Damage Control Surgery Research Articles

Debunking the lethal triad and delineating damage control surgery.

The last three decades of literature in trauma have been erroneously hammered by the belief the lethal triad (LT) of acidosis, hypothermia and coagulopathy was, as claimed originally, the statutory rationale underlying for the application of damage control surgery (DCS) strategy. As a matter of fact, the LT is not all lethal: only acidosis is lethal and a reliable hard sign for DCS, indicating severe levels of hypoxemia and tissues hypoxia. The mainstream flow of events leading to exitus in hemorragic shock pass through macro and microcirculation dynamics, oxygen, acidosis, and ischemia-reperfusion toxemia. It is solely by interfering or manipulating these variables dynamics that we can decrease morbidity and mortality. A solid synoptic list of the indications and timing of DCS has been elaborated.

Boerhaave’s syndrome in a case of acute exacerbation of chronic obstructive pulmonary disease managed with non-invasive ventilation: a case report

Barotraumatic esophageal rupture (Boerhaave’s syndrome) is a rare and life-threatening disease, described as a Non-Invasive Ventilation (NIV) complication in a very small series. We report the case of a 72-year-old man admitted to the Emergency Department (ED) for severe dyspnea in a Chronic Obstructive Pulmonary Disease (COPD) stage Gold III. After NIV treatment, the patient suffered esophageal perforation with mediastinal and pleural contamination: emergency surgical treatment was successful for the esophageal repair, but the patient developed a fatal septic shock 12 days after surgery. Among NIV complications, few cases concern esophagogastric perforation: our case report describes an uncommon clinical situation treated with a successful damage control surgery approach.

1210 Network Meta-Analysis of Associated Mortality with Transfusion Strategies for Major Haemorrhage in Adults

Abstract Aim The aetiology of a large proportion of mortality in trauma patients is attributed to acute major haemorrhage. Damage control resuscitation and surgery have been developed as part of management, which often includes large volume blood product transfusion. The aim of this meta-analysis was to investigate differences in mortality between transfusion strategies used in major haemorrhage in adults (18+ years). Method A frequentist random effects network meta-analysis (NMA) using the netmeta package in R 4.0.5 of the eligible papers in the systematic review “Optimal dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a systematic review” compared a 1:1:1 ratio of red blood cells (RBC), fresh frozen plasma (FFP) and platelets (P) to a ratio of 2:1:1, whole blood, and laboratory-guided replacement. Homogeneity and heterogeneity were assessed with Cochran’s Q. Results Mortality at one month by group was 21.8% (12/55) for whole blood, 17.0% (58/342) for 2RBC:1FFP:1P, 14.3% (5/35) for laboratory-guided transfusion and 22.3% (96/43) for standard 1RBC:1FFP:1P ratio. The NMA showed no significant differences between groups, with relative risk of death when compared to 1RBC:1FFP:1P by one month of 1.42 (0.631; 3.19, p = 0.398) for whole blood, 0.7643 (0.562; 1.04, p = 0.0871) for 2RBC:1FFP:1P and 0.4396 (0.1741; 1.1099, p = 0.0820) for laboratory-guided transfusion. Conclusions The results demonstrated no significant differences in mortality between transfusion strategies in major haemorrhage - however, some arms of the NMA contain few patients and so may be underpowered to detect differences between groups. On this evidence, current use of component therapy is not inferior to another transfusion strategy.

Damage control surgery by transverse colon perforation: case report

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The outcomes of these different resections when performed in acute clinical situations remain substantially unexplored. Case report: 65 years old diabetic and obese female, with abdominal pain accompanied by the absence of channeling of flatus and bowel movements as well as countless vomiting of low intestinal content, wich is why its refer to the emergency of the IAHULA, Merida Venezuela. Physical examination: tachycardic, tachypneic, with, HR: 130 TA: 90/60, FR: 28m oxygen saturation 89%. Abdomen distended, diminished hydro aerial sounds, painful on palpation, with voluntary muscular defense. An emergency laparotomy show: general fecal peritonitis, perforations of the transverse colon, stenosing sigmoid tumor. For this reason, phase 1 damage control surgery was performed by transversectomy + placement of proximal and distal threads, requiring phase II in an intensive care unit, ventilatory support and vasopressor drugs. Phase III was planned in 48 to 72 hours for probable complete left colectomy, however, the patient died after 18 hours of postoperative. Discussion: damage control surgery has been considered an appropriate approach to the treatment of critically ill patients with severe intra-abdominal sepsis. Conclusion: Abdominal sepsis and a septic shock are both possible as a critical scenarios in patients with perforation and obstruction of the colon secondary tumors and carcinomas, for that reason it is important to know which patient can be selected to a damage control surgery in orden to improve the morbimortality.

178 Damage Control Surgery in Severe Ballistic Trauma

Abstract Introduction Severe ballistic lesions are the cause of hemodynamic disorders and early coagulopathy causing a high mortality rate, their management needs to be adapted to each situation. Materials & Methods This retrospective study aims to evaluate the feasibility and outcomes of abbreviated laparotomy and early re-exploration. It includes patients suffering from severe ballistic injuries who had to undergo a Damage Control Surgery (DCS) due to a high severity trauma score. Moreover, morbidity and mortality rates were analysed. Results The sample included 73 male patients with an average age of 31years. Most patients suffered from haemorrhagic shock 74%, respiratory distress 40%, and peritoneal contamination 63%. The severity score was 64. After (DCS), the re-exploration was impossible in certain cases. The mortality rate was 28, 8%. Conclusion Abbreviated laparotomy and DCS are effective practices for stabilizing victims of gunshot and maintaining the function and integrity of the organism.

FTP1.11 Retroperitoneal injury is associated with anastomotic leak after colonic injury

Abstract Background The aim of this retrospective observational study was to investigate the association between concomitant retroperitoneal injury and colonic repair failure. Operative repair of perforating colonic injury should ideally maintain bowel continuity. Diversion may be preferable where the repair is likely to fail. To make this decision surgeons must be aware of factors associated with risk of operative failure. Concomitant retroperitoneal injury (RPI) may represent an occult risk factor for post-operative colonic complications. Methods Single-centre study of adult patients admitted to a Level 1 trauma centre between June 2015 and July 2020. Trauma patients with full thickness perforation of either the colon or intraperitoneal rectum were included. We compared clinical outcomes and specifically the incidence of colonic repair leak in patients with or without retroperitoneal injury (RPI). Results Seventy-seven patients met inclusion criteria, of whom 33/77 (43%) had RPI. Mechanism of injury was penetrating in 61/77 (79%) and 49/77 (64%) had isolated abdominal injuries. Patients with RPI had significantly more leaks compared to patients without (9/33 [27%] versus 3/44 [7%], RR 2.0, 95%CI 1.2 to 3.1 p=0.024). Post-operative leak was higher in shocked patients (shock 3/11 [27%] versus not-shocked 9/65 [14%], p=0.37) or those requiring damage control surgery (DCS) (DCS 6/23 [26%] versus non-DCS 6/54 [11%], p=0.17) but neither reached statistical significance. Conclusions RPI is associated with an increased incidence of complications after colonic repair. When selecting operative strategy for perforating colonic injury, surgeons should be aware of increased risk of operative failure in the presence of concomitant RPI.

Animal model of polytrauma for surgical training

Introduction: The aim of this study was to develop a training program for surgeons that would enable them to improve their practical skills using an animal model of polytrauma. Methods: Injury to the stomach, small and large bowel as well as spleen and liver injury were caused laparoscopically, and tension pneumothorax was induced thoracoscopically, in 60 laboratory pigs. A thus obtained polytrauma model was then used for the training of examination processes according to ATLS (advanced trauma life support) principles and of the treatment protocol according to DCS (damage control surgery) principles. Less experienced surgeons (N=10) completed a total of 4 training sessions, and experienced surgeons with postgraduate certification in surgery (N=10) performed 2 treatments. The relative training benefit was subsequently assessed by comparing the first and the last attempt. Furthermore, the absolute benefit of training for the beginners (novice trainees) was evaluated by comparing their last attempt with the first attempt of experienced surgeons. Results: The beginners (less experienced surgeons) showed an improvement (first vs fourth attempt) in all parameters except bowel injury management and laparotomy closure time. Based on the comparison of the experienced surgeons’ first attempt and the beginners’ first attempt, the beginners performed significantly worse in all parameters except the two mentioned above. Average total blood loss was also higher in the beginners’ group – 2531 (±661.1) g vs 1189 (±509.5) g in the experienced surgeons’ group (p<0.001). Conclusion: A novel animal model of polytrauma that can be used for the training of life threatening injury management was developed and validated in the study. The beginners improved significantly in all parameters after the training. However, longer training would be required to achieve results comparable to those of experienced surgeons.

Peripheral vascular trauma - basic management, diagnosis and treatment.

Peripheral vascular injuries occur in 1-3% of all traumas in civilian settings. The management of these injuries is often based on experience derived from war medicine where these injuries are more common. The goal of this article is to summarize basic guidelines for the diagnosis and treatment of vascular injuries. Western Trauma Association (WTA) and Eastern Association for the Surgery of Trauma (EAST) both have their own guidelines for vascular trauma management. Vascular injuries occur both in penetrating and blunt traumas. Complete vessel disruption occurs more frequently in penetrating traumas. In the case of blunt trauma, intimal defects are more common, resulting in dissection, false aneurysm, or intramural hematoma. The limb is mostly endangered due to ischemia, reperfusion injury and the compartment syndrome. Prompt diagnosis and treatment are paramount. Vascular trauma management is part of the ATLS protocol and life-over-limb principle. The primary goal is to stop the massive external bleeding. Clinical examination and CT angiography are the most helpful for the diagnosis. Surgical revision is indicated when hard signs are present. This can be a damage control surgery with the primary goal to stop the bleeding as quickly as possible. A shunt can be used for temporary reperfusion of the limb. Definitive treatment can take the form of a simple suture, patches or graft interposition; both prosthetic and autologous grafts are used. Sufficient debridement and fasciotomy are important steps in the therapy. In some cases, endovascular treatment can be used. Over the last century, the treatment strategy changed dramatically. Data from recent military conflicts show a decrease in amputation rates, and limb salvage has become a standard.

Lessons learned from the ROLE 3rd International Hospital in Afghanistan. The necessity of training in expanded surgical skills

Introduction: Acquiring and maintaining a wide range of surgical skills is challenging both for military surgeons and all physicians providing surgical treatment in a wartime conflict. In the article we analyze the activities of the surgeons of the field surgical team of the Army of the Czech Republic operating in the multinational hospital ROLE 3 in Kabul, Afghanistan, in the International Security and Assistance Force (ISAF) operation. Methods: All patients undergoing surgery between 21st June and 26th September 2012 were evaluated. ISAF soldiers, Afghan Army soldiers, Afghan National Police officers, Afghan civilians and non-Afghan civilians of various nationalities were operated on including children. Combat and noncombat injuries and illnesses requiring acute surgical treatment or elective surgery were monitored. Results: In a period of three months, a total of 442 procedures were performed on 263 patients, 23% of whom were pediatric patients with the mean age of 10 years. Thirty seven percent were operated on due to a combat injury, 29% were operated on due to a non-combat injury, and 34% of the patients were operated on due to a chronic or acute illness. In combat injuries, 57% were combined injuries requiring a solution based on the principle of damage control surgery, and 26% required life-saving procedures for injuries to the chest and large vessels. Conclusion: A military surgeon, as well as a surgeon treating wounds in a war conflict, must have extensive professional knowledge and must master a wide variety of surgical skills to quickly and effectively deal with especially life-threatening conditions, including thoracic and vascular trauma. In contrast to the direction of current surgery towards specializations and sub-specializations, it seems necessary to develop and implement in the Czech Republic a comprehensive surgical training program focusing on war injuries.

Hepatic compartment syndrome treated with damage control surgery and transarterial embolization: A case report

Hepatic compartment syndrome (HCS) is a complication of nonoperative management in patients with blunt hepatic injury. Although decompression of elevated intrahepatic pressure through surgical exploration or drainage and hemorrhage control are required to manage this condition, evidence for such a management for this complication is insufficient. Herein, we report a pediatric patient treated with a planned combination strategy of surgical decompression with perihepatic packing to reduce intrahepatic pressure and subcapsular hemorrhage control as well as angioembolization to control intraparenchymal hemorrhage.A 12-year-old boy was referred to our emergency department 5 h after sustaining severe bruising in the upper abdomen in a traffic accident. Computed tomography (CT) showed an intraparenchymal hematoma in the right lobe of the liver; nonoperative management was selected based on stable hemodynamic status. Two days after the injury, he complained of severe abdominal pain and shock. CT showed an intraparenchymal and large subcapsular hematoma with right branch compression of the portal vein and extravasation of contrast material. Laboratory data showed progression of hepatocellular damage. We successfully managed this patient with a planned combination strategy of surgical decompression with perihepatic packing for reduction of intrahepatic pressure and subcapsular hemorrhage control, followed by angioembolization for control of intraparenchymal hemorrhage.Our study suggests that for the management of HCS, a planned combination strategy of damage control surgery and angioembolization is a therapeutic option.

Damage control surgery in emergency general surgery: What you need to know.

Damage-control surgery (DCS) is a strategy adopted to limit initial operative interventions in the unstable surgical patient, delaying definitive repairs and abdominal wall closure until physiologic parameters have improved. Although this concept of "physiology over anatomy" was initially described in the management of severely injured trauma patients, the approaches of DCS have become common in the management of nontraumatic intra-abdominal emergencies.While the utilization of damage-control methods in emergency general surgery (EGS) is controversial, numerous studies have demonstrated improved outcomes, making DCS an essential technique for all acute care surgeons. Following a brief history of DCS and its indications in the EGS patient, the phases of DCS will be discussed including an in-depth review of preoperative resuscitation, techniques for intra-abdominal source control, temporary abdominal closure, intensive care unit (ICU) management of the open abdomen, and strategies to improve abdominal wall closure.

The Royal College of Surgeons of England Damage Control Orthopaedic Trauma Skills course (DCOTS): resuscitative knowledge and confidence in surgical skills are reliably maintained at six months post course.

Since 2012, the Damage Control Orthopaedic Trauma Skills course (DCOTS) has trained more than 250 surgeons in the principles and practice of damage control orthopaedics and early appropriate care. This Royal College of Surgeons of England (RCS England) course takes place at the RCS England Partner cadaver laboratory at Brighton and Sussex Medical School. Trauma is a leading cause of morbidity and mortality in the UK, and the course has tried to pass on the lessons of war and conflict from its military faculty and hard-won lessons of "developed world" trauma from its experienced civilian faculty. Participating surgeons were invited to score their self-reported confidence before attending the DCOTS course, immediately afterwards and again 6 months later. A modified four-point Likert scale was used, with responses from 1 = No Confidence to 4 = Very Confident. Damage control resuscitation principles with damage control surgery showed the greatest retained increase at 6 months - 100% - which is extremely satisfying. Self-reported confidence in pelvic external fixation was initially 93% dropping to 85%, which is also considered good to excellent. For pelvic packing, confidence was 90% at the end of the course, up from 19% precourse. This dropped to 62%, which was still considered good but low for the high standards of the course. This may relate to UK trainees' lack of familiarity with the concept. Three of the main skills taught on the DCOTS are effectively retained at 6 months post course.

Surgical rescue strategies and techniques for gastrointestinal fistulas

Abstract A gastrointestinal fistula is a severe medical condition that may lead to sepsis or septic shock. It requires immediate response and valid treatment to prevent subsequent deterioration. Surgical rescues are effective measures to cope with aforementioned situations, but there remain challenges in successful implementation. Institutional factors, including constrained hospital volume, technological gap, and limited competence of surgeons and nurses, could lead to surgical failure to rescue (FTR), while high-risk patient characteristics such as aging, diabetes mellitus, and chronic organ dysfunction have a bearing on the outcome as well. Surgical rescue strategies encompass damage control surgery and resuscitation. Based on disease severity, sequential damage control measures involving vessel catheter removal, abdominal drainage tube replacement, trocar-assisted percutaneous abscess drainage, laparoscopic drainage, and open abdomen therapy should be applied accordingly.

Clinical and biostatistical approach to assessing the severity of physical status of patients with combined midface trauma. Part 2

Objective. To develop a method for predicting mortality among patients with combined midface trauma (CMFT).
 Materials and methods. This study is based on the examination results of 95 patients with CMFT. Depending on the outcome of CMFT, 2 groups of patients were formed: the first group – patients with a favorable outcome (n=50); the second group – patients with an unfavorable outcome (n=45). A group of physiological parameters was measured on the 1st, 3rd, 7th and 14th days of patients’ hospital stays. The creation of the CMFT outcomes predicting method was carried out using factor analysis (principal component method) and discriminant analysis.
 Results. The CMFT outcomes predicting method has been developed in two variants. The first variant (with parameters of the blood gas test) includes the following parameters: leukocyte index of intoxication according to Ya.Ya. Kalf-Kalifu (LII), blood glucose level, concentration of potassium ions in the blood (K+), international normalized ratio, partial pressure of carbon dioxide in arterial blood, partial pressure of oxygen in arterial blood, measured on the 3rd day after injury, and also the age of the patient, evidence of cardiovascular diseases in patient’s medical history and the occurrence of cerebral edema after the injury. The second variant (without the parameters of the blood gas test) includes the following parameters: absolute number of leukocytes (on the 1st day after injury), LII, K+, blood urea level, absolute number of lymphocytes, measured on the 3rd day after injury, as well as patient’s age, evidence of cardiovascular diseases in patient’s medical history and the occurrence of cerebral edema after injury. The classification accuracy when using the first variant was 100%, the second variant – 98.4%.
 Conclusions. Taking into account the set of variables included in our study, and based on the results of this study published in the first and in this part of this article, we can conclude that the optimal time point for predicting the CMFT outcomes is the 3rd day after injury. The method for predicting the CMFT short-term outcomes developed in our study can be used in determining the timing for reconstructive surgery as part of the damage control surgery treatment of patients with this pathology.

Is Damage Control Surgery Better than Traditional Surgery in Multiple Trauma: A Meta Analysis

ABSTRACT Background: The concept of damage control surgery (DCS) has been proposed and used for many years. In this study, we investigated whether the DCS is more effective than traditional surgery (TS) for treating multiple traumas. Methods: After formulating the retrieval strategy, we searched 12 databases and two clinical trial centers. Data from eligible studies were included and extracted based on the inclusion and exclusion criteria. To analyze the results, we used the risk ratio (RR), weighted mean difference (WMD), and 95% confidence interval (95% CI). The Cochrane Collaboration tool was used to assess the risk of bias in all the included studies. RevMan (version 5.3) and Stata (version 14 and 17) were used for data analysis. Results: First, the mortality rate of DCS group was reduced (RR = 0.27, 95% CI: 0.22 to 0.34, P < 0.001), and the success rate of rescue was improved (RR = 1.36, 95% CI: 1.29 to 1.44, P < 0.001). Second, the DCS group had shorter in-hospital length of stay (WMD = −5.58, 95% CI: −6.83 to −4.32, P < 0.001) and intensive care unit (ICU) length of stay (WMD = −3.54, 95% CI: −4.57 to −2.51, P < 0.001), and significantly reduced the incidence of complications (RR = 0.36, 95% CI: 0.31 to 0.43, P < 0.001), especially disseminated intravascular coagulation (DIC) (RR = 0.27, 95% CI: 0.20 to 0.36, P < 0.001), multiple organ dysfunction syndrome (MODS) (RR = 0.44, 95% CI: 0.31 to 0.61, P < 0.001), and shock (RR = 0.38, 95% CI: 0.25 to 0.56, P < 0.001). Then, the recovery time of body temperature (WMD = −7.68, 95% CI: −9.39 to −5.97, P < 0.001), clearance time of lactic acid (WMD = −17.58, 95% CI: −21.05 to −14.12, P < 0.001), the recovery time of prothrombin time (PT) (WMD = −11.79, 95% CI: −13.67 to −9.91, P < 0.001), activated partial thromboplastin time (APTT) (WMD = −12.69, 95% CI: −14.53 to −10.85, P < 0.001) and base excess (BE) (WMD = −16.07, 95% CI: −16.58 to −15.55, P < 0.001) of DCS group decreased. Finally, the DCS group showed reduced intraoperative blood loss (WMD = −421.53, 95% CI: −494.44 to −348.62, P < 0.001), operation time (WMD = −24.65, 95% CI: −35.50 to −13.80, P = 0.007), and red blood cell transfusion volume (WMD = −5.95, 95% CI: −7.01 to −4.89, P < 0.001). Conclusion: Our research shows that for patients who have suffered multiple trauma, DCS is more efficient than TS for patients who have experienced multiple traumas. In the future, more detailed, large-scale, multicenter, randomized controlled trials are required to verify our findings.

Use of preoperative contrast-enhanced computed tomography in damage control strategy for blunt liver injury: A case report

For patients with unstable abdominal trauma unresponsive to initial transfusion, the damage control strategy includes prompt hemostasis by open surgery and packing. Recently, a hybrid treatment that combines packing and transcatheter arterial embolization as a damage control strategy was reported to be effective; however, the indications and techniques are yet to be established. A 25-year-old male patient who was in shock due to severe liver injury after a traffic accident was brought to our emergency room by emergency services. After initial resuscitation, including resuscitative endovascular balloon occlusion of the aorta and blood transfusion, preoperative contrast-enhanced computed tomography indicated grade IV liver injury with active bleeding from the right hepatic artery. Damage control strategy with packing and subsequent transcatheter arterial embolization was determined to be useful. During treatment, bile leakage was observed. An endoscopic nasobiliary drainage tube was inserted, and the patient was treated conservatively. He was discharged on day 83 of hospitalization. Although using preoperative contrast-enhanced computed tomography before damage control surgery remains controversial, it can provide useful information to determine damage control strategy, including morphological evaluation of the injured area and the presence of active bleeding.

Contemporary management of blunt colonic injuries – Experience from a level one trauma center in New Zealand

Blunt colonic injury (BCI) is relatively rare, and literature on the topic is sparse. This study reviews our contemporary experience in its management at a level-one trauma centre in New Zealand. This was a retrospective study (January 2012 to December 2020) that included all patients who sustained a BCI managed at Waikato Hospital, New Zealand. Of the total of 1181 patients with blunt abdominal trauma, 69 (6%) of them sustained a BCI (49% male, mean age: 36 years). 78 separate colonic injuries were identified in the 69 cases. The most commonly injured segment was the ascending colon 49% (38/78). Eighty percent (55/69) underwent a CT scan, with only 16 showing definite evidence of a colonic injury. AAST Grade 1 was the most common (81%). Fifteen patients underwent damage control surgery. All 11 grade 1 injuries were repaired primarily, whilst the other four grade 4 and 5 colonic injuries were resected, with 3 having a subsequent stoma formation and one delayed anastomosis. There were four mortalities. Patients who had negative or equivocal admission CT findings for colonic injury had delays to the operating theatre and had poorer outcomes. BCI is rare but is associated with a prolonged hospital stay. The treatment of BCI is similar to that of penetrating colonic injury. CT appeared inaccurate in many cases.

EXPERIENCE IN TREATMENT OF GUNSHOT WOUNDS OF LIMBS IN TRAUMATIC AMPUTATIONS DUE TO EXPLOSIVE TRAUMA

Abstract. Aim. To improve the results of surgical treatment in patients with traumatic limb amputations by developing diagnostic and treatment strategy for managing patients with soft tissue wounds of amputation stumps.
 Materials and methods. 283 wounded in-patients of Military Medical Clinical Center of the Central Region with gunshot traumatic limb amputations or their segments as a result of explosive injury were retrospectively studied during the period of February 24, 2022 to February 24, 2023.
 Results and discussion. Being admitted to the third level of medical service, surgical clinic, full-scale medical aid was provided to
 283 wounded servicemen including surgical interventions with continuous intensive therapy. If necessary, the strategy of damage control surgery was continued and extended.
 Diagnostic and treatment strategy consisted of mandatory primary examination of amputation stump in the dressing room, X-ray examination of the limb, ultrasonography and Doppler ultrasound of the extremity (stump) vessels, and spiral computer tomography. 52 patients (18.37 %) underwent emergency operations. In 231 patients (81.63 %) treatment consisted of staged repeated (secondary if indicated) debridement of amputation stump and gunshot wounds of the limbs, and placement of VAC systems using negative pressure therapy. Repeated debridement was carried out every 3-5 days, performing necrectomy and using sanitation with antiseptic solutions. Polyurethane sponges were used to fill wound defect of the stump tissue, followed by 3-4 dermatotension sutures, and then VAC bandage was formed by conventional method.
 The following early complications occurred: bleeding — in 8 (2.83 %) patients, development of tension hematomas in 7 (2.47 %) and purulent inflammation in the form of suppuration, phlegmon and abscess in 43 (15.19 %) patients, requiring a greater number of repeated and secondary surgical debridements and placement of VAC systems. Late postoperative complications were: "defective stumps" in 17 (6.01 %) patients, ligature fistulas in 11 (3.89 %), formation of osteophytes in 3 (1.06 %), neurinoma — in 2 (0.71 %) and phantom pain syndrome in 11 (3.89 %) patients.
 Conclusions. To decrease the number of complications associated with purulent inflammation in amputation stump, primary surgical intervention should be carried out in the form of radical primary surgical debridement of gunshot wound, leaving long stump with no sutures. Following clear diagnostic and treatment strategy in managing patients with wound defects of soft tissues of amputation stumps in gunshot traumatic limb amputations leads to decreased number of postoperative complications.

P-049 DAMAGE CONTROL SURGERY FOR AN INCARCERATED GIANT UMBILICAL HERNIA IN A SUPEROBESE PATIENT

Abstract Aim To report the case of the emergency management of an incarcerated giant umbilical hernia in a superobese patient with a damage control surgery as the first step for its treatment. Material & Methods We present the case of a 47-year-old man with a BMI of 62 kg/m2 who arrived to the emergency department for abdominal pain. Examination and CT scan revealed a giant umbilical incarcerated hernia with loss of domain, with an 8 cm hernia neck and containing the entire bowel except for the rectosigmoid and duodenum. Results The emergency managment was a laparotomy with a subcutaneous right lateral approach, opening first the hernia sac to verify bowel viability. Then, we performed a tranverse chelotomy on the right side of the defect, leaving the defect open and wider to prevent hernia strangulation. We left two drains in the subcutaneuos space and the wound was covered with vacuum therapy dressing. The patient recovery was uneventful and he was discharged in the sixth postoperative day. After this episode the patient started a very strict weight loss treatment, so we coul plan the final wall reconstruction surgery, which hasn't already been performed, but which will include botulinum toxin and progressive preoperative pneumoperitoneum. Conclusions We belive that damage control surgery was the most appropiate option as the first step for the management of an incarcerated complex hernia, so in a second time an elective complex wall reconstruction surgery could be performed.

OC-052 Study of incisional hernia as a result of patients with open abdomen management in a tertiary hospital

Abstract Aim Open abdomen (OA) is a useful resource in critical situations, such as damage control surgery, abdominal sepsis, or compartment syndrome. However, it is not an innocuous technique with repercussions on the abdominal wall, for this reason, we have reviewed the results in our center. Material and Methods Retrospective descriptive study was carried out in a tertiary hospital between 2015–2022, all patients who required OA therapy were included. Results 92 patients (68 men, 24 women) were operated, with a mean age of 65 years, 65.3% were ASA 3–4. The most frequently system used was negative pressure therapy (NPT) (81 patients). 45 patients were closed without need replacement and 14 died before being performed. In the rest, the first TPN change was performed in 48–72 h, requiring a mean of 3.5 changes. Of the 78 patients underwent closure, 30 received primary fascial closure, 43 associated prophylactic mesh and other 5 only skin closure due to poor short-term prognosis. 24 patients died before discharge. 5 of the 30 patients with primary fascial closure had an incisional hernia. There were no hernias in the patients treated with prophylactic mesh but there was one case of chronic rejection. Conclusions OA is a useful resource; however, it is not exempt from short and long-term complications. At the time of definitive closure, it must be taken into account that these patients present multiple risk factors for the development of incisional hernias. For this reason, the use of prophylactic meshes in a protocolized manner is justified.