    Joseph B, Azim A, Zangbar B, Bauman Z, O’Keeffe T, Ibraheem K et al (2017) Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: analysis of 1,030 consecutive trauma laparotomies. J Trauma Acute Care Surg 82(2):328–333CrossRefGoogle Scholar
  3. 3.
    Duke MD, Guidry C, Guice J, Stuke L, Marr AB, Hunt JP et al (2012) Restrictive fluid resuscitation in combination with damage control resuscitation: time for adaptation. J Trauma Acute Care Surg 73(3):674–678CrossRefGoogle Scholar
  4. 4.
    Hatch QM, Osterhout LM, Ashraf A, Podbielski J, Kozar RA, Wade CE et al (2011) Current use of damage-control laparotomy, closure rates, and predictors of early fascial closure at the first take-back. J Trauma 70(6):1429–1436CrossRefGoogle Scholar
  5. 5.
    Cirocchi R, Montedori A, Farinella E, Bonacini I, Tagliabue L, Abraha I (2013) Damage control surgery for abdominal trauma. Cochrane Database Syst Rev 3:Cd007438Google Scholar
  6. 6.
    Higa G, Friese R, O’Keeffe T, Wynne J, Bowlby P, Ziemba M et al (2010) Damage control laparotomy: a vital tool once overused. J Trauma 69(1):53–59CrossRefGoogle Scholar
  7. 7.
    Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA et al (2017) Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 82(3):605–617CrossRefGoogle Scholar
  8. 8.
    Park J-M (2016) Outcomes of the support services for the establishment of regional level 1 trauma centers. J Korean Med Assoc 59(12):923–930CrossRefGoogle Scholar
  9. 9.
    Healey C, Osler TM, Rogers FB, Healey MA, Glance LG, Kilgo PD et al (2003) Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma 54(4):671–678; discussion 8–80CrossRefGoogle Scholar
  10. 10.
    Steiner SH, Cook RJ, Farewell VT, Treasure T (2000) Monitoring surgical performance using risk-adjusted cumulative sum charts. Biostatistics (Oxford, England) 1(4):441–452CrossRefGoogle Scholar
  11. 11.
    Kim CH, Kim HJ, Huh JW, Kim YJ, Kim HR (2014) Learning curve of laparoscopic low anterior resection in terms of local recurrence. J Surg Oncol 110(8):989–996CrossRefGoogle Scholar
  12. 12.
    Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR et al (1993) ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 35(3):375–382; discussion 82–83CrossRefGoogle Scholar
  13. 13.
    Martin MJ, Hatch Q, Cotton B, Holcomb J (2012) The use of temporary abdominal closure in low-risk trauma patients: helpful or harmful? J Trauma Acute Care Surg 72(3):601–606; discussion 6–8CrossRefGoogle Scholar
  14. 14.
    Weber DG, Bendinelli C, Balogh ZJ (2014) Damage control surgery for abdominal emergencies. Br J Surg 101(1):e109–e118CrossRefGoogle Scholar
  15. 15.
    Joseph B, Zangbar B, Pandit V, Vercruysse G, Aziz H, Kulvatunyou N et al (2014) The conjoint effect of reduced crystalloid administration and decreased damage-control laparotomy use in the development of abdominal compartment syndrome. J Trauma Acute Care Surg 76(2):457–461CrossRefGoogle Scholar
  16. 16.
    Harvin JA, Wray CJ, Steward J, Lawless RA, McNutt MK, Love JD et al (2016) Control the damage: morbidity and mortality after emergent trauma laparotomy. Am J Surg 212(1):34–39CrossRefGoogle Scholar
  17. 17.
    Park JS, Ahn HK, Na J, Lee HH, Yoon YE, Yoon MG et al (2018) Cumulative sum analysis of the learning curve for video-assisted minilaparotomy donor nephrectomy in healthy kidney donors. Medicine 97(17):e0560CrossRefGoogle Scholar
  18. 18.
    Holcomb JB, del Junco DJ, Fox EE, Wade CE, Cohen MJ, Schreiber MA et al (2013) The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg 148(2):127–136CrossRefGoogle Scholar
  19. 19.
    Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM et al (2015) Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 313(5):471–482CrossRefGoogle Scholar
  20. 20.
    Lewis SR, Pritchard MW, Evans DJ, Butler AR, Alderson P, Smith AF et al (2018) Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev 8:Cd000567Google Scholar
  21. 21.
    MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL et al (2006) A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 354(4):366–378CrossRefGoogle Scholar
  22. 22.
    Nathens AB, Jurkovich GJ, Cummings P, Rivara FP, Maier RV (2000) The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA 283(15):1990–1994CrossRefGoogle Scholar
  23. 23.
    Moore L, Champion H, Tardif PA, Kuimi BL, O’Reilly G, Leppaniemi A et al (2018) Impact of trauma system structure on injury outcomes: a systematic review and meta-analysis. World J Surg 42(5):1327–1339. CrossRefGoogle Scholar
  24. 24.
    Jang JY, Shim H, Jung PY, Kim S, Bae KS (2016) Preperitoneal pelvic packing in patients with hemodynamic instability due to severe pelvic fracture: early experience in a Korean trauma center. Scand J Trauma Resusc Emerg Med 24:3CrossRefGoogle Scholar
  25. 25.
    Hwang K, Kwon J, Cho J, Heo Y, Lee JC-J, Jung K (2017) Implementation of trauma center and massive transfusion protocol improves outcomes for major trauma patients: a study at a single institution in Korea. World J Surg 7(42):2067–2075. Google Scholar

Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  1. 1.Division of Trauma Surgery, Department of SurgeryChonnam National University Hospital and Medical SchoolGwangjuKorea
  2. 2.Department of Trauma SurgeryWonkwang University HospitalIksanKorea

Personalised recommendations