Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma

Choi, Kyunghak; Keum, Min Ae; Choi, Byungho; Noh, Minsu; Choi, Seong‐Ho; Kyoung, Kyu-Hyouck; Kim, Sungjeep; Hong, Eun Seog; Kim, Jihoon T

doi:10.1016/j.injury.2022.11.003

Cited by 8 publications

(6 citation statements)

References 22 publications

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“…Majority of bleeds in the pelvis are from the venous plexus, and appropriate packing should be able to control most of them [ 20 , 30 , 33 ]. In instances where the arterial component is suspected or identified, we would directly ligate the vessel or consider a trial of internal iliac artery ligation as described by Choi et al [ 36 ]. The bleeding in majority of patients in our patients stopped with pelvic packing.…”

Section: Discussionmentioning

confidence: 99%

The Role for Preperitoneal Pelvic Packing in Low‐to‐Middle‐Income Countries: A 16‐Year Experience at a Johannesburg Trauma Unit

Moeng,

Viljoen,

Makhadi

2023

World j. surg.

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Introduction Preperitoneal pelvic packing for early pelvic haemorrhage control reduces mortality. Bleeding noted with pelvis fractures is predominantly due to associated venous complex injuries. More studies are advocating for angiography as first-line therapy for haemodynamic instability in pelvic fractures; however, these facilities are not in abundance in middle- and low-income countries. We hypothesized that PPP improves outcomes under these circumstances. Methods Retrospective analysis of data from the patients charts over a period of 16 years from 01 January, 2005 to 31 December, 2020. All patients over the age of 18 years who presented with haemodynamic instability from a pelvic fracture and required PPP were included. The demographics, physiological parameter in emergency department, blood products transfused, morbidity and mortality were analysed. Results There were 110 patients identified in the study period who underwent pelvic preperitoneal packing for refractory shock or ongoing bleeding. The majority (75.5%) of patients were men (n = 83). The median age was 38 years. The most common mechanism of injury was pedestrian vehicle collision (51%), followed by motor vehicle collisions (27.3%). The median ISS and NISS were 35 and 40, respectively. The median RTS in ED was 4.8(3–6.8). None of our patients rebleed after pack removal and no one needed repacking or adjunct angioembolization in our study group. The in-hospital mortality rate was 43.6% (n = 48) in patients who underwent preperitoneal pelvic packing. The operating room table mortality was 20% (n = 22/110), and the mortality rate of those who survived to ICU transfer was 29.5% (n = 26/88). Conclusions Pelvic preperitoneal packing has a role in the acute management of haemodynamically abnormal patients with pelvic fractures in our environment. In the absence of immediate angioembolization, preperitoneal packing can be lifesaving.

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Section: Discussionmentioning

confidence: 99%

The Role for Preperitoneal Pelvic Packing in Low‐to‐Middle‐Income Countries: A 16‐Year Experience at a Johannesburg Trauma Unit

Moeng,

Viljoen,

Makhadi

2023

World j. surg.

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“…Ligation of the anterior division of the IIA The instrument should be passed beneath the artery, approximately 3 cm below the bifurcation, from lateral to medial in order to ensure the ligation of only the anterior division and to avoid iatrogenic injury to the external iliac vessels. Identifying the posterior division of the IIA is unnecessary and could even be dangerous, potentially leading to injury of the underlying veins [46][47][48]. The tips of the instrument should be directed slightly toward the IIA and not toward the underlying vein [3,11,13,31,45,46].…”

Section: Surgical Technique Of Iia Ligationmentioning

confidence: 99%

“…The internal iliac vein is located below and slightly medial to the IIA. Clearing the adventitia of the artery may help to identify the correct dissection plane [ 11 , 44 , 45 , 46 , 47 , 48 ]. The artery can be gently elevated without injuring the vein.…”

Section: Surgical Technique Of Iia Ligationmentioning

confidence: 99%

“…The ligatures should be tied firmly in order to avoid transection of the artery [ 3 , 11 , 13 , 31 ]. Immediately after suturing the artery, the pulsation of the ipsilateral femoral artery within the inguinal region should be confirmed [ 47 ]. It is not necessary to divide the vessel between two ligatures, as doing so could be dangerous and may lead to iatrogenic injury to the underlying vein [ 5 , 48 ].…”

Section: Surgical Technique Of Iia Ligationmentioning

confidence: 99%

“…Moreover, hip claudication, urinary bladder atony, lumbosacral plexopathies, and impotence may also be observed [ 10 , 11 , 49 ]. Therefore, it is crucial that ligation of the IIA should be performed distal to its posterior division (SGA) [ 10 , 11 , 45 , 46 , 47 , 48 , 49 ]. Fortunately, these complications are rare due to the extensive collateral circulation in the pelvis after ligation [ 10 , 11 , 48 , 49 ].…”

Section: Perioperative Complicationsmentioning

confidence: 99%

See 2 more Smart Citations

Internal Iliac Artery Ligation in Obstetrics and Gynecology: Surgical Anatomy and Surgical Considerations

Kostov,

Kornovski,

Watrowski

et al. 2023

Clinics and Practice

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The internal iliac artery (IIA) is the main arterial vessel of the pelvis. It supplies the pelvic viscera, pelvic walls, perineum, and gluteal region. In cases of severe obstetrical or gynecologic hemorrhage, IIA ligation can be a lifesaving procedure. Regrettably, IIA ligation has not gained widespread popularity, primarily due to limited surgical training and concerns regarding possible complications, including buttock claudication, impotence, and urinary bladder and rectum necroses. Nowadays, selective arterial embolization or temporary balloon occlusion are increasingly utilized alternatives, which can be applied preoperatively or intraoperatively for threatening severe genital or pelvic bleeding. However, IIA ligation retains its relevance, as the previously described procedures are not always available and have limitations. This article provides a step-by-step guide to the IIA ligation procedure and its possible complications. It also includes a detailed description of the anatomy of the IIA and pelvic arterial anastomoses. This review highlights the importance of a thorough understanding of pelvic anatomy as a prerequisite for safe IIA ligation and posits that training in this procedure should be an integral part of obstetrics and gynecology curricula.

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Emergency treatment of pelvic ring injuries: state of the art

Madsen,

Flugsrud,

Hammer

et al. 2024

Arch Orthop Trauma Surg

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High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.

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Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma

Cited by 8 publications

References 22 publications

The Role for Preperitoneal Pelvic Packing in Low‐to‐Middle‐Income Countries: A 16‐Year Experience at a Johannesburg Trauma Unit

The Role for Preperitoneal Pelvic Packing in Low‐to‐Middle‐Income Countries: A 16‐Year Experience at a Johannesburg Trauma Unit

Internal Iliac Artery Ligation in Obstetrics and Gynecology: Surgical Anatomy and Surgical Considerations

Emergency treatment of pelvic ring injuries: state of the art

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