New concepts in trauma

Abstract

As other surgical disciplines have noted in this issue of the Journal, new concepts and techniques have been introduced into the surgery of trauma in recent years. In this section, two of the more clinically significant developments will be discussed. The first is “abbreviated” or “damage control” laparotomy with planned reoperation for severely injured patients. A common complication of this technique, known as the abdominal compartment syndrome, will also be discussed. The second development is the rapidly evolving relationship between the trauma surgeons and the interventional radiologists. Interventionalists are becoming more like surgeons than radiologists, and they are performing operations that once were exclusively in the domain of surgeons. Finally, as state wide and regional trauma systems mature, data regarding the performance of different institutions are emerging that may be of great assistance to states or regions whose trauma systems are still in their infancy. One significant development in trauma has been the acceptance by trauma surgeons of “abbreviated” or “damage control” laparotomy with planned reoperation for injured patients who develop hypothermia, acidosis and coagulopathy.‘.’ The concept of staged operations is, of course, not new; however, what is novel has been the application of this concept as a routine part of trauma care in large numbers of patients. The realization that patients with a core temperature less than 34°C a pH less than 7.2, and a clinically apparent coagulopathy are at high risk for sudden death has permitted trauma surgeons to abort the procedure and avoid what Moore referred to as the “bloody vicious spiral.“’ Prior to abbreviated laparotomy, surgeons continued to operate on patients until the blood bank was emptied, the rate of blood loss exceeded transfusion capabilities, or a fatal arrhythmia occurred. Now, when such patients are identified, the procedure is terminated as quickly as possible by ligating or stapling enteric injuries, packing diffusely bleeding surfaces, leaving clamps on or ligating unrepaired vascular injuries, or otherwise simply not treating parenchymal injuries of the pancreas or kidneys. The ahdominal incision is closed using multiple sharp towel clips. With these maneuvers, operations can be concluded within l-5 minutes once the decision has been made. The patient is then covered with dry, warm blankets and resuscitated either in the surgical intensive care unit or the operating room. When the patient’s core temperature approaches normal and the dilutional coagulopathy has been corrected, the