Discussion
The original indications for ‘damage control’ approaches in abdominal trauma include hypothermia <35°C, a metabolic acidosis with a pH <7.2 or a base deficit <−15, and/or a coagulopathy with an international normalized ratio or partial thromboplastin time >50% of normal reflected intraoperative concerns about ‘physiologic exhaustion’.1–4 The number of indications has increased substantially since then, and the technique is now one of the most overused in the field of abdominal trauma.5 6 The patient described, however, with a history of significant preoperative blood loss, profound hypotension at admission, the presence of combined abdominal vascular injuries, and other intra-abdominal visceral injuries would fit everyone’s indication for ‘needs damage control’.
The operative approach to patients with vascular injuries posterior or adjacent to the inguinal ligament has been discussed in a previous ‘Case of the Month’ in Trauma Surgery and Acute Care Open.7 Using a midline abdominal incision to obtain intra-abdominal retroperitoneal control of the external iliac vessels and a separate longitudinal groin incision to obtain control of the common femoral vessels ‘saves’ the overlying inguinal ligament. The inguinal ligament will then be another layer of coverage over any vascular repair, graft, or ligation in the retroperitoneum and should help protect any of these from a postoperative infection in superficial soft tissue of the groin.
In the modern era, many surgeons would have inserted temporary intraluminal shunts into the external iliac artery or both artery and vein in light of the patient’s profound hypotension and combined major vascular injuries. It is important to recognize, however, that the larger shunts needed to fit the common or external iliac artery may not be available in every operating room (Pruitt F3 Outlying and Inlying Carotid Shunts with T-Ports, 10F, LeMaitre, Burlington, Massachusetts; Bard Burbank Carotid Bypass Shunt, 18 F tapered to 12 F, and Bard Javid Carotid Bypass Shunt, 17 Fr tapered to 10 F, Bard Peripheral Vascular, Tempe, Arizona). In such a circumstance, large-bore intravenous tubing or an appropriately sized thoracostomy tube may be used as a shunt.
Short-term and long-term data document that ligation of an injured external iliac vein is generally well tolerated in young and otherwise healthy trauma patients.8 Important principles of management after this ligation include the following: (1) elevation of the entire ipsilateral lower extremity when the patient is supine or sitting (unless compartment syndromes are impending); (2) elastic wraps whenever the patient is sitting or standing if any postoperative edema is present; and (3) a vigorous walking program once the patient has recovered from a laparotomy.
The disadvantages of ligation of the external iliac vein (and common iliac vein and inferior vena cava) were well demonstrated in the patient described. First, there was severe intraoperative bleeding from every pelvic venous collateral, including those around the injured bladder, that mandated extensive suture ligation. Second, the patient needed both a four-compartment fasciotomy of the leg during the first operation and a three-compartment fasciotomy of the thigh in the postoperative period. While the need for thigh fasciotomy is uncommon in injured patients, a compartment pressure exceeding capillary pressure (30–35 mm Hg) which is likely to be prolonged should always prompt consideration for performing the procedure. This is particularly true when diffuse swelling is due to ischemia/reperfusion or venous ligation rather than an isolated fracture. And, third, the patient developed early postoperative and chronic edema of the left lower extremity.
The choice of a substitute vascular conduit in wounds of the common iliac, external iliac, or common femoral artery at a first operation or after removal of a temporary intraluminal shunt at a reoperation depends on hemodynamic status, presence of associated gastrointestinal injuries, and, often, the size of the contralateral greater saphenous vein. Replacement of these vessels requires an 8–10 mm conduit, and the greater saphenous vein will usually not dilate to this size after retrieval. In the patient described, as in all critically injured patients in the author’s experience, creating a spiral vein or panel vein graft (a 45-minute endeavor) has no appeal. Without an associated gastrointestinal injury, a ringed PTFE graft of appropriate size was chosen for arterial replacement under the inguinal ligament. Mandatory precautions to avoid infections and maintain patency in synthetic conduits after vascular trauma include the following: (1) complete coverage of the prosthesis with well-vascularized tissue; (2) administration of perioperative antibiotics; (3) early administration of rectal or oral daily aspirin 81 mg/day; (4) cessation of smoking; (5) avoid sitting for long periods when the prosthesis crosses the hip or knee joint; and (6) a vigorous walking program after recovery from operation.
Ever since the admonition against the use of ‘prosthetic material’ in military vascular wounds in Vietnam by Norman Rich and the late Carl Hughes in 1972, there has been a reluctance during subsequent military conflicts to counter this advice.9 A novel approach to overcome this concern, however, has been reported from the experience in Iraq and Afghanistan.10 In patients with vascular trauma in an extremity and in whom there were ‘limited noninjured vein conduits’, PTFE grafts were inserted as a temporary solution to maintaining arterial flow. This allowed for ‘patient stabilization, transport to a higher echelon of care’, and later elective revascularization (PTFE graft removed) ‘with remaining limited autologous vein’.