Trauma is one of the leading causes of death in every age group, it is the leading cause of death for people aged one to 44 years (Feliciano 2007). Abdominal trauma is subdivided into two groups based on the mechanism of injury, which may be penetration or blunt trauma. Motor vehicle crashes account for about 75% of blunt abdominal trauma cases, while gunshot and stab wounds are the main mechanisms of injury in cases of penetrating trauma. For blunt abdominal trauma, non-operative management has become the standard treatment in most trauma centres.
In major abdominal trauma patients, impaired coagulation, metabolic acidosis from low tissue perfusion, haemodynamic instability, infections, and pulmonary complications significantly contribute to morbidity and mortality (Moore 1998). During initial operative and resuscitation efforts, the presence of acidosis, hypothermia, and coagulopathy is associated with high mortality in patients with traumatic injuries (Mikhail 1999; Moore 1996). Consequently, suitable interventions are needed to control bleeding and prevent further heat loss (Zacharias 1999).
In the early 1980s, Harlan Stone described the first damage control procedure performed on a patient who developed coagulopathy during a laparotomy performed for trauma (Stone 1983). The term 'damage control surgery' (DCS) was first described for trauma treatment by Rotondo and Schwab, who, in 1993, outlined a three-phase procedure for patients with major abdominal trauma (Rotondo 1993). DCS avoids extensive procedures on unstable patients and may stabilize potentially fatal problems at initial operation. Extensive procedures are later applied in staged surgery after the successful initial resuscitation (Lee 2006). The DCS strategy is fundamentally based on 'damage control laparotomy', which is also called 'abbreviated laparotomy'. This phase is essentially aimed at obtaining surgical control of haemorrhage and contamination as quickly as possible. It is then followed by temporary abdominal closure (Burch 1992). The main methods for achieving control of haemorrhage are ligation, suturing, or temporal shunting of vascular injuries; packing of liver injuries; and splenectomy (in the presence of splenic injury) (Sharp 1992). Due to bowel oedema, trauma patients' abdominal walls may not feasibly be closed because of the risk of intra-abdominal hypertension (IAH) (Raeburn 2001). The simplest option for abdominal closure, direct suture of the abdominal wall, is not the preferred technique as it results in tissue tension and IAH. Several techniques have been suggested for abdominal closure in order to prevent abdominal compartment syndrome. These are towel clip closure of the skin, temporary silos, vacuum-assisted wound closure, open packing, and absorbable or permanent meshes (Letoublon 2005). In phase three, which usually takes place within 24 to 36 hours of phase one, the abdominal packs are removed, definitive repairs take place, there is a second look laparotomy for missed injuries, and then the abdomen is closed (Germanos 2007).
Description of the condition
In major trauma patients, impaired coagulation, metabolic acidosis, haemodynamic instability, infections, and pulmonary complications significantly contribute to morbidity and mortality (Moore 1998). During initial operative and resuscitation efforts the presence of acidosis, hypothermia, and coagulopathy is associated with high mortality (Mikhail 1999).
Description of the intervention
Damage control surgery is characterized by a staged approach to patients with major abdominal trauma. The approach considers, when necessary, the immediate arrest (with packing or vascular clamps and suture ligatures) of severe bleeding from parenchymal injuries (liver, spleen, pancreas, and kidney), major vessels injuries, retroperitoneal injuries, and the stapling of the intestines for the temporary control of peritoneal contamination from hollow visceral injuries (stomach, small bowel, colon-rectum, and bladder). Initial resuscitation, if necessary, is followed by a brief initial laparotomy, intensive care unit management, and a final planned re-operation. In the final stages of surgery, the abdomen is left open to avoid abdominal compartment syndrome.
The rationale for damage control surgery is that mortality in surgical patients who develop hypothermia, acidosis, and coagulopathy (the 'lethal triad') is extremely high unless patients' physiologic stability is re-established. The control intervention in this review is immediate, traditional surgical treatment for the injuries.
How the intervention might work
The advantage of damage control surgery is the immediate control of severe haemorrhage and the rapid correction of hypothermia, acidosis, and coagulopathy. The disadvantages include the need for further surgical repair with the possibility of high morbidity. The immediate and definitive repair of the injuries (for example bleeding from liver trauma, retroperitoneal injuries, or peritoneal contamination from traumatic bowel perforation) presents the advantages of not requiring re-operation for definitive surgical treatment. The disadvantage is a long operative time for a complex repair of injuries.
Why it is important to do this review
The effects of the damage control surgery approach compared to traditional immediate surgical repair is an unanswered clinical question.
To assess the effects of damage control surgery compared to traditional immediate definitive surgical treatment for patients with major abdominal trauma.
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs).
Types of participants
Patients with major abdominal trauma (Abbreviated Injury Scale > 3 (Champion 1989)) undergoing surgery. Patient selection is crucial as patients with relatively simple abdominal injuries should not undergo unnecessary procedures. Haemodynamic instability, manifested by hypotension, tachycardia and tachypnoea, coagulopathy, or hypothermia, is an important indication for the damage control approach. The control intervention is immediate, traditional surgical repair of the injuries.
Types of interventions
Damage control surgery for major abdominal trauma (Abbreviated Injury Scale > 3) versus immediate, traditional surgical repair in the management of major abdominal trauma.
Types of outcome measures
- Overall short-term mortality (within 30 days of surgery)
- Overall short-term morbidity (within 30 days of surgery)
Search methods for identification of studies
Searches were not restricted by language, date, or publication status.
We searched the following electronic databases:
- Cochrane Injuries Group Specialised Register (19 December 2012);
- CENTRAL (The Cochrane Library 2012, Issue 12 of 12);
- MEDLINE (OvidSP) (1946 to December (week 1) 2012);
- EMBASE (OvidSP) (1980 to December 2012 (week 51);
- ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to Dec 2012);
- ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to Dec 2012);
- CINAHL (1982 to 19 December 2012);
- Zetoc (19 December 2012);
- Current Controlled Trials metaRegister (29 December 2012);
- Clinicaltrials.gov (searched 29 December 2012).
Details of the search strategies can be found in Appendix 1.
Searching other resources
We searched abstracts presented at the following international scientific society conferences:
- American Association for the Surgery of Trauma (1999 to December 2012);
- American College of Surgeons (2000 to December 2012);
- Eastern Association for the Surgery of Trauma (2005 to December 2012);
- Società Italiana di Chirurgia (1985 to December 2012).
We checked the reference lists of all relevant studies retrieved from our search and from relevant, published systematic reviews in order to identify other possible studies for inclusion. We conducted an Internet search for grey literature and other information related to our topic.
Data collection and analysis
Selection of studies
Two authors (RC, IA) assessed titles or abstracts of all studies identified by the initial search and excluded clearly irrelevant studies. We obtained the full text of potentially relevant studies, including any studies with unclear methodologies. Two authors independently assessed the full-text articles to determine whether they met the inclusion criteria for this review and to evaluate the method of randomisation and adequacy of allocation concealment. We resolved disagreements about study inclusion by discussion and, if necessary, with the assistance of an independent third author (AM).
Data extraction and management
In the future, if studies are included in the review, two investigators (IA, RC) will independently extract the following information for each included trial: method of outcome, blinding of outcome evaluators, and balance of prognostic factors.
Assessment of risk of bias in included studies
In the future if studies are included in the review, IA and RC will record whether the authors of the studies used a sample size calculation, and whether or not they performed the analysis using an intention-to-treat method. IA and RC will assess the methodological quality of each trial independently. IA and RC will clarify any unclear or missing information by contacting the authors of the specific trials. We will resolve differences in opinion between the authors extracting data through discussion. AM will serve as arbitrator when differences in opinion persist.
Assessment of methodological quality of studies
In the future if studies are included in the review, IA and RC will assess the methodological quality of the trials independently, without masking of the trial names. The review authors will follow the instructions given in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2008) and by the Cochrane Injuries Group. Due to the risk of biased overestimation of intervention effects in randomised trials with inadequate methodological quality (Schulz 1995; Wood 2008), IA and RC will consider the methodological quality of the trials by evaluating the reported randomisation and follow-up procedures in each trial. If information is not available in the published trial, IA and RC will contact the authors for this information. IA and RC will assess generation of the randomisation sequence, allocation concealment, blinding, and follow up.
Adequate: if a computer-generated or random number table was used.
Unclear: if the trial was described as randomised, but the report failed to describe the method of allocation sequence.
Inadequate: if patients were allocated according to names, dates, admittance numbers, etc. These are known as quasi-randomised trials and we will exclude them from the review.
Adequate: if centralised or pre-numbered containers are administered serially to patients, an on-site computer with allocations in a locked unreadable file, or sequentially numbered sealed opaque envelopes.
Unclear: if the trial is described as randomised, but failed to describe the method of allocation concealment.
Inadequate: if a completely transparent procedure was used. For example, if case record numbers, dates of birth, or an open list of random numbers was used.
Adequate: if the numbers and reasons for dropouts and withdrawals in all intervention groups were described or if it was specified that there were no dropouts or withdrawals.
Unclear: if the report gave the impression that there had been no dropouts or withdrawals, but this was not specifically stated.
Inadequate: if the number or reasons for dropouts and withdrawals were not described.
IA and RC will record sample size and duration of follow up.
Measures of treatment effect
In the future if studies are included in the review, we will analyse dichotomous data with risk ratio (RR) or odds ratio (OR). Absolute effects will be measured with risk differences. We will calculate 95% confidence intervals (CI) for these measures of effect. We will perform intention-to-treat analysis by extracting the number of patients originally allocated to each treatment group, irrespective of compliance. If numbers extracted by the two authors are different, a third author (FS) will resolve differences. We will use the Mantel-Haenszel method for the meta-analysis (Greenland 1985; Mantel 1959). We will present results on a forest plot.
Dealing with missing data
If studies are included in the review in the future, we will contact trial investigators if additional information is required.
Assessment of heterogeneity
If studies are included in the review in the future, we will use the Chi
Assessment of reporting biases
In the future if there are 10 or more studies included in the review, we will use a funnel plot to explore publication bias (Egger 1997; Macaskill 2001). We will perform linear regression using the approach described by Egger et al to determine the funnel plot asymmetry (Egger 1997).
In the future if trials are included in the review, IA and RC will independently perform a sensitivity analysis by examining the trial inclusion criteria, re-assessing excluded studies, re-analysing data imputing, and re-analysing data using the DerSimonian and Laird method (DerSimonian 1986).
Description of studies
Results of the search
|Figure 1. Study selection according to PRISMA (Moher 2009) flow diagram (searches from first publication to Dec 2012).|
No randomised controlled studies comparing DCS with immediate and definitive repair in patients with major abdominal trauma were found.
Risk of bias in included studies
No studies were included in this review.
Effects of interventions
No studies were included in this review.
We found no published or pending randomised controlled trials that compared DCS with immediate and definitive repair in patients with major abdominal trauma for inclusion in this review.
Most of the current information relating to DCS comes from case studies (Colombo 2005; Kudera 2004) and observational studies (Bach 2008; Cotton 2008; Feliciano 1988; Hirshberg 1994; Rotondo 1993; Saifi 1990; Sharp 1992).
In light of the paucity of studies, evidence that supports efficacy of DCS compared to immediate, traditional laparotomy is limited. Good quality randomised controlled trials comparing DCS and traditional, immediate repair are warranted. A carefully designed RCT of this intervention is possible, and the results of such a trial will help to improve the critical decision making of multidisciplinary teams in the future.
Implications for practice
Patients with major trauma are usually unstable and are at risk of complications including bleeding, acidosis, hypothermia, and coagulopathy. Damage control surgery avoids extensive procedures on unstable patients by applying staged surgery after the patient has stabilised. However, its benefits cannot be established as there are no published randomised controlled trials. Good quality randomised controlled trials are needed to produce reliable recommendations.
Implications for research
Good quality randomised controlled trials comparing DCS with immediate surgical repair for patients suffering major abdominal trauma are needed. These prospective trials should have as major outcomes measures short-term mortality and morbidity, and hospital and intensive care unit stays.
The authors thank Emma Sydenham, Deirdre Beecher and the staff of the Cochrane Injuries Group editorial base. The authors acknowledge the contribution of Prof. Francesco Sciannameo who was a co-author of the original protocol and first version of this review.
Data and analyses
This review has no analyses.
Appendix 1. Search strategies
Cochrane Injuries Group Specialised Register
(abdominal or abdomen) and (injur* or trauma* or perforat* or penetrate*) and (surg*)
CENTRAL (The Cochrane Library)*
#1MeSH descriptor: [Abdominal Injuries] explode all trees
#2(abdominal or abdomen) near/5 (injur* or trauma* or perforat* or penetrat*)
#3(abdominal or abdomen) near/5 (multiple trauma or polytrauma)
#4(wound* or stab* or gunshot or shot or penetrat*) near/3 (abdomen* or abdominal or stomach or splenic or spleen)
#5(#1 or #2 or #3 or #4)
#6MeSH descriptor: [General Surgery] explode all trees
#7damag* near/5 control* near/5 surg*
#8(surgery or surgical):ti (Word variations have been searched)
#9(surgery or surgical):ab (Word variations have been searched)
#10#9 or #8
#11#6 or #7 or #10
#12#5 and #11
*For this 2012 update the CENTRAL search strategy has been slightly modified due to recent development of the database new search interface but the keywords and MeSH have not been changed.
1. exp Abdominal Injuries/
2. exp Thoracic Injuries/
3. ((abdominal or abdomen) adj3 (injur* or trauma* or perforat* or penetrat*)).ab,ti.
4. exp Multiple Trauma/
5. (multiple trauma or polytrauma).ab,ti.
6. 4 or 5
7. exp Hemoperitoneum/
9. exp Retroperitoneal Space/
11. exp abdomen/
12. (abdomen* or abdominal).ti,ab.
13. 7 or 8 or 9 or 10 or 11 or 12
14. 6 and 13
15. (damag* adj3 control*).ti,ab.
16. (1 or 2 or 3 or 14) and 15
17. (abdominal adj3 compartmental adj3 syndrome).ab,ti.
18. (Hernia* adj3 Diaphragm* adj3 Trauma*).ab,ti.
19. ((splenic or spleen) adj3 rupture*).ab,ti.
20. ((stomach or gastric) adj3 (rupture or perforation or injur* or burst*)).ab,ti.
21. exp Wounds, Stab/
22. exp Wounds, Gunshot/
23. exp Rupture/
24. 21 or 22 or 23
25. 13 and 24
26. ((wound* or stab* or gunshot or shot or penetrat*) adj3 (abdomen* or abdominal or stomach or splenic or spleen)).ab,ti.
27. ((spleen or splenic) adj3 (wound* or injur* or trauma* or perforat* or penetrate*)).ab,ti.
28. ((liver or hepatic) adj3 (wound* or injur* or trauma* or perforat* or penetrate*)).ab,ti.
29. 1 or 2 or 3 or 14 or 16 or 17 or 18 or 19 or 20 or 25 or 26 or 27 or 28
30. exp Surgery/
31. exp Laparotomy/
32. (laparotomy or re-laparotomy).ab,ti.
35. (laparotom* or re-laparotom*).ab,ti.
37. 29 and 36
39. randomized controlled trial.pt.
40. controlled clinical trial.pt.
42. clinical trials as topic.sh.
47. 45 and 46
48. 47 and 37
1. exp Abdominal Injury/
2. exp Abdomen/
3. exp Hemoperitoneum/
4. exp retroperitoneum/
5. 2 or 3 or 4
6. exp Multiple Trauma/
7. 5 and 6
8. 1 or 7
9. ((abdominal or abdomen) adj3 (injur* or trauma* or perforat* or penetrat*)).ab,ti.
10. ((stab* or gunshot or shot or wound*) adj3 (abdomen* or abdominal)).ab,ti.
11. 8 or 9 or 10
12. exp Abdominal Surgery/
13. exp Laparotomy/
14. 12 or 13
15. exp Injury/
16. 14 and 15
17. ((laparotomy or re-laparotomy or minilaparotomy) adj3 (injur* or trauma*)).ab,ti.
18. ((surgery or surgical) adj3 (abdomen or abdominal)).ti.
19. 16 or 17 or 18
20. 11 and 19
21. (damag* adj3 control*).ti,ab.
22. 19 and 21
23. 20 or 22
25. (placebo or randomised or randomized or randomly or random order or random sequence or random allocation or randomly allocated or at random or controlled clinical trial*).tw,hw.
26. 24 and 25
27. 23 and 26
ISI Web of Science: Conference Proceedings Citation Index-Science;
ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED);
Topic=(abdominal or abdomen or spleen or splenic or stomach or gastric or retroperitoneum or hemoperitoneum or haemoperitoneum or thoracic or thorax) AND Topic=(injur* or trauma* or wound* or perforat* or penetrate* or multiple trauma or polytrauma) AND Topic=((surgery or surgical or laparotomy or re-laparotomy or minilaparotomy) and (damage control)) AND Topic=(random* or group* or trial or study or placebo)
Timespan=All Years. Databases=STP.
Current Controlled Trials MetaRegister: http://www.controlled-trials.com/
((surgery or surgical or laparotomy or re-laparotomy or minilaparotomy) and (damage control))
(abdominal OR abdomen) AND (injury OR trauma) AND (surgery)
abdom* injur* surg* random*
abdom* trauma* surg* random*
CINAHL (Ebsco Host)
TX ( abdominal or abdomen or spleen or splenic or stomach or gastric or retroperitoneum or hemoperitoneum or haemoperitoneum or thoracic or thorax ) and TX ( injur* or trauma* or wound* or perforat* or penetrate* or multiple trauma or polytrauma ) and TX ( (surgery or surgical or laparotomy or re-laparotomy or minilaparotomy) and (damage control) ) and TX ( random* or group* or trial or study or placebo)
Last assessed as up-to-date: 19 December 2012.
Contributions of authors
All authors contributed to the production of the review.
Declarations of interest
Sources of support
- Department of General Surgery, University of Perugia, Terni, Italy.
- No sources of support supplied
Medical Subject Headings (MeSH)
MeSH check words