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BackgroundDamage control is well established as a potentially life-saving procedure in a few selected critically injuredpatients. In these patients the “lethal triad” of hypother-mia, acidosis, and coagulopathy is presented as a viciouscycle that often cannot be interrupted and which marksthe limit of the patient’s ability to cope with the physio-logical consequences of injury.Theprinciplesofdamagecontrolhaveledtoimproved survival and to the stopping of bleeding untilthe physiologic derangement has been restored and thepatient could undergo a prolonged operation for defini-tive repair.MethodsThere are five critical decision-making stages of damagecontrol: I, patient selection and decision to performdamage control; II, operation and intraoperative reas-sessment of laparotomy; III, resuscitation in the inten-sive care unit; IV, definitive procedures after returningto the operating room; and V, abdominal wallreconstruction.ResultsAlthough morbidity remains high, it is acceptable if itcomes in exchange for improved survival. Damage con-trol surgery offers a simple effective alternative to thetraditional surgical management of complex or multipleinjuries in critically injured patients. Phases I and II canbe done at a rural hospital before transfer to a majortrauma centre for definitive repair.ConclusionsThere is a complex interplay between primary injury,particularly major abdominal injury in the multi-systemtrauma patient, and secondary injury, which relates topatient physiology, decision making and surgical techni-que. Analysis of outcomes is further confounded by thevariety of surgical techniques used. The challenge is tomatch the correct operation, for a critically injuredpatient, with the patient’s physiology. Excellence in gen-eral surgery does not equate with excellence in traumasurgery, and a clear understanding of damage control isessential.

Damage control surgery: a new “way of thinking” in the treatment of the critically injuried