Because sometimes the victory isn’t closing, it’s coming back tomorrow.
Start With the Truth
Definitive surgery is a luxury.
Damage control is survival.
By the time you reach for DCL, the body is already trying to die, acidosis, hypothermia, coagulopathy, hyperkalaemia, hypocalcaemia creeping in like a tide you can’t stop with sutures.
DCL is not an operation.
It’s a strategy, buying physiology enough time to stop falling apart.
The smartest surgeons know when to stop.
Indications: When the Body Tells You “Enough”
If the patient has:
- pH < 7.2
- Core temperature < 35°C
- Base deficit > 6
- Lactate > 4
- INR > 1.5
- On the table hypotension despite transfusion
…you’re now in damage control territory.
Not heroics. Not elegance.
Just bleeding control + contamination control + exit.
Step-by-Step (The Actual Doing It)
Here’s how I run a DCL, swiftly and without self-indulgence:
1. Massive laparotomy → quick exposure
- Long midline incision, xiphoid to pubis if needed
- Scoop clot, evacuate chaos
- Packs to all four quadrants while anaesthesia catches up
Time: <60–90 seconds
2. Identify the killer bleed
Aorta? Liver? Pelvis?
Find it. Control it.
Control options, pick one fast:
- Packing (liver or retroperitoneum)
- Stapled resection (shredded bowel)
- Pringle manoeuvre
- Pelvic packing
- Clamp or suture major vessels only if visible without adventure
- REBOA or aortic clamp if necessary
Rule: If you can’t see it in 60 seconds, pack it and move on.
3. Control contamination
If the bowel is spilling:
- Staple and exteriorise ends
- No fancy anastomoses
- No long dissections
- No pretty sutures
If stomach or duodenum?
- Close holes only if fast
- Patch or drain + come back later
If the biliary tree leaking?
- Drain, don’t rebuild
Damage control = simple control
4. Strategic drains
Put a drain only where needed for leaked bile or pancreas insult.
Don’t scatter them like confetti.
5. Temporary closure, get out clean
Methods:
- Bogota bag
- VAC dressing
- Opsite silo
- Any temporary closure that:
Prevents bowel drying
Allows re-entry
Avoids compartment syndrome
Time from incision to exit:
→ Aim for 20–40 minutes
If longer, you’re drifting away from damage control and toward disaster.
What You DO NOT Do
✘ No anastomoses in dying patients
✘ No major reconstructions
✘ No lengthy mobilisation
✘ No “one more thing”
✘ No pride
If you catch yourself saying:
“Just let me fix this one last thing…”
You are the complication.
ICU Resuscitation: The Second Operation
The real repairs happen here:
- Warm the patient
- Balanced transfusion or fresh whole blood
- Calcium, fibrinogen, platelets
- Reverse coagulopathy
- Correct acidosis
- Fix ventilation and perfusion
- Replete volume, but never ignore IAP
- Ongoing monitoring for abdominal compartment syndrome
Goal:
Return when:
pH > 7.30
Temp > 36°C
Lactate trending down
Pressor support tapering
The Planned Return: 24–48 Hours Later
You open again to:
- Remove packs
- Confirm haemostasis
- Perform anastomoses
- Close fascia only if safe
If still unstable → repack → live to fight day three.
Damage control is a series, not a single act.
The Mental Shift
This isn’t “giving up.”
It’s prioritising survival over pride.
You don’t win by finishing the operation.
You win by finishing the patient alive.
And From the Other Side of the Drapes…
They won’t know about the packs or the clamp or the rush to temporary closure.
They’ll never remember that you chose to stop, and that choice saved them.
But someone will.
A mother. A child. A partner.
Someone whose entire world stayed intact because you walked away at the right time, so you could come back tomorrow.
