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12/31/2018 Pelvic ring - Reduction & Fixation - Extraperitoneal pelvic packing - AT - AO Surgery Reference

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Executive Editor:
Peter Trafton
Authors: Rahul
Extraperitoneal pelvic packing
Banerjee, Peter Brink,
Matej Cimerman, Tim
1 Packing versus angio-embolization
Pohlemann, Matevz
Tomazevic In an emergency situation the decision whether to go for
packing or angiography with embolization depends on
Pelvic ring - several factors.
Acute pelvic The condition of the patient

treatment When the patient is in extremis, angiography takes too


long
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Availability of direct angiography or an operating room
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Availability of adequate personnel to perform angio-
embolization
Shortcuts
When a laparotomy is mandatory, extraperitoneal
All Preparations
packing could be part of the same procedure
All Approaches
Combining the two techniques (extraperitoneal pelvic
All Reductions &
packing and angio-embolization) is an option.
Fixations
2 Patient positioning

Place the patient in supine


position.
A urinary catheter should be
inserted prior to beginning
the procedure.
In male with a pelvic
fracture, urethral ruptures
should be excluded before
introduction to the catheter to avoid creation of a false
route.

If present, a temporary pelvic binder should be removed


and replaced more distally (A).
Internal rotation of the legs can be preserved during the
procedure by taping the legs in this position (B) with
adequate padding.

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12/31/2018 Pelvic ring - Reduction & Fixation - Extraperitoneal pelvic packing - AT - AO Surgery Reference

For pelvic packing to


compress the source of
bleeding, the pelvis should
be stabilized.

3 Skin incision

Horizontal incision
(“Pfannenstiel”)
A Pfannenstiel incision can
be used when there is no
obvious bleeding in the
abdomen.
Perform a horizontal incision
about 2 fingerbreadths
proximal to the pubic tubercle.
The length of this incision is typically 5-10 cm. It can be
extended further laterally on one or both sides depending
on the needed exposure.

Vertical incision
There may be a need for
extension of the incision
cranially in case of
abdominal bleeding. In this
case a vertical incision is
preferred.

4 Deep dissection

Dissect the subcutaneous


tissue and identify the
anterior rectus fascia.
Locate the linea alba and
incise it longitudinally.

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12/31/2018 Pelvic ring - Reduction & Fixation - Extraperitoneal pelvic packing - AT - AO Surgery Reference

Both bellies of the rectus


abdominis muscle are gently
retracted laterally.
Identify the peritoneal sack
but do not open it.

Use your fingers to bluntly


retract the peritoneal sack
superiorly. It can be
dissected as far posteriorly
as the SI joints to create
retroperitoneal spaces
bilaterally. These may
already have been torn open
by the injury.
Care is taken not to tear the peritoneum.

5 Extraperitoneal pelvic packing

Fill the retroperitoneal


spaces with as many big
gauzes as possible to create
a good pressure on both
sides of the retroperitoneal
region.

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12/31/2018 Pelvic ring - Reduction & Fixation - Extraperitoneal pelvic packing - AT - AO Surgery Reference

Reduction of the pelvis


To realign and stabilize the
pelvis an anterior external
fixator or C-clamp is placed.
In case of a disrupted
symphysis, immediate
reduction and plate fixation
can be performed through
the same incision when the patient is relatively stable after
packing.

6 Temporary closure

Prior to closure the wound is


irrigated and the bladder is
inspected for any signs of
injury. The urine in the Foley
catheter bag is inspected to
ensure there is no bleeding.
The fascia of the abdomen is
temporarily closed.
Skin incision can be left open and dressed with a large
plastic adhesive drape.

7 Packing removal

A "second look" must be done between 24 and 48 hours. If


bleeding has stopped, the packs soaked and gently
removed. If bleeding persists, they should be replaced.

8 Final closure

The midline incision in the rectus abdominis is closed in one


or two layers. The subcutaneous tissues and skin are then
closed in layers.

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12/31/2018 Pelvic ring - Reduction & Fixation - Extraperitoneal pelvic packing - AT - AO Surgery Reference

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