Bleeding in the Pelvis
58
Edward Kelly
Penetrating injuries to the pelvis often cause complex multi-
organ injuries due the crowded space of the pelvic cavity,
which contains the rectum, the bladder and ureters, the iliac
arteries and veins, and the boney pelvis. The trauma sur-
geons urgent goals are hemostasis and control of contamina-
tion; restoration of continuity of hollow organs should only
be undertaken after the urgent goals are met. In this chapter,
we will focus on rapid control of bleeding and briefly discuss
reconstruction options.
Modern techniques enable control of bleeding prior to
operative exposure, using resuscitative balloon occlusion of
the aorta (REBOA). In cases of pelvic injury without evidence
of aortic disruption, this approach involves insertion of a
1012 French vascular sheath into the common femoral artery
either percutaneously or by open technique. An endovascular
balloon catheter is then advanced to the aortic bifurcation with
or without radiographic guidance. The balloon is inflated
using radiographic contrast dye to produce inflow occlusion to
the pelvic vessels. Upon occlusion of the aorta, peripheral
blood pressure should rise, and the patient may then be trans-
ported more safely and undergo further evaluation and repair
of injuries. Removal of the balloon and sheath often requires
surgical repair of the entry site in the common femoral artery.
Adoption of this approach in the emergency room and in the
field has been growing in the USA and in Japan, and early
results have shown a benefit in transfusion requirement.
Bleeding from the pelvis can be encountered unexpect-
edly, for example, in a patient with a bullet entry wound in
the chest or lower extremity. Therefore, every operation for
penetrating trauma should have long vascular instruments
ready and a self-retaining retractor system available to facili-
tate exposure in the pelvis. Likewise, have the appropriate
sutures (40 Prolene for the iliac artery, 30 for the aorta,
and 60 for the iliac vein), grafts, and vascular shunts avail-
E. Kelly
Department of Surgery, Brigham Womens Hospital,
75 Francis St, Boston, MA MA02115, USA
e-mail: ekelly1@partners.org
Springer-Verlag Berlin Heidelberg 2017
G.C. Velmahos et al. (eds.), Penetrating Trauma, DOI 10.1007/978-3-662-49859-0_58
able. Have endovascular balloon occlusion catheters ready to
control bleeding from vessels that are hard to reach (distal
external iliac, internal iliac). Have at least two suction lines
available, and cell-scavenging equipment may also be
useful.
Midline laparotomy is the exposure of choice for pene-
trating injuries to the pelvis, as it offers the best access to the
crowded space, and enables proximal vascular control in the
abdomen, outside of the field of injury. The pelvis also bor-
ders the extremities, and injuries to the pelvis can also
involve the groins or more distal structures. When more dis-
tal control is indicated, a vertical incision in the groin can be
used to expose the femoral arteries and the vein. Therefore,
the skin prep should include chest, abdomen, both groins,
and extremities down to the knees.
Begin with a long vertical midline laparotomy. Liquid
blood, bowel contents, and clots should be removed
quickly to enable exposure. Four quadrant packing can be
used to control abdominal sources of bleeding. Evisceration
of the small intestine out of the abdomen will facilitate
exposure, as will wide retraction with a Bookwalter
retractor.
First we will discuss hematomas. Unlike blunt trauma,
pelvic hematomas from penetrating trauma should always be
explored, as they are strongly associated with injury to the
iliac vessels. Obtain proximal control outside of the hema-
toma at the origin of the iliac artery or at the distal aorta. For
a hematoma on either side of the pelvis, perform a right-
sided medial visceral rotation, taking care not to disrupt the
hematoma, in order to expose the inferior vena cava and the
distal aorta. If the origin of the iliac artery is free, clamp it
with an angled vascular clamp; if the origin is not free, cross
clamp the aorta with a large straight vascular clamp. For
rapid distal control, direct pressure on the external iliac ves-
sels in the groin will suffice, or compression with a sponge-
on-a-stick applied to the distal vessel within the pelvis, if not
involved with hematoma. Rapid proximal control of the infe-
rior Vena Cava (IVC) can also be achieved with simple
compression.
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Once proximal and distal control is obtained, open the
hematoma and identify the injury. Keep in mind that the
internal iliac vessels are not controlled with this approach
and may bleed copiously. Keep in mind that the ureter may
be inside the hematoma, or compressed, or distorted, or
injured. After the vascular injury is dealt with, it is neces-
sary to expose the ureter and determine if it is injured.
When the hematoma is entered, there may be ongoing
bleeding from the uncontrolled internal iliac artery or vein.
These may be rapidly controlled with a balloon occlusion
catheter, or, if the exposure is sufficient, vessel loops or
vascular clamps.
The surgeon then is faced with the decision to repair the
injury in some fashion or to ligate the injured vessel and
manage the consequences. This decision is challenging, as
the patient may have other injuries that require urgent atten-
tion, or may be physiologically depleted (in terms of tem-
perature, coagulation, and acidosis) and may benefit from
the damage control approach. In order to make the best deci-
sion, identify the injury completely before committing to a
specific approach. That is, do not decide on placing an inter-
position graft until you have seen both ends of the vessel you
plan to repair, and do not ligate vessels until you know you
have all bleeding ends identified. Damage control surgery
only works if the damage is actually controlled!
Proximal iliac vein injury deserves special attention.
Anatomically the confluence of the IVC lies behind the aor-
tic bifurcation, immediately posterior to the right common
iliac artery. Rapid control can be achieved with compression
as outlined above, but to ligate or repair the vein requires
more exposure. Division of the right common iliac artery
between vascular clamps will enable exposure of the IVC
and proximal common iliac veins. Once the vein injury has
been addressed, the artery can be repaired with 40 Prolene
suture or temporized with a shunt.
Iliac vein injuries have a high rate of thrombosis, even if
the injury is limited and a good technical repair is achieved.
It is therefore not reasonable to expend valuable time to
achieve a perfect venous repair via paneled vein patch or
venous interposition graft when the patient has multiple inju-
ries that require intervention.
Destructive complex injuries with profuse bleeding call
for lifesaving interventions to stop the hemorrhage. These
injuries require a damage control approach, using suture
ligation, compression with packing, and topical hemostatic
agents (such as BioGlue) to achieve control. By comparison,
injuries to the iliac or femoral arteries are more forgiving.
The higher flows in these vessels make them more resistant
E. Kelly
to thrombosis, and thus the results of repair are much bet-
ter. Single layer repair with 30 or 40 Prolene yields a
reliable long-term outcome for simple arterial lacerations.
Transections with no loss of length can be managed with
primary anastomosis, again with good results. Destructive
injuries to the arteries, characterized by loss of length that
is too great to allow straightforward primary anastomosis,
should be controlled in one of three ways: (1) Reconstruct
immediately with conduit. (2) Insert a shunt and return to
the operating room when the patient is more stable for
definitive reconstruction. (3) Ligate the ends and recon-
struct extra-anatomically as soon as possible.
Immediate reconstruction with conduit should only be
undertaken when the patient is hemodynamically stable and
does not have a high burden of other injuries. Time spent on a
definitive repair should not be time taken away from control-
ling bleeding from the mesenteric vein or liver injury. However,
when the patient is stable and has minimal other injuries,
reconstruction with conduit yields a reliable long-term result.
In the setting of gross spillage of bowel contents, there is
a high rate of infection for both arterial and venous graft
reconstruction. When bioprosthetic conduits such as reversed
saphenous vein become infected, there is often severe necrol-
ysis of the conduit, leading to renewed hemorrhage in the
necrotic infected field. This observation has prompted the
author to use non-biological conduits such as expanded
PolyTetraFluoroEthylene (ePTFE) or Dacron. Irrespective of
the strategy for managing penetrating injury of the pelvis, the
risks of deep vein thrombosis, venous hypertension, and pul-
monary embolism are very high and should be considered as
part of the treatment of all such patients. The author advo-
cates early lower extremity fasciotomy for patients with
combined arterial and venous injury.
58.1 Summary (For Springer eBook
Publication)
Penetrating injury to the pelvis requires early rapid interven-
tion via endovascular approach or open surgery to control
bleeding and contain contamination from the bowel. Vascular
control outside of the pelvis should be achieved using an
anatomical exposure of the aorta and inferior vena cava.
Distal control may be most effectively achieved using com-
pression against the bony pelvis. Balloon occlusion catheters
can be used for control of the hypogastric vessels. Once con-
trol is established, the total burden of injury and the com-
plexity (i.e., time to repair) of the pelvic injury should guide
58 Bleeding in the Pelvis
the surgeons decision to ligate, shunt, or repair the vascular
injury. Prosthetic material is usually the best choice when a
conduit or patch is needed. Early fasciotomy and IVC filter
Important Points
Be Prepared! Have the deep vascular instruments
you use ready every time you explore a penetrating
injury that may include the pelvis.
Trap the external iliac artery against the boney pel-
vis for rapid control.
Remember vascular shunts for the bailout option.
It is OK to divide the common iliac artery to expose
the confluence of the IVC.
Fasciotomy is indicated for complex injury.
445
should be employed liberally due to the high rate of throm-
boembolic complications.
Recommended Reading
1. Burch J, Richardson RJ, Martin RR, Mattox KL (1990) Penetrating
iliac vascular injuries: recent experience with 233 consecutive
patients. J Trauma 30:14501459
2. Carillo E, Spain DA, Wilson MA, Miller FB, Richardson DJ (1998)
Alternatives in the management of penetrating injuries to the iliac
vessels. J Trauma 44:10241030
3. Mattox KL, Rea J, Coyness LE, Beall AC, DeBakey ME (1978)
Penetrating injuries to the iliac arteries. Am J Surg 136:663667
4. Norii T, Crandall C, Terasaka Y (2015) Survival of severe blunt
trauma patients treated with resuscitative endovascular balloon
occlusion of the aorta compared with propensity score/adjusted
untreated patients. J Trauma ACS 78:721728
5. Ryan W, Snyder W, Bell T, Hunt J (1982) Penetrating injuries to the
iliac vessels. Am J Surg 144:642645