Damage control surgery in neonates: Lessons learned from the battlefield.

INTRODUCTION

Mortality for neonates requiring surgery for serious pathology such as NEC, remains high. Damage control surgery (DCS) has evolved as an operative strategy in battlefield trauma that sacrifices the completeness of the initial surgery to address the deadly triad of acidosis, hypothermia and coagulopathy. This approach is now used routinely in sick adults with nontrauma surgical emergencies. Here we describe our experience of using DCS in neonates.

METHOD: Neonates undergoing DCS at our hospital from 1/8/2010 to 30/11/17 had data collected prospectively.

RESULTS

27 neonates (median age 21 days; gestation 29 weeks; weight 1200 g; M:F 18:9) underwent DCS. Diagnosis (NEC 23, volvulus 2, meconium peritonitis 1, spontaneous perforation 1). Preoperative physiology: median temperature 35.5 °C, lactate 3.7, Activated prothrombin time 49; on a median of 1 inotrope (range 0 to 4); 19 had surgery on the intensive care unit. Surgery involved resection of dead bowel with the ends ligated and the abdomen left open. Operation took 38 min (26-80 min) and crew-resource management techniques were used to optimize efficiency. Second look occurred at 48 h (24-108 h) when the physiology had normalized. There were a total of 32 anastomoses in 18 patients with one leak; 3 patients had stomas for distal rectal disease. Overall mortality was 15% (4/27) or 18% in the NEC group (4/23).

CONCLUSION

Though techniques such as "clip and drop" exist, they have not been routinely incorporated into an operative strategy for sick neonates based on physiological derangement. The two benefits from our DCS approach were a low mortality and an avoidance of stomas. This approach deserves more investigation to see whether it is as effective in babies and children with nontrauma associated abdominal catastrophes as it is in adults.

TYPE OF STUDY: Case controlled study.

LEVEL OF EVIDENCE: Level III.