In the early 1980’s trauma surgeons recognized when they operated in the setting of the “bloody viscous cycle” of acidosis, hypothermia and coagulopathy, operating room (OR) mortality from bleeding was unacceptably high [
34]. This prompted the develop of the concept of an abbreviated laparotomy using gauze packing to stop bleeding combined temporary abdominal closure (
TAC) and triage to the ICU with the intent of optimizing physiology [
35]. The patient is taken back to the OR after 24–48 hours for definitive treatment of injuries and abdominal closure. This concept was initially promoted for major liver injuries as a way to avoid major liver resections but was soon extended to all emergency trauma laparotomies [
36]. Over the next decade this concept evolved into “damage control” which was a major paradigm shift for trauma surgeons [
37‐
39]. This practice became standard of care worldwide by the mid-1990s and has saved the lives of many patients who previously exsanguinated on the OR table. However, the role of
DCL in emergency general surgery is controversial [
40‐
43]. It is often confused with the concept of a
planned relaparotomy (described above). Moore et al. proposed that the purpose of
DCL in intra-abdominal sepsis is different from trauma. While the “bloody viscous cycle” can occur with intra-abdominal sepsis, exsanguination is uncommon short of technical mishaps. Rather patients with intra-abdominal sepsis can present in persistent septic shock [
40]. Initially, they are too unstable to undergo immediate operation. An immediate operation in these patients results in a high risk for postoperative acute kidney injury (AKI) sets the stage for MOF, prolonged intensive care unit (ICU) stays and dismal long-term outcomes [
40,
44,
45]. By their protocol, patient presenting in septic shock warrant pre-operative optimization with early goal directed therapy. If they are not optimized pre-operatively, they will experience profound hypotension when subjected to general anesthesia and require high doses vasopressors (typically boluses of phenylephrine) to maintain mean arterial pressure (MAP) and if they undergo a traditional
HP this will be prolonged and contribute substantially to post-operative AKI [
45]. After optimization (described below), the patient is taken to the OR. After undergoing general anesthesia, the surgeon assesses whether the patient is still in septic shock. If so, the OR team is informed that a
DCL is going to be performed. They should anticipate a short operation (roughly 30–45 minutes) and get the supplies necessary for a
TAC. A limited colon resection of the inflamed perforated colon is performed using staplers (referred to as a “
perforection”) with no colostomy and a
TAC is performed using a “vac pack” technique. The patient is returned to the ICU for ongoing resuscitation. Once physiologic abnormalities are corrected, the patient is returned to the OR for peritoneal lavage and colostomy formation. A definitive resection should be done if feasible for patients who have undergone a limited resection at the previous
DCL to prevent a fistula and recurrence. However, Kafka-Ritsch et al. propose an alternative reason to perform
DCL in patients with diverticulitis is to avoid a colostomy by performing a delayed anastomosis [
43]. In a prospective study 51 patients with perforated diverticulitis (stage III/IV) were initially managed with limited resection, lavage and
TAC with a vacuum-assisted closure device followed by second, reconstructive operation 24–48 hours later supervised by a colorectal surgical specialist. Bowel continuity was restored in 38 (84%) patients, of which four were protected by a loop ileostomy. Five anastomotic leaks (13%) were encountered requiring loop ileostomy in two patients or
HP in three patients. Postoperative abscesses were seen in four patients, abdominal wall dehiscence in one and relaparotomy for drain-related small bowel perforation in one. The overall mortality rate was 10% and 35/46 (76%) of the surviving patients left the hospital with reconstructed colon continuity. Fascial closure was achieved in all patients.