Managing uncontrolled bleeding in elective surgery: The role of damage control techniques

The main text introduction expands on the initial introduction by providing a more detailed discussion of massive bleeding in elective surgeries and its challenges. It describes how traditional hemostatic procedures are essential but may not always be sufficient, especially in uncontrolled coagulopathy despite aggressive transfusion. It then introduces DCS as a well-established approach in trauma surgery, emphasizing its role in stabilizing patients with hemorrhagic shock, coagulopathy, hypothermia, and acidosis. It highlights that DCS can be a lifesaving intervention when unexpected massive bleeding occurs and justifies its use in patients with unstable vital signs or increased intra-abdominal pressure by our two experienced cases presentation.

A 76-year-old obese male diagnosed with advanced transverse colon cancer with regional balky lymph node metastasis was identified at the root of the regional colic vein trunk. A robotic surgical approach was changed to open laparotomy because of bleeding tendency due to fatty mesentery. During the balky node dissection, the root of the vein was injured and induced massive bleeding during the compressive hemostatic procedure. As the hypotensive control rapidly became quite tricky, DCS by gauze packing and covered by the commercial dressing kit with open abdominal management (OAM). The second look operation, by supporting the Restrictive Endovascular Balloon Occlusion of the Aorta, repaired the superior mesenteric vein's injured parts. He survived for nine months.

The 72-year-old male patient was diagnosed as solitary 3 cm of hepatocellular carcinoma at S6 with alcoholic liver cirrhosis. The laparoscopic limited hepatic resection was changed to the open laparotomy due to the bleeding tendency at the transected parenchyma. After accomplishing limited resection, massive hepatic venous bleeding occurred; DCS was decided due to continuing hypotension, oozed hemorrhage, and low platelet level with metabolic acidosis by peri-hepatic gauze packing around the right liver. The second look operation for remnant hemostasis and the de-packing with abdominal closure could be achieved without severe events. The postoperative course showed no hepatic failure, and they recovered during a hospital stay.

It describes how conventional hemostatic procedures are essential but may not always be sufficient, especially in uncontrolled coagulopathy despite aggressive transfusion. DCS is a well-established approach in trauma surgery, emphasizing its role in stabilizing patients with hemorrhagic shock, coagulopathy, hypothermia, and acidosis. The role of DCS is well known even in elective surgery in unforeseen emergency situations such as hemodynamic instability, severe coagulopathy, and prolonged surgery over 24 h. It highlights that DCS can be a lifesaving intervention when unexpected massive bleeding occurs and justifies its use in patients with unstable vital signs or increased intra-abdominal pressure, where prolonged surgery is not feasible. It reinforces that DCS was successfully utilized in the reported cases, leading to favorable second-look operations.

The main text introduction is a more comprehensive and structured expansion of the initial introduction. While the initial version introduces the problem concisely, the revised introduction elaborates on the challenges of massive bleeding, the principles of DCS, and its potential role in elective surgeries before transitioning into the case reports.