Phase III: Second Operation Repair of All Injuries General and Orthopedics

The primary objectives of Damage Control Phase III (DC III) are definitive organ repair and fascial closure. Timing for this stage is critical to successful outcomes. The decision to proceed is predicated upon all physiological and biochemical deficits being corrected. The patient should be normothermic, have normal coagulation studies, have a normal pH, and have normal lactate. This state usually takes 24–36 h to achieve following aggressive ICU management. During this time, a complete tertiary survey of potential missed injuries, particularly extremity soft tissue and orthopedic injuries, is performed. An incidence of missed injuries of 10–20% has been reported in similar patient populations [1]. Additional necessary radiographic and ancillary studies must be completed. Planning by surgical specialty consultants for definitive management of associated injuries is initiated during this time. Occasionally, the timing of definitive repair is influenced by other clinical circumstances. One pressing concern that often leads to early planned reoperation is salvage of an ischemic limb due to shunt occlusion or suboptimal vascular repair following restoration of a normal coagulation profile. Other situations in which early planned reoperation is advisable include: (1) bowel that has been interrupted at several sites, resulting in a closed loop obstruction mechanism that threatens bowel viability and (2) suboptimal control of spillage at the initial laparotomy from packed or drained duodenal, pancreas, kidney, or bladder disruption.


Trauma Patient Damage Control Open Abdomen Fascial Closure Operation Repair 
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  1. 1.
    Hirshberg A, Wall MJ Jr., Mattox KL. Planned reoperation for trauma: A two year experience with 124 consecutive patients. J Trauma 1994;37:365–369.CrossRefPubMedGoogle Scholar
  2. 2.
    Hirshberg A, Scott BG. Damage control for vascular trauma. In Rich NM, Mattox KL, Hirshberg A (eds) Vascular trauma 2nd ed. Philadelphia: WB Saunders, 2004, 165–176.CrossRefGoogle Scholar
  3. 3.
    Braslow B, Schwab CW, Brooks AJ. Damage control. In Mahoney PF, Ryan JM, Brooks AJ, Schwab CW (eds) Ballistic trauma: A practical guide. London: Springer, 2005, 180–208.CrossRefGoogle Scholar
  4. 4.
    Fox CJ, Starnes BW. Vascular Surgery on the modern battlefield. Surg Clin N Am 2007;87:1193–1211.CrossRefPubMedGoogle Scholar
  5. 5.
    Chavarria-Aguilar M, Cockerham WT, Barker DE, Ciraulo DL, Richart CM, Maxwell RA. Management of destructive bowel injury in the open abdomen. J Trauma 2004; 56:560–564.CrossRefPubMedGoogle Scholar
  6. 6.
    Miller PR, Chang MC, Jason Hoth J, Holmes JH, Meredith JW. Colonic resection in the setting of damage control laparotomy: Is delayed anastomosis safe? Am Surgeon 2007;76:606–610.Google Scholar
  7. 7.
    Brundage SI, Jurkovich GJ, Hoyt DB, Patel NY, Ross SE, Marburger R, Stoner M, Ivatury RR, Ku J, Rutherford EJ, Maier RV, for the WTA Multi-institutional Study Group. Stapled versus sutured gastrointestinal anastomosis in the trauma patient: A multicenter trial. J Trauma 2001;51:1054–1061.CrossRefPubMedGoogle Scholar
  8. 8.
    Witzke JD, Kraatz JJ, Morken JM, Ney AL, West MA, Van Camp JM, Zera RT, Rodriguez JL. Stapled versus hand sewn anastomosis in patients with small bowel injury: A changing perspective. J Trauma 2000;49:660–666.CrossRefPubMedGoogle Scholar
  9. 9.
    Demetriades D, Murray JA, Chan LS. Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: A multicenter study. J Trauma 2002;52:117–121.CrossRefPubMedGoogle Scholar
  10. 10.
    Behrman SW, Bertken KA, Stefanacci HA, Parks SN. Breakdown of intestinal repair after laparotomy for trauma: Incidence, risk factors, and strategies for prevention. J Trauma 1998;45:227–233.CrossRefPubMedGoogle Scholar
  11. 11.
    Miller RS, Morris JA, Diaz JJ, Herring MB, May AK. Complications after 344 damage-control open celiotomies. J Trauma 2005; 59:1365–1374.CrossRefPubMedGoogle Scholar
  12. 12.
    Cioffi WG (Moderator), Biffl WL, Croce MA, Feliciano DV (Panelists). Component separation for the open abdomen (Symposium). Contemp Surg 2006; 62(5):216–220.Google Scholar
  13. 13.
    Miller PR, Meredith JW, Johnson JC, Chang MC. Prospective evaluation of vacuum-assisted fascial closure after open abdomen: Planned ventral hernia rate is substantially reduced. Ann Surg 2004;239:608–616.CrossRefPubMedGoogle Scholar
  14. 14.
    Rowlands BJ, Flynn TC, Fischer RP. Temporary abdominal wound closure with a silastic “chimney”. Contemp Surg 1984;24:17.Google Scholar
  15. 15.
    Gawande AA, Studert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348(3):229–235.CrossRefPubMedGoogle Scholar
  16. 16.
    Tremblay LN, Feliciano DV, Schmidt J, Cava RA, Tchorz KM, Ingram WL, Salomone JP, Nicholas JM, Rozycki GS. Skin only or silo closure in the critically ill patient with an open abdomen. Am J Surg 2001 Dec;182(6):670–675.CrossRefPubMedGoogle Scholar
  17. 17.
    Mastboom WJ, Kuypers HH, Schoots FJ, Wobbes T. Small-bowel perforation complicating the open treatment of generalized peritonitis. Arch Surg 1989;124:689–692.PubMedGoogle Scholar
  18. 18.
    Goverman J, Yelon JA, Platz JJ, Singson RC, Turcinovic M. The “fistula VAC,” a technique for the management of enterocutaneous fistulae arising within the open abdomen: Report of 5 cases. J Trauma 2006;60:428–431.CrossRefPubMedGoogle Scholar
  19. 19.
    Jamshidi R, Schecter WP. Biological dressings for the management of enteric fistulas in the open abdomen: A preliminary report. Arch Surg 2007 Aug;142(8):793–796.CrossRefPubMedGoogle Scholar
  20. 20.
    Girard S, Siderman M, Spain DA. A novel approach to the problem of intestinal fistulization arising in patients managed with open peritoneal cavities. Am J Surg 2003;184:166–167.CrossRefGoogle Scholar
  21. 21.
    Livingston DH, Sharma PK, Glantz AI. Tissue expanders for abdominal wall reconstruction following severe trauma: Technical note and case reports. J Trauma 1992;32:82.CrossRefPubMedGoogle Scholar
  22. 22.
    Ramirez OM, Raus E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg 1990;86:519–526.CrossRefPubMedGoogle Scholar
  23. 23.
    Jernigan TW, Fabian TC, Croce MA, Moore N, Pritchard FE, Minard G, Bee TK. Staged management of giant abdominal wall defects: Acute and long-term results. Ann Surg 2003;238:349–357.PubMedGoogle Scholar
  24. 24.
    Fabian TC, Croce MA, Pritchard FE, Minard G, Hickerson WL, Howell RL, Schurr MJ, Kudsk KA. Planned ventral hernia. Staged management for acute abdominal wall defects. Ann Surg 1994;219:643–650.CrossRefPubMedGoogle Scholar
  25. 25.
    Rutherford EJ, Skeete DA, Brasel KJ. Management of the patient with an open abdomen: Techniques in temporary and definitive closure. Curr Probl Surg 2004;41(10):821–876.CrossRefGoogle Scholar
  26. 26.
    Franklin ME Jr, Gonzalez JJ Jr, Glass JL. Use of porcine small intestinal mucosa as a prosthetic device for laparoscopic repair of hernias in contaminated fields: 2-year follow-up. Hernia 2004;8:186–189.PubMedGoogle Scholar
  27. 27.
    Helton WS, Fisichella PM, Berger R, Horgan A, Espat NJ, Abcarian H. Short-term outcomes with small intestinal submucosa for ventral abdominal hernia. Arch Surg 2005;140:549–562.CrossRefPubMedGoogle Scholar
  28. 28.
    Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh related complications. Plast Reconstr Surg 2005;116:1263–1277.CrossRefPubMedGoogle Scholar
  29. 1.
    Cuthbertson D. Post-shock metabolic response. Lancet 1942;1:433–437.CrossRefGoogle Scholar
  30. 2.
    Krettek C, Simon RG, Tscherne H. Management priorities in patients with polytrauma. Langenbecks Arch Surg 1998;383:220–227.CrossRefPubMedGoogle Scholar
  31. 3.
    Pape H-C, Stalp M, van Griensven M, Weinberg A, Dahlweit M, Tscherne H. Optimal timing for secondary surgery in polytrauma patients: An evaluation of 4,314 serious-injury cases. Chirurg 1999;70–11:1287–1293.Google Scholar
  32. 4.
    Waydhas C, Nast-Kolb D, Trupka A et al. Posttraumatic inflammatory response, secondary operations, and late multiple organ failure. J Trauma 1996;40:624–631.CrossRefPubMedGoogle Scholar
  33. 5.
    Waydhas C, Nast-Kolb D, Kick M, Zettl R, Wiesholler J, Trupka A, Jochum M, Schweiberer L. Operation planning of secondary interventions after polytrauma. Unfallchirurg 1994;97:244–249.PubMedGoogle Scholar
  34. 6.
    Pape HC, Giannoudis PV, Krettek C, Trentz O. Timing of fixation of major fractures in blunt polytrauma: Role of conventional indicators in clinical decision making. J Orthop Trauma 2005;19:551–562.CrossRefPubMedGoogle Scholar
  35. 7.
    Harwood PJ, Giannoudis PV, van Griensven M, Krettek C, Pape HC. Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma 2005;58:446–452.CrossRefPubMedGoogle Scholar
  36. 8.
    Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: Evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect 2005;54:447–462.PubMedGoogle Scholar
  37. 9.
    Giannoudis PV, Hildebrand F, Pape HC. Inflammatory serum markers in patients with multiple trauma. Can they predict outcome? J Bone Joint Surg Br 2004;86:313–323.CrossRefPubMedGoogle Scholar
  38. 10.
    Pape HC, Grimme K, Van Griensven M, Sott AH, Giannoudis P, Morley J, Roise O, Ellingsen E, Hildebrand F, Wiese B, Krettek C; EPOFF Study Group. Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: Prospective randomized analysis by the EPOFF Study Group. J Trauma 2003;55:7–13.CrossRefPubMedGoogle Scholar
  39. 11.
    Roumen RM, Redl H, Schlag G, Zilow G, Sandtner W, Koller W, Hendriks T, Goris RJ. Inflammatory mediators in relation to the development of multiple organ failure in patients after severe blunt trauma. Crit Care Med 1995;23:474–480.CrossRefPubMedGoogle Scholar
  40. 12.
    Smith RM, Giannoudis PV, Bellamy MC, Perry SL, Dickson RA, Guillou PJ. Interleukin-10 release and monocyte human leukocyte antigen-DR expression during femoral nailing. Clin Orthop Relat Res 2000;373:233–240.CrossRefPubMedGoogle Scholar
  41. 13.
    Hensler T, Hecker H, Heeg K, Heidecke CD, Bartels H, Barthlen W, Wagner H, Siewert JR, Holzmann B. Distinct mechanisms of immunosuppression as a consequence of major surgery. Infect Immun 1997;65:2283–2291.PubMedGoogle Scholar
  42. 14.
    Naldini A, Borrelli E, Carraro F, Giomarelli P, Toscano M. Interleukin 10 production in patients undergoing cardiopulmonary bypass: Evidence of inhibition of Th-1-type responses. Cytokine 1999;11:74–79.CrossRefPubMedGoogle Scholar
  43. 15.
    Pape HC, Remmers D, Grotz M, Schedel I, von Glinski S, Oberbeck R, Dahlweit M, Tscherne H. Levels of antibodies to endotoxin and cytokine release in patients with severe trauma: Does posttraumatic dysergy contribute to organ failure? J Trauma 1999;46:907–913.CrossRefPubMedGoogle Scholar
  44. 16.
    Rabinovici R, John R, Esser KM, Vernick J, Feuerstein G. Serum tumor necrosis factor-alpha profile in trauma patients. J Trauma 1993;35:698–702.CrossRefPubMedGoogle Scholar
  45. 17.
    Zallen G, Moore EE, Johnson JL, Tamura DY, Aiboshi J, Biffl WL, Silliman CC. Circulating postinjury neutrophils are primed for the release of proinflammatory cytokines. J Trauma 1999;46:42–48.CrossRefPubMedGoogle Scholar
  46. 18.
    Pape HC, van Griensven M, Rice J, Gansslen A, Hildebrand F, Zech S, Winny M, Lichtinghagen R, Krettek C. Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: Determination of the clinical relevance of biochemical markers. J Trauma 2001;50:989–1000.CrossRefPubMedGoogle Scholar
  47. 19.
    Giannoudis PV, Smith RM, Bellamy MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br 1999;81:356–361.CrossRefPubMedGoogle Scholar
  48. 20.
    Pape HC, Remmers D, Grotz M, Kotzerke J, von Glinski S, van Griensven M, Dahlweid M, Sznidar S, Tscherne H. Reticuloendothelial system activity and organ failure in patients with multiple injuries. Arch Surg 1999;134:421–427.CrossRefPubMedGoogle Scholar
  49. 21.
    Tanaka H, Ogura H, Yokota J, Sugimoto H, Yoshioka T, Sugimoto T. Acceleration of superoxide production from leukocytes in trauma patients. Ann Surg 1991;21:187–192.CrossRefGoogle Scholar
  50. 22.
    Botha AJ, Moore FA, Moore EE, Kim FJ, Banerjee A, Peterson VM. Postinjury neutrophil priming and activation: An early vulnerable window. Surgery 1995;118:358–365.CrossRefPubMedGoogle Scholar
  51. 23.
    Nijsten MWN, Hack CE, Helle M, ten Duis HJ, Klasen HJ, Aarden LA. Interleukin-6 and its relation to the humoral immune response and clinical parameters in burned patients. Surgery 1991;109:761–767.PubMedGoogle Scholar
  52. 24.
    Ogura H, Tanaka H, Koh T, Hashiguchi N, Kuwagata Y, Hosotsubo H, Shimazu T, Sugimoto H. Priming, second hit priming, and apoptosis in leukocytes from trauma patients. J Trauma 1999;46:774–783.CrossRefPubMedGoogle Scholar
  53. 25.
    Johnson JL, Moore EE, Tamura DY, Zallen G, Biffl WL, Silliman CC. Il-6 augments neutrophil cytotoxic potential via selective enhancement of elastase release. J Surg Res 1998;76:91–94.CrossRefPubMedGoogle Scholar
  54. 26.
    Biffl WL, Moore EE, Zallen G, Johnson JL, Gabriel J, Offner PJ, Silliman CC. Neutrophils are primed for cytotoxicity and resist apoptosis in injured patients at risk of MOF. Surgery 1999;126:198–202.PubMedGoogle Scholar
  55. 27.
    Kettritz R, Gaido M, Haller H, Luft FC, Jennette CJ, Falk RJ. Interleukin 6 delays spontaneous and TNF alpha–mediated apoptosis of human neutrophils. Kidney Int 1998;53:84–91.CrossRefPubMedGoogle Scholar
  56. 28.
    Afford S, Pongracz J, Stockley R, Croker J, Burnett D. The induction of human Il-6 of apoptosis in the promonocytic cell line U937 and human neutrophils. J Biol Chem 1992;267:21612–21616.PubMedGoogle Scholar
  57. 29.
    Teague T, Marrack P, Kappler J, Vella AT. Il-6 rescues resting mouse T cells from apoptosis. J Immunol 199;158:5791–5796.Google Scholar
  58. 30.
    Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O’Malley TA, Goroll AH, Caplan Ch, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845–850.CrossRefPubMedGoogle Scholar
  59. 31.
    Vacanti CJ, VanHouten RJ, Hill RC. A statistical analysis of the relationship of physical status to postoperative mortality in 68,388 cases. Anesth Analg 1970;49:564–566.CrossRefPubMedGoogle Scholar
  60. 32.
    Shoemaker WC, Appel PL, Bland R, Hopkins JA, Chang P. Clinical trial of an algorithm for outcome prediction in acute circulatory failure. Crit Care Med 1982;10:390–397.CrossRefPubMedGoogle Scholar
  61. 33.
    Goris RJA, Boekhorst TPA, Nuytinck JKS, Gimbrere JSF. Multiple organ failure: Generalized autodestructive inflammation? Arch Surg 1985;120:1109–1115.PubMedGoogle Scholar
  62. 34.
    Baker SP, O’Neill B, Haddon W, Long WB. The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187–196.CrossRefPubMedGoogle Scholar
  63. 35.
    Goris RJ. Multiple organ failure: Whole body inflammation? Schweiz Med Wochenschr 1989;119:347–353.PubMedGoogle Scholar
  64. 36.
    Regel G, Pohlemann T, Krettek C, Tscherne H. Frakturversorgung beim Polytrauma. Zeitpunkt und Taktik. Unfallchirurg 1997;100:234–248.CrossRefPubMedGoogle Scholar
  65. 37.
    Waydhas C, Flohe S. Intensive medicine criteria for operability. Unfallchirurg 2005;108:866–871.CrossRefPubMedGoogle Scholar
  66. 38.
    Harwood PJ, Giannoudis PV, Probst C, Krettek C, Pape HC.The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma 2006;20:181–189.PubMedGoogle Scholar
  67. 39.
    Przkora R, Bosch U, Zelle B, Panzica M, Garapati R, Krettek C, Pape HC. Damage control orthopedics: A case report. J Trauma 2002;53:765–769.CrossRefPubMedGoogle Scholar

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© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of Pennsylvania School of MedicinePhiladelphiaUSA

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