There are several points in the care of injured patients where a surgeon may decide to proceed with a damage control approach. Sometimes it is obvious from the outset. The presence of hypotension, hypothermia, and acidosis on presentation are all obvious markers for abbreviated laparotomy. Following injury, any hypotension in the presence of multiple body system injuries should be a tip off that damage control approach may be warranted. Acidosis and high lactate levels on arterial blood gas analysis and the need for emergent transfusion are also indicators of deranged physiology where a damage control approach may be necessary. More insidious is the patient that “doesn’t look too bad” upon presentation but rapidly deteriorates in the operating room. It is here where ongoing discussion with anesthesia regarding the patient’s temperature, acid–base status, and need for intermittent vasopressor support should indicate that the patient’s physiology is deteriorating and a shift in mind-set to damage control is needed. Other intraoperative signs are increasing bowel edema, cold tissues, and diffuse oozing, especially in areas that were formerly hemostatic. Lastly, certain injuries by themselves or in combination with others are better served by abbreviated laparotomy. High grade liver injuries, combination of major abdominal vascular and intestinal injuries, intraabdominal injuries in the setting of a massive pelvic fracture are among those frequently discussed in the literature as indications for damage control procedures.

There are times when the source of hemorrhage is not straightforward. In patients with penetrating thoracoabdominal wounds, the source of hemorrhage may be in the chest, the abdomen, or both cavities. In addition, massive bleeding from the chest could actually be coming from an intraabdominal source when the diaphragm is lacerated. Making that assessment early with chest radiography and cardiac ultrasound will help in operative planning. Patients with blunt trauma and hemoperitoneum who have an associated pelvic fracture may have substantial retroperitoneal hemorrhage in addition to intraabdominal bleeding. This particular group of patients will be discussed in the following sections.

Damage control laparotomy begins with rapid access and wide exposure followed by control of bleeding and contamination in that order. Rapid control of hemorrhage followed by resuscitation with blood, plasma, and platelets in a 1:1:1 ratio is designed to prevent the lethal triad of hypothermia, acidosis, and coagulopathy. Again, constant communication with your anesthesia colleagues is of paramount importance. One needs to be aware of not only patient’s vital signs that you can see on the monitor but also of other physiological parameters such as temperature, base deficit, blood transfusion requirements, and need for vasopressor and ionotropic support.

The patient needs to be prepped and draped from neck to the knees. Enter peritoneal cavity through midline incision from xyphoid to pubis using a scalpel or curved mayo scissors. Large volumes of blood coming from the peritoneal cavity render the electrocautery useless in this circumstance. We preferentially go around the umbilicus on the left as it avoids having to take down the falciform ligament. We also advocate opening the skin, subcutaneous tissue, and fascia widely prior to entering the peritoneal cavity as the rapid egress of blood through a small hole in the peritoneum can obscure vision and opening the remaining incision difficult. The peritoneal cavity can be ideally accessed just superior to umbilicus where peritoneum is the thinnest. Once inside, incise the remaining peritoneum taking down the preperitoneal fat along the left side with scissors taking care to avoid injuring underlying intestines, left lobe of the liver, and transverse colon superiorly and bladder inferiorly.

Four quadrant packing is the first step in damage control laparotomy. This requires that the scrub team should have 20–30 large laparotomy pads opened and ready to go. They should be handed to surgeon completely open as time is truly of the essence. Prior to packing blood and clot must be scooped from the peritoneal cavity. Suction is NOT useful in this circumstance. Clots and liquid blood should be removed manually and with the aid of lap pads. There is also no time to worry about neatness or the mess you are making on the field or the floor. The scrub team should provide the surgeon with a large basin to aid with removal of blood and clots but this is not an absolute either. Once the clots are removed you are ready to pack. At this point one may get an idea of which quadrants are bleeding. The left upper quadrant is packed from the right side with the assistant pulling up in the abdominal wall. The spleen should be palpated and 3–5 laparotomy pads will fit into the space. Conversely, the liver and right upper quadrant is best packed from the left by placing several pads above the liver. Liver is then pressed against the packs and diaphragm and the subhepatic space packed cephalad. Again the liver should be palpated and the identification of any liver injuries made at that time. One has to be careful not to compress the inferior vena cava (IVC) when packing the liver and right upper quadrant. Again, communication with anesthesia is the key here. The lower quadrants are packed by grasping the omentum and transverse colon cephalad and eviscerating the small intestine up and to the patient’s right. Identification of a zone III hematoma in the face of a pelvic fracture can be made at this time. Lap pads are placed into the pouch of Douglas and along each gutter. With small intestine out of the way, packing is much more effective as it is almost impossible to pack the lower quadrants with the small bowel in place. Eviscerating the small bowel also allows the identification and clamping of any mesenteric vascular injuries. Careful and systematic packing works to arrest, at least temporarily, venous and most lower volume arterial bleeding, but it is unlikely to arrest substantial arterial hemorrhage from named vessels. Nonetheless it cleans the field and temporizes the situation. It also allows anesthesia to resuscitate the patient and the surgeon to call for any needed equipment and catch their breath so that the abdomen can be fully explored in a more organized way. Setting up a self-retaining retractor system can be extremely helpful when extra assistance is not available. While it may take several minutes to set up, it will likely result in less hemorrhage down the line, provide far better exposure, and is well worth the setup time.