Salvage Surgery.

ABSTRACT: Salvage surgery is an essential method in the armamentarium of the surgeon caring for the severely injured patient. The patient in unstable condition with multiple abdominal injuries is a challenge, even to the most experienced trauma surgeon. The first priority should be to control major vascular injuries and other sources of bleeding that are immediately life-threatening. Often after massive blood loss, the deadly triad of hypothermia, acidosis, and coagulopathy is present. Additional time in the operating room often worsens these physiologic parameters and patient outcome. Once surgically correctable bleeding has been addressed, such patients are best served by cessation of the operation, packing of the abdomen, and transfer to the intensive care unit. Resuscitative steps should then be taken. Once the physiologic derangement has been corrected, the patient can undergo definitive operative procedures.

SALVAGE SURGERY is not a new concept. It was reported as early as World War II in the management of severe liver injuries. It has evolved into a common approach to deal with the multiply injured patients frequendy seen in trauma centers today. Improved trauma systems, resuscitative strategies, and operative improvements have allowed these patients to survive long enough to have physiologic derangements considered fatal in the past. The most common metabolic problem seen is the triad of hypothermia, acidosis, and coagulopathy. It is critical that the surgeon recognize this fatal combination and initiate aggressive resuscitative efforts. We describe a patient with multiple injuries who had an abbreviated celiotomy with repair of vascular injuries and packing of other injuries. In this case, hypothermia, acidosis, and coagulopathy developed. The procedure was terminated, and the patient was taken to the surgical intensive care unit (SICU), where resuscitation was continued.

CASE REPORT

A 22-year-old man had a single gunshot wound to the back with no exit. The patient was combative, and initial vital signs in the field were systolic blood pressure 70 mm Hg, pulse rate 116/min, and respiratory rate 28/min. The patient was taken directly to the level I trauma center, where his condition remained unstable. On primary survey, the patient's airway was maintained and breath sounds were clear to auscultation bilaterally; no pulses were palpable peripherally, but there was a palpable carotid pulse. Two 16-gauge intravenous catheters were inserted at this time in the antecubital fossa. The patient's Glasgow Coma Scale score was 15.

On secondary survey, the patient had no injuries to the head or neck and had symmetrical chest expansion with clear breath sounds. The abdomen was firm with no audible bowel sounds, and rectal tone was poor; stool was positive for occult blood. There was a 1.5 cm entrance wound in the right sacroiliac region, with an extruding bone fragment. The patient was unable to move the right lower extremity. He was initially given 2 L lactated Ringer's solution and 1 unit of O-negative blood via a pressure bag. A plain abdominal film was obtained in the resuscitation room, showing destruction of the right sacroiliac joint with scattering of metallic debris upward throughout the abdomen (Figure).

The patient was taken immediately to the operating room (OR) for an exploratory laparotomy. The right colon was mobilized, revealing an inferior vena cava injury, which was compressed. The aorta was cross-clamped, then the two injuries to the inferior vena cava were repaired with 4-0 polypropylene (Prolene). Dissection of the iliac vessels showed no evidence of injury. An injury to the dome of the gallbladder was treated with hemicholecystectomy. A liver injury with minimal bleeding was packed with fibrillar absorbable hemostat. A through-and-through duodenum injury was closed in one layer. A defect in the right sacral brim with brisk venous bleeding was packed with laparotomy pads, as was the right side of the abdomen. The skin was closed with a No. 2 nylon running suture, and the patient was taken to the (SICU) for resuscitation.

During the operation, there was noticeable oozing from venous puncture sites and most wounds. The patient lost a total of 5,800 mL of blood and received 12 units of packed red blood cells, 4 units of fresh frozen plasma (FFP), and 1,150 mL red cell fraction blood products from the plasma separator. The patient's temperature was 34.9[Degrees]C, and a coagulation profile showed a prothrombin time (PT) of 23.4 seconds, partial thromboplastin time (PTT) of 161.9 seconds, and an international normalized ratio of 4.1. Arterial blood gas measurements showed the following values: pH 7.275, [PCO.sub.2] 44 mm Hg, [PO.sub.2] 284 mm Hg, and [HCO.sub.3] 20 mEq/L. At this point, it was decided to pack the wounds and return the patient to the SICU. In the SICU, the coagulopathy was corrected with FFP, hypothermia was corrected with warmed fluids and a heating blanket, and acidosis was corrected with vigorous fluid resuscitation.

The patient was taken again to the OR the next day. At that time, it was found that a 20-cm segment of right ureter was destroyed, and a nephrostomy tube was inserted. The duodenal injury was reinforced with an omentum patch, and completion of the cholecystectomy and a cholangiogram were done. Gastrostomy tube and feeding jejunostomy were inserted, and wounds were packed. The patient was subsequently returned to surgery several times for washout and repacking. As of this writing, the patient remained in critical condition in the SICU. As an interesting aside, this patient had a bullet embolism to the pulmonary vasculature within 8 hours of injury with no apparent sequelae.

DISCUSSION

Salvage surgery evolved from the realization that the critically injured patient, with severe metabolic abnormalities from life-threatening hemorrhage, is a poor candidate for definitive repair at the time of initial operation. This was presented by Stone et al, who introduced the concept of "bailing out" of a laparotomy in coagulopathic trauma patients. Over the past 15 years, this idea has been refined to yield a methodical three-step approach to salvage surgery. [2] The first step is the initial laparotomy. In this step, four-quadrant packing is done initially with subsequent unpacking, first defining major abdominal vascular injuries, then solid organ injuries, and finally controlling spillage of intestinal content. The major vascular injuries have been approached by many methods, including packing, ligation, clamps, and balloon catheter tamponade.

After the hemorrhage has been controlled temporarily, simple repairs that do not consume a great amount of time may be made. For more complex injuries that require much time to repair definitively, temporary vascular shunts may be used. These same ideas apply to solid organ injuries. This almost always means splenectomy for the bleeding spleen and, in the case of the liver, the briefest maneuver to gain control of hemorrhage. This may entail suture ligation of an individual bleeding vessel, packing with a hemostatic dressing, large parenchymal mattress stitches, or packing. Hollow viscus injuries may be addressed rapidly with stapling devices, ligation, or simple running suture techniques. After both hemorrhage and spillage have been controlled, the procedure is terminated, and the abdomen is rapidly closed.

Certain intraoperative criteria indicate that salvage surgery should be instituted. These include initial body temperature less than 35[Degrees]C initial pH of less than 7.2 with a base deficit of less than 15 mmol/L in patients younger than 55 years of age or less than -6 mmol/L in patients older than 55 years, serum lactate greater than 5 mmol/L, and PT and/or PTT greater than 50% of normal. [3]

The second phase of salvage surgery is the secondary resuscitation. Correcting the metabolic abnormalities of massive hemorrhage is the main order of business at this point. An effort should be made to maximize hemodynamics, restore oxygen delivery, and reverse lactic acidosis. This is done with vigorous hydration with lactated Ringer's solution and blood if needed. Several parameters are used to follow the correction of acidosis. These are cardiac index, base deficit, lactate levels, oxygen delivery, and oxygen consumption. Reversing and preventing further hypothermia is also important in this phase. Maneuvers to achieve this include infusing crystalloid solution and blood through a warming device, covering the patient's head with a turban or warming device, covering body parts out of the operative field with a warming device, irrigating nasogastric and thoracostomy tubes with warm saline during laparotomy, and irrigating the open pericardial, pleural, or peritoneal cavity during sternotomy, thoracotomy, or laparotomy. [3] Other techniques are currently being used to rewarm hypothermic patients, such as continuous arteriovenous rewarming [4] and standard cardiopulmonary bypass, but these methods are not always available. Finally, coagulopathy is treated aggressively with infusion of FFP and platelets until PT and PTT values are within normal limits. Coagulopathy will also be improved by correcting hypothermia.

There are two indications to return to surgery in this critical second phase. [2] First, patents with normal temperature and coagulation profile who have ongoing transfusion requirements or who have other evidence of ongoing hemorrhage should be reexplored. In this group, complete surgical control of bleeding has not been obtained at initial laparotomy. Second, patients in whom abdominal compartment syndrome develops should have immediate decompression of the abdomen. This is heralded by decreasing urine output, increased peak inspiratory pressures, and a high bladder pressure. There are several open-abdomen techniques to deal with this problem.

Stage three of salvage control is the definitive operation. Once the patient's metabolic problems are corrected, he may be returned to the OR for removal of packing and completion of definitive surgical procedures. Important in this stage is a thorough search for intra-abdominal injuries that may have been missed during the initial laparotomy. Definitive vascular repairs, more intricate procedures on the gastrointestinal and genitourinary tracts, and procedures for long-term access to the gastrointestinal tract can now be done. When all of these injuries have been addressed, the abdominal wall can be evaluated for the possibility of primary closure.

In summary, the most important aspect of salvage surgery is to recognize which patients need this approach and institute it as early as possible. Initial laparotomy should be as brief as possible, but it should control hemorrhage and spillage from the gastrointestinal tract. Resuscitation in the SICU should be directed toward correcting hypothermia, acidosis, and coagulopathy. Definitive operative procedures should be performed when the patient's metabolic state has been corrected.

From the Trauma Program, Charity Hospital in New Orleans, and the Department of Surgery, Louisiana State University Health Sciences Center, New Orleans.

References

(1.) Stone H, Strom P, Mullins R: Management of major coagulopathy with onset during laparotomy. Ann Surg 1983; 197:532-535

(2.) Rotondo M, Zonies D: The damage control sequence of an underlying logic. Surg Clin North Am 1997; 77:761-779

(3.) Feliciano D, Moore E, Mattox K: Trauma damage control. Trauma. Moore E, Mattox K, Feliciano D (eds). Norwalk, Appleton & Lange, 3rd Ed, 1999

(4.) Eddy V, Morris J, Cullinane D: Hypothermia, coagulopathy, and acidosis. Surg Clin North Am 2000; 80:845-854