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
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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