Preperitoneal Packing for Pelvic Fracture Bleeding Control: A Human Cadaver Study

Abstract

Background Preperitoneal packing (PPP) has been widely accepted as a damage control technique for severe bleeding from pelvic fractures. It is supposed to work by direct compression and tamponade of the bleeding source in the pelvis and it has been suggested to be effective for both venous and arterial bleeding. However, there is little evidence to support its efficacy or the ability to place the laparotomy pads in proximity of the desired location. Methods Bilateral PPP was performed on 10 fresh human cadavers, followed by laparotomy and measurements of resultant pad placement in relation to critical anatomic structures. Results A total of 20 assessments of laparotomy pad placement were performed. Following completion of PPP, a midline laparotomy was performed to determine proximity and closest distance of the laparotomy pads to sites of potential bleeding in pelvic fractures. In almost all cases, the pad placement was not contiguous with the key anatomic structure with mean placement 3.9 ? 1.1 cm from the sacroiliac joint, 3.5 ? 1.6 cm from the common iliac artery, 1.1 ? 1.2 cm from the external iliac artery, 2.8 ? 0.8 cm from the internal iliac artery, and 2.3 ? 1.2 cm from the iliac bifurcation. Surgeon experience resulted in improved placement relative to the sacroiliac joint, however the pads still did not directly contact the target point. Conclusion This human cadaver study has shown that PPP, even in experienced hands, may not be placed in significant proximity of anatomical structures of interest. The role of PPP needs to be revisited with better clinical or human cadaver studies.

Author's Reply: Preperitoneal Packing for Pelvic Fracture Bleeding Control: A Human Cadaver Study

“…Thank you to Drs. Bagaria, Rani, and Gora for their comments regarding our article, “Preperitoneal Packing for Pelvic Fracture Bleeding Control: A Human Cadaver Study” [1]. Certainly, we agree with your concerns of generalizing these data too immediately to clinical practice, but we feel it is important to highlight the potential weaknesses of the discussed intervention.…”

Letter to the Editor: Preperitoneal Packing for Pelvic Fracture Bleeding Control—A Human Cadaver Study

“…A recent publication by Benjamin et al in the World Journal of Surgery captivated our attention immensely [1]. In their publication, the authors performed an experimental study assessing preperitoneal packing (PPP) efficacy by manually measuring pack distance with important anatomical landmarks in noninjured fresh human cadavers and concluded that considering the noncontact placement of packs, the role of PPP needs to be revisited in pelvic hemorrhage management.…”