Damage Control Phase III: Repair of All Injuries, General Surgery

The primary goals of the third phase of damage control surgery (DC III) are to achieve definitive repair of organ injuries and to close the fascia over surgical wounds where possible. Although the optimal timing is variable and dependent on numerous patient factors, DC III is typically undertaken 24–36 h after the initial surgery. This time is needed for appropriate resuscitation, allowing the patient to reestablish proper homeostasis. The patient will thereby tolerate the longer operative time and more extensive intervention(s) that may be necessary to definitively repair the injuries sustained. Specifically, the decision to proceed with DC III should not be undertaken until the patient’s coagulopathy has been corrected and he/she is normothermic and has a normal acid-base balance. Additional considerations such as vasopressor requirements also impact on the timing and probability of success of DC III. Ideally, patients should be weaned off of vasopressors entirely or, at a minimum, their pressor requirements should be decreasing. Ongoing physiologic instability or hypothermia despite appropriate medical therapy should raise concern for a missed injury. Definitive repair should be delayed but early operative re-exploration to evaluate for missed injury may be warranted. On-demand repeat laparotomy in these cases can decrease patient mortality [1].