Pre-peritoneal packing

Reviewed and revised 6 June 2016

OVERVIEW

Pre-peritoneal packing is a method of directly packing the retroperitoneum without the need for a laparotomy

INDICATION

• haemodynamically unstable pelvic fracture prior to angiographic embolisation to stop venous bleeding
• alternatively, can be performed after embolisation

DESCRIPTION OF PROCEDURE

The 2011 EAST guidelines describe the procedure as follows:

• a midline incision 8 cm in length just above the pubis extending toward the umbilicus
• Skin and subcutaneous tissue is opened in the midline, as is the fascia
• The bladder is retracted away from the fracture and three laparotomy pads are placed in the retroperitoneal space on each side toward the iliac vessels
• The procedure is repeated on the opposite side and the fascia and skin are closed

Packs are usually left in situ for 24-48 hours

ADVANTAGES

• often successful at controlling hemorrhage in retrospective studies (>80% of cases)
• can be performed in 20 minutes by experienced surgeons
• easy to learn and perform
• especially useful if angiography is unavailable or if there is a delay in its availability
• can be used to rescue failed angiography
• can be performed at smaller centers prior to transfer to a trauma center for definitive angiography
• can be performed concurrently with pelvic fixation and other surgical procedures
• does not require laparotomy for direct retroperitoneal packing and is not associated with increased rates of abdominal compartment syndrome
• less invasive than laparotomy with minimal blood loss

DISADVANTAGES

• fails to control hemorrhage in about 15% of cases
• unlikely to control arterial hemorrhage
• not all general surgeons are familiar with the technique
• requires operating theatre, staff and resources
• no prospective head-to-head studies with angiography for first line treatment in the management of hemodynamically unstable pelvic fractures have been performed
• may increase rate of pelvic infections
• patient needs to return to the operating theatre for removal of packs

References and Links

Journal articles

• Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, Holevar M, Sabater EA, Sems SA, Vassy WM, Wynne JL. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture–update and systematic review. J Trauma. 2011 Dec;71(6):1850-68. PMID: 22182895.
• Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. PMID: 19278678.

FOAM and web resources

• EMCrit — Severe Pelvic Trauma