E2503. Damage Control Surgery: Critical Findings and Clinical Implications
  1. Bryce Beutler; University of Southern California, Keck School of Medicine
  2. Arthur Baghdanian; University of Southern California, Keck School of Medicine
  3. Armonde Baghdanian; University of Southern California, Keck School of Medicine
Our educational exhibit focuses on patients underdoing damage control surgery (DCS). DCS is a limited exploratory laparotomy that is performed in unstable trauma patients who, without immediate intervention, would acutely decompensate. Patients usually present with shock physiology and metabolic derangements including acidosis, hypothermia, and coagulopathy. Delayed medical correction leads to irreversible coagulopathic hemorrhagic shock and inevitable patient demise. Therefore, once a patient meets DCS criteria, a limited exploratory laparotomy is performed to stabilize life-threatening injuries and expedite initiation of medical resuscitation in the intensive care unit (ICU). The surgeon plans to return to the operating room for definitive surgical treatment once the patient is stabilized and metabolic derangements have been corrected. MDCT is performed before transport of the patient to the ICU to assess for injuries in unexplored areas, stability of surgical repairs, presence of foreign bodies, unknown fractures, and the presence of intracranial or spinal injury. MDCT may also be performed during ICU resuscitation if a patient fails to respond to medical management.

Educational Goals / Teaching Points
Explain the indications for DCS and the surgical techniques and processes involved. Discuss how to optimize CT protocols in DCS patients to increase the sensitivity of detecting acute findings. Describe the characteristic appearances on MDCT of DCS patients which includes open abdomens, retained surgical equipment, and incomplete surgeries. Illustrate with case examples: pitfall sites for injury in areas not explored at surgery, areas at high risk for injury, and failed surgical repairs.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
DCS patients are in hypovolemic shock and present in a state of hypoperfusion. They also present from surgery with an open abdomen that frequently contains intraabdominal packing material. Patients often present with ligated ends of bowel in discontinuity or viscus removal due to high grade injury. The MDCT imaging technique must be tailored to each patient based on the source of injury, surgeries performed, and areas where there is concern for persistent injury. Radiologists also need to be aware of the pitfalls of diagnosing bowel injury as the commonly seen secondary signs of bowel injury such as free air, bowel wall thickening, and inflammatory stranding are already present in postsurgical patients presenting with shock physiology. Therefore, the use of oral and rectal contrast will be discussed on a case-by-case basis.

Severely traumatized patients are prone to life-threatening metabolic derangements and may meet criteria to undergo DCS. It is crucial that radiologists be able to identify expected post-DCS findings and diagnose unknown injuries and complications after DCS. In addition, oral and rectal contrast is essential to detect gastrointestinal tract injuries, given that the secondary signs of bowel injury lack sensitivity in the post-DCS patient. An understanding of the DCS process will aid radiologists in making diagnoses of unknown injuries or failed surgical repairs.