Damage Control Laparotomy
[Penetrating abdominal trauma with hemorrhagic shock / Blunt abdominal trauma with hemorrhagic shock / Abdominal catastrophe with damage control physiology (acidosis, hypothermia, coagulopathy)]
[Same, with injuries identified: list injuries and grades, e.g., grade IV liver laceration, two small bowel injuries]
Damage control laparotomy with [hemorrhage and contamination control / hemorrhage control / contamination control], abdominal packing, and temporary abdominal closure
[***, MD/DO]
[Resident / Fellow / PA name]
General endotracheal. Massive transfusion protocol activated.
The patient is a [age]-year-old [male / female] with [penetrating abdominal trauma / blunt abdominal trauma / an abdominal catastrophe] and [hemodynamic instability refractory to resuscitation / peritonitis / evisceration]. [FAST was positive in the [right upper quadrant / left upper quadrant / pelvis].] Physiology precluded definitive repair: pH [___], core temperature [___]°C, INR [___], lactate [___] mmol/L. A damage control approach was chosen for rapid hemorrhage and contamination control, temporary abdominal closure, and ICU resuscitation, with planned return to the operating room in 24–48 hours for definitive repair. [Consent was implied under the emergency doctrine / Consent was obtained from the patient / Consent was obtained from the family].
On entry, [massive hemoperitoneum / enteric contamination / feculent contamination] was encountered. [Active hemorrhage from the [liver / spleen / mesentery / pelvic retroperitoneum].] [Hollow viscus injury of the [small bowel / colon] at [location].] [List additional injuries and grades.]
The patient was brought emergently to the operating room with resuscitation ongoing and the massive transfusion protocol active. General endotracheal anesthesia was induced. A surgical timeout was performed. The chest and abdomen were prepped rapidly and draped in sterile fashion.
A rapid midline laparotomy was performed from xiphoid to pubic symphysis. Approximately [___] L of blood and clot was evacuated. All four quadrants were packed with laparotomy pads for temporary tamponade while anesthesia continued resuscitation. The packs were then removed sequentially to identify the sources of hemorrhage. [Manual compression of the [supraceliac aorta / mesentery / liver] was applied as needed.]
[LIVER: [Perihepatic packing with [___] laparotomy pads / Tractotomy with suture ligation and perihepatic packing]. [Pringle maneuver for [___] minutes.] See concurrent hepatorrhaphy note.]
[SPLEEN: Splenectomy was performed. See concurrent note.]
[MESENTERY: [Mesenteric vessel] injury was [repaired / ligated].]
[PELVIS: Retroperitoneal pelvic hematoma, [stable and left undisturbed / expanding, and preperitoneal pelvic packing was performed with [___] laparotomy pads].]
[CONTAMINATION CONTROL: Injured bowel was resected with a linear stapler and left in discontinuity, with anastomosis deferred pending resuscitation. Enteric contents were suctioned and the abdomen was irrigated.]
Hemorrhage and contamination were controlled. [___] laparotomy pads were left in place ([location of each]), and the count was confirmed with the nursing team.
TEMPORARY CLOSURE: The viscera were covered with a nonadhesive barrier, and a [commercial negative-pressure (ABThera) / vacuum-pack / Bogota bag] temporary abdominal closure was applied. The fascia was not approximated, to prevent abdominal compartment syndrome.
The patient was transported to the ICU intubated for continued resuscitation, with planned relook laparotomy in 24–48 hours for pack removal and definitive repair.
None beyond the operative injuries
[Resected bowel / Spleen / None] [Peritoneal cultures sent]
[___] mL
Temporary abdominal closure device
Transported directly to the trauma ICU intubated for continued resuscitation. Planned relook laparotomy in 24–48 hours.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same, with injuries: ***
PROCEDURE PERFORMED: Damage control laparotomy with hemorrhage and contamination control, abdominal packing, and temporary abdominal closure
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal. MTP activated.
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** and hemodynamic instability. pH ***, temp ***°C, INR ***, lactate *** mmol/L. Damage control approach chosen because physiology precluded definitive repair. Plan: hemorrhage and contamination control, packing, TAC, ICU resuscitation, relook in 24-48 h. Consent ***.
FINDINGS: ***
DESCRIPTION OF PROCEDURE:
Rapid midline laparotomy. *** L blood evacuated. Four-quadrant packing, sources identified sequentially. [Liver: perihepatic packing with *** pads.] [Spleen: splenectomy.] [Mesentery: vessel ***.] [Pelvis: preperitoneal packing with *** pads.] [Bowel: injured segments stapled off in discontinuity, anastomosis deferred.] Hemorrhage and contamination controlled. *** pads left in place (***), count confirmed with nursing. Temporary closure with ***. Fascia not closed.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: ***
COMPLICATIONS: None beyond operative injuries
DRAINS: Temporary abdominal closure device
DISPOSITION: To trauma ICU intubated. Relook planned in 24-48 hours.
Signed: .ME, .MYDEGREE
.TODAYVariants
Relook Laparotomy: Pack Removal and Definitive Repair
This is a planned [second / third] relook laparotomy. The temporary closure was taken down. [___] laparotomy pads were removed, matching the count placed at the index operation. The abdomen was explored. Hemostasis was confirmed. Bowel viability was confirmed. [Bowel continuity was restored with [stapled / hand-sewn] anastomosis.] [An [end ileostomy / end colostomy] was matured.] The fascia was [closed primarily with running #1 PDS / closed with component separation / not closed, and progressive closure with mesh-mediated fascial traction was begun] given [no tension / residual bowel edema / loss of domain].
Open Abdomen: Temporary Closure Exchange
Given [persistent bowel edema / risk of abdominal compartment syndrome / ongoing resuscitation requirements], the abdomen was left open. The temporary closure was replaced with a fresh device after confirming adequate bowel coverage. Fascial tension was assessed and the fascia was [advanced toward the midline with [___] cm of residual gap / not advanced]. Planned return to the operating room in [48–72 hours].
Charting Tips
- Document the physiology that drove the damage control decision as values, not just the conclusion: pH, core temperature, INR, lactate, and base deficit. Common triggers are pH 7.2 or below, temperature below 35°C, and INR 1.5 or above.
- Record the number of laparotomy pads placed, where they are (by quadrant), and that the count was confirmed with nursing at temporary closure. The relook note must document the same number removed. A retained surgical item is a never event.
- List every injury identified and what was done or explicitly deferred for each. One line per injury is enough.
- Record blood products transfused intraoperatively (pRBC, plasma, platelets, cryoprecipitate) and the ratio.
- State the relook plan in the operative note and the orders, including expected timing and the responsible service, so the ICU team does not assume the operation is complete. Aim for early fascial closure, since enteroatmospheric fistula risk rises the longer the abdomen stays open.
Documentation & Reimbursement Considerations
- Primary service: Report Damage Control Laparotomy as the primary service when it is the definitive operation performed.
- Report the exploratory laparotomy (12.23 wRVU, 90-day global) when no named definitive repair applies, such as exploration with packing-only hemorrhage control. When definitive organ procedures are performed (liver hemorrhage control with packing, splenectomy, bowel resection, intestinal suture, intra-abdominal vessel repair), report the most extensive as the primary service and the others with the multiple-procedure modifier. Enterolysis is bundled into concurrent intra-abdominal surgery and is not a primary service for a damage control laparotomy.
- When injured bowel is resected and left in discontinuity, report the resection with the reduced-services modifier, and state in the note that anastomosis was deferred pending resuscitation.
- Abdominal packing is included in the primary procedure, except that preperitoneal pelvic packing for pelvic fracture hemorrhage (8.14 wRVU, 0-day global) is separately reportable when documented as a distinct procedure. At the relook, report the re-exploration of a recent laparotomy (17.19 wRVU), the hepatic re-exploration for removal of liver packing (22.95 wRVU), or the pelvic re-exploration for removal of pelvic packing (6.56 wRVU), plus any definitive repairs.
- Temporary abdominal closure (ABThera, vacuum pack, Bogota bag) is bundled into the index operation. Negative-pressure wound therapy (0.54 or 0.59 wRVU by wound size) may be reported for later open-abdomen dressing changes, depending on payer, documented wound dimensions, and whether the surgeon performs the service.
- Report planned relooks with the staged-procedure modifier, which starts a fresh 90-day global and pays in full. The unplanned related return-to-OR modifier is for unplanned complications, does not reset the global, and pays only the intraoperative portion. Document in the index note that the relook was planned.
- REBOA is reported by the performing provider as vascular occlusion for hemorrhage with the reduced-services modifier, because no permanent device is deployed. Document REBOA use, zone, and occlusion time.
- The increased-procedural-services modifier can be appended when operative time, blood loss, or complexity substantially exceeds typical. Document operative time, EBL, and blood products transfused to support it.