The use of surgical damage control tactics in the treatment of severely wounded with combat abdominal trauma in modern warfare

Objective. To analyse the results of the implementation of surgical damage control tactics in the treatment of severely wounded patients with combat abdominal trauma in an intense military conflict in terms of reducing the incidence of complications and mortality. Materials and methods. The results of treatment of 259 severely wounded with combat abdominal trauma, who underwent surgical control of injuries, were analysed. All the wounded were men, their average age was (32 ± 3.2) years. General clinical parameters, markers of sepsis and coagulogram, electrolyte and alkaline–base blood composition were determined for all wounded. Ultrasound examination of the chest and abdominal cavities was performed according to the FAST protocol, multislice computed tomography and radiographic examination of the head, chest and abdominal cavities, pelvis, electrocardiography and thromboelastography were performed as indicated. The criteria used to determine the use of surgical control of injuries were as follows: level of consciousness (stunning, sopor, coma), body temperature less than 35 °C, Algover shock index greater than 1.0, blood saturation less than 85%, positive abdominal ultrasound according to the FAST protocol. In accordance with the tactics of surgical control of injuries, the scope of "reduced" laparotomy (first stage) in severely injured combat abdominal trauma patients included bleeding control, control of intestinal contamination and temporary wound closure, the second stage included haemostatic resuscitation, correction of acidosis, hypothermia and coagulopathy, and the third stage included preparation for final reconstructive surgery. Results. Among 259 severely injured patients with combat abdominal trauma, 26 (10.0%) were delivered in a critical state of clinical death, and underwent left–sided resuscitative thoracotomy with temporary clamping of the descending aorta and direct heart massage as the first stage of treatment in the antishock ward of the emergency department. In 12 (46.2%) patients, after effective resuscitation with the restoration of cardiac activity, a midline laparotomy with resuscitative abdominal polytamping was performed. The average time to evacuate the victim from the moment of injury was (32 ± 4) minutes. In the diagnostic department, the wounded were examined and referred to the operating department. The average time from delivery to the stage of care to surgical intervention was (25 ± 5) minutes. In 92% of patients, a total midline laparotomy was used for abdominal access, which allowed for a quick examination of all parts of the abdominal cavity and pelvis. The use of modern coagulators in the "cutting" and spray coagulation modes ensured both bloodless and fast surgical access without wasting time to stop bleeding from the surgical wound. A total of 691 abdominal injuries were diagnosed in the study patients. The first stage of surgical control of injuries was completed by temporary closure of the abdominal access, which took (85 ± 2.2) minutes. Achievement of sufficient physiological parameters allowed the interval between the first and second stages to be minimised to 24–36 hours. The third stage on average lasted (92 ± 3.2) min. Complications developed in 16.3% of severely wounded with combat abdominal trauma. The postoperative mortality rate was 10.4%. Conclusions. The use of surgical control of injuries in severely wounded with combat abdominal trauma at levels of medical care that are as close as possible to the focus of sanitary losses, subject to clearly defined indications for staged treatment and its scope, can reduce the incidence of postoperative complications to 16.3% and mortality to 10.4% (for this category of wounded, the literature reports an average mortality rate of 31% and complication rate of 39–43%).

Gunshot wounds of the abdomen have been an urgent problem of military field surgery for many decades.In the context of the Anti-Terrorist Operation/Joint Forces Operation, gunshot wounds of the abdomen accounted for 1.9 to 9.8% of the total number of combat injuries [1,2].
They differ in severity, are always accompanied by bleeding and the development of shock, and the outcome of treat-ment directly depends on the timing of the surgical intervention and the implementation of anti-shock therapy.
The change in the paradigm of warfare has also changed the structure of injuries.Whereas in positional combat operations using light artillery and handguns, the proportion of seriously wounded and critically injured was 25%, today, in the context of a "dynamic" front and the widespread use The Ukrainian Journal of Clinical Surgery of heavy rocket and artillery weapons and unmanned aerial vehicles, the proportion of wounded in extremely serious condition is 70%, and in serious condition -3% [3].
Severe injuries deplete the adaptive reserve, which leads to a significant complication rate that ranges from 39 to 43% [2].
It should be noted that the mortality rate for severe injuries caused by the use of handguns and light artillery in positional warfare is also quite high, reaching 31% [4,5].
Therefore, the issue of tactics for providing care to this category of wounded is relevant.The introduction of surgical damage control tactics (SDCT) is a well-known world practice, characterised by a greater focus on the patient's physiological reserve than on the anatomy of the injury, and aims to treat abdominal trauma in accordance with the physiological tolerance of the victim [6-9].
Russia's large-scale invasion of Ukraine has become the largest military conflict in Europe since World War II, and in terms of the volume and methods of use of military equipment and the intensity of hostilities, it has no equal in the world since the end of the military conflict in East Asia (1965)(1966)(1967)(1968)(1969)(1970)(1971)(1972)(1973).Therefore, the use of the TC-CU in the context of a large-scale invasion and intense military conflict requires preliminary analysis and understanding.
The aim of the study is to analyse the results of the introduction of TCM in the treatment of severely wounded patients with combat abdominal trauma in the context of intense military conflict in terms of reducing the incidence of complications and mortality.

Materials and methods
The article analyses the results of treatment of 259 severely wounded with combat abdominal trauma at the stages of medical care, in which THA was applied.All the wounded were men, their average age was (32 ± 3.2) years.The criteria for the use of THA were as follows: level of consciousness (stunning, soporas, coma), body temperature less than 35 °C, Algover's shock index greater than 1.0, blood saturation less than 85%, positive abdominal ultrasound (US) according to the FAST (Focused Assessment with Sonography in Trauma) protocol.
General clinical laboratory tests were performed on the Respons 920 (Germany) and Lab Analyt (China), HumaClot Duo Plus (Germany), Labline 40 and Sunrise (Austria) with additional BIORAD and BIOSAN equipment.Blood group and Rh factor were determined using standard sera.To control the assessment of the haemostatic system, thromboelastography was performed using a CPS11UM-IE(AA) device (Germany).
Blood electrolytes and alkaline-base composition and blood gases were determined using E-lyte Plus Electrolyte Analyzer Type C (USA) and GEM Premier 3500 (USA).
Ultrasonography of the chest (OGP) and abdominal (OB) cavities according to the FAST protocol was performed using the SONOSITE MICROMAXX, 2017.
Multislice computed tomography (MSCT) of the head, TBI and PFO, and pelvis was performed on a Toshiba Activion 16 with a tomographic step of 0.5 mm.Radiographic examinations of the head, OGP and PFO were performed using the radiographic diagnostic complex KRD-50 "INDIASCOP-01" (Ukraine), electrocardiography -on the electrocardiograph HAI REOK (Ukraine).
According to the TCCU, in severely wounded combat casualties with abdominal trauma, the scope of "abbreviated" laparotomy (first stage) included bleeding control, control of intestinal contamination and temporary wound closure, the second stage included haemostatic resuscitation, correction of acidosis, hypothermia and coagulopathy, and the third stage included preparation for final reconstructive surgery.

Results
The evacuation of the wounded to the secondary (specialised) medical care stage was provided by crews of combat medics from the medical service of military units or the forces of the emergency medical care and disaster medicine centre, providing assistance in accordance with the Advanced Trauma Life Support (ATLS) protocols.The average time to evacuate a casualty from the moment of injury was (32 ± 4) minutes.
After being delivered to the emergency department, the wounded was moved to the anti-shock ward, where a range of diagnostic and treatment measures were taken to assess the severity of his condition and injuries, determine treatment tactics, and perform preoperative resuscitation.
The main task of the medical team involved in the examination of the wounded man was to recognise early on the indications for urgent surgical intervention to achieve surgical control of the bleeding.
There are many techniques that help determine the severity of a wounded person's condition.But, in our opinion, they are quite cumbersome and take some time to apply.In an emergency, we decided to use TKU based on the assessment of the level of consciousness, body temperature, Algover's shock index, blood saturation, and ultrasound of the abdomen and adjacent cavities according to the FAST protocol.
In our opinion, the selection of wounded for treatment under TKU is crucial, as multi-stage surgical procedures are inappropriate for wounded with relatively simple (non-severe) combat abdominal injuries.
Of the 259 wounded in serious and extremely serious condition with combat abdominal injuries, 26 (10.0%) were admitted in critical clinical death, and the first stage of treatment in the anti-shock ward of the emergency

The Ukrainian Journal of Clinical Surgery
department was a left-sided resuscitation thoracotomy with temporary clamping of the descending aorta and direct heart massage.
In 12 (46.1%)patients, after effective resuscitation with the restoration of cardiac activity, a midline laparotomy with resuscitative abdominal polytamping was performed.
After anti-shock measures, the operation was continued in the form of a "shortened" laparotomy with subsequent suturing of the thoracic wound, provided that the cardiac function was stable.
If the hemodynamics were unstable, the thoracic wound was not temporarily closed, but a closed thoracostomy was formed using Buckhouse pins for quick access to the heart and direct heart massage in case of repeated cardiac arrest.
In the diagnostic department, the wounded were quickly examined -the average time from arrival at the stage of care to surgery was (25 ± 5) minutes -and sent to the operating department.
The main diagnostic methods were physical examination of the wounded, analysis of the characteristics of the wound canal, ultrasound, X-ray, MSCT, endoscopy of the digestive tract as indicated.
In the case of a significant amount of blood in the abdomen and unstable hemodynamics, resuscitative abdominal polytamponade was performed in the anti-shock ward (Fig. 1) and after stabilisation, the wounded was sent to the operating room.
In 92% of patients, a total median laparotomy was used for abdominal access, which allowed for a quick examination of all parts of the abdominal cavity and pelvis, and a surgical procedure appropriate to the patient's condition ("reduced" laparotomy).
The use of modern coagulators in the "cutting" and spray coagulation modes ensured both bloodless and fast surgical access without losing time for further bleeding control from the surgical wound.

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A total of 691 abdominal injuries were diagnosed (Fig. 2).These injuries were distributed by location (Table 1).
In combat abdominal trauma, 17.6% of wounded were injured in the colon, and 45.1% in the transverse colon.The main method of surgical correction in 76.2% of patients was obstructive resection of the colon in the scope of a "reduced" laparotomy.Colon defects were sutured in the case of single wounds up to 5-6 mm in diameter without concomitant wounds of other organs and without signs of widespread peritonitis.The scope of the "reduced" laparotomy does not include simultaneous resection and removal of the stoma; the latter is formed after stabilisation of the physiological state during the second operation at the third stage of THCU.
Vascular injuries are complicated in combat abdominal trauma and were detected in 2.9% of patients.The most frequently damaged vessels were the iliac vessels (43%) with simultaneous injury to an artery and a vein.Vascular injuries are accompanied by the formation of voluminous haematomas that quickly exsanguinate the wounded.The main method of surgical correction was suturing of the damaged vessel (lateral suture, circular anastomosis) in 42.5% of the wounded and temporary bypass surgery in 27.5% of the wounded.
The first stage of THA was completed by temporary closure of the abdominal access (Fig. 3).The closure of the anterior abdominal wall wound with Buckhouse pins was performed in 11.3% of patients in critical condition during intraoperative stabilisation of haemodynamics after resuscitative abdominal polytamping to achieve haemostasis.
This method is fast, with an average wound closure time of 60 seconds, which can help reduce intraoperative hypothermia and mortality.In 75.4% of patients, suturing with a knotted or continuous suture was performed to close the wound of the anterior abdominal wall.
Temporary wound closure with a Bagota bag or Wittmann dressing, Wound Management System was used in 13.3%

The Ukrainian Journal of Clinical Surgery
of patients with elevated intra-abdominal pressure (more than 15 cm Hg).In 6.3% of patients, a vacuum dressing was used as a temporary wound closure with a treatment period of 3 to 25 days using negative pressure therapy.The system was replaced for the first time after 3 days, and then as indicated.
A. Hirshberg and co-authors [6], who used computer modelling of hypothermia during traumatic laparotomy, reported that in the operating room in a patient in critical condition, the heat balance is dominated by increased heat loss from the open surface of the peritoneum, while in a closed abdominal cavity, heat loss decreases despite bleeding.The authors proved that the duration of laparotomy for damage control should be limited to 60-90 minutes.Due to preoperative MSCT (planning if technically possible), and more often due to the work of a multidisciplinary team of thoracoabdominal and vascular surgeons, the use of modern elec-trosurgical equipment, disposable suturing devices, the average duration of "shortened" laparotomy as the first stage of THA was (85 ± 2.2) minutes.
The second stage of THA lasted from 24 to 72 hours in the intensive care unit (Fig. 4), where all efforts were focused on restoring the general physiological condition of the wounded.Intensive treatment consisted of warming, correction of coagulopathy, acidosis, and minimal transfusion of crystalloids and blood products.The physiological state was corrected to a systemic lactate concentration of less than 2.5 mmol/l, a base deficiency of more than 4 mmol/l, a body temperature above 35 °C, a haemoglobin level of more than 100 g/l and a haematocrit of more than 30%.
Taking into account the peculiarity of obstructive resection of the small intestine, which consists in the rapid progression of necrosis of the mucous membrane of the driving loop, the interval between the first and second stages of TCU was minimised to 24-36 hours when sufficient physiological parameters were achieved.
The third stage of THA included removal of tampons, final repair of abdominal injuries, staged necrectomy, reconstruction of the digestive tract according to indications and closure of the anterior abdominal wall wound, unless re-examination and rehabilitation of the abdominal cavity were planned.On average, the third stage of THA treatment lasted (92 ± 3.2) minutes.
When using THA, complications developed in 16.3% of severely wounded with combat abdominal trauma (Table 2).
The most common postoperative complication is ventilator-associated pneumonia.It develops on the 4th to 5th day in 30.5% of severely injured patients.The microbial landscape is represented by aerobic gram-negative enterobacteria K. pneumoniae and aerobic gram-negative non-fermenting bacteria A. baumanii, P. aeruginosa with high sensitivity to sodium colistimethate.
Postoperative wound suppuration, which developed in 13.3% of severely injured patients, required secondary surgical treatment and etiotropic antibiotic therapy.Dialysis renal replacement therapy was required in 8.1% of severely injured patients due to massive blood component transfusion syndrome with acute kidney injury.
The average postoperative mortality rate was 10.4%.Due to a reduction in the duration of evacuation to the level of The Ukrainian Journal of Clinical Surgery qualified medical care from the site of injury, a shorter preoperative preparation period, and a reduction in the duration of "shortened" laparotomy, the intraoperative mortality rate was 2.8%.Mortality on the 1st day after surgery (Table 3) was associated with the progression of decompensated shock against the background of acute massive blood loss, during the 2nd day -with acute cardiovascular failure, vasoplegic shock.In later periods, the causes of death were acute hypoxemic respiratory failure, sepsis, and multiple organ failure.

Discussion
Gunshot combat trauma to the abdomen and, accordingly, the abdominal organs remains an urgent problem in modern military surgery.
The nature of hostilities definitely affects the proportion of abdominal injuries in the overall structure of combat injuries, which ranges from 1.9 to 9.8%, and the specific features of gunshot wounds cause a high severity of functional disorders, more frequent development of complications (54 -81%) and high mortality (12 -31%) [1,2].
The introduction of TCCU dates back to the early 90s of the XX century, and since then, the tactic has proven itself as a way to save the lives of soldiers who have been wounded on the battlefield [10].At the same time, the nature of the hostilities that are taking place as a result of the Russian Federation's large-scale invasion of Ukraine is fundamentally different from those of previous armed conflicts and wars.Therefore, a preliminary analysis of the effectiveness of the TCCU in the current situation is appropriate.
The analysis of the results of the use of THA has shown that in the case of clear organisation and adherence to algorithms, the incidence of postoperative complications and mortality is reduced.However, this requires compliance with clearly defined indications for staged treatment and its scope, which, in particular, are set out in the guidelines for THA and stabilisation of the victims at the evacuation stage [11].The timing of the delivery of the wounded from the battlefield to a stabilisation medical centre and a secondary (specialised) medical centre is also important.

Conclusions
The use of THA in dynamic large-scale combat operations, characterised by the intensity and saturation of firepower, allows, subject to clearly defined indications for staged treatment and its scope, to reduce the incidence of postoperative complications to 16.3% and mortality to 10.4% in combat gunshot wounds of the abdomen.
The results of the study demonstrate the need for the use of TCM in the provision of medical care to the wounded and the viability of this concept in the system of medical care for soldiers who were injured in a high-intensity military conflict.
Funding.There were no external sources of funding or support.No honoraria or other compensation was paid.Author contributions.All authors contributed equally to this work.Conflict of interest.The authors who participated in this study have declared that they have no conflicts of interest regarding this manuscript.Consent for publication.All authors have read and approved the final version of the manuscript.All authors have agreed to the publication of this manuscript.Ethical aspects.All procedures performed in the study with the involvement of patients complied with ethical standards for clinical practice and the Declaration of Helsinki, 1964, as amended.

Fig. 1 .
Fig. 1.Resuscitative polytamping of the abdomen in the conditions of the anti-shock ward.

Fig. 4 .
Fig. 4. Antishock therapy in the intensive care unit with separate ventilation with two lung ventilators ( second stage of mechanical ventilation).