Chapter 21 Operative Exposure in Abdominal Trauma: Exposure of Complex Injuries to the Pelvis and Perineum

This chapter will discuss complex pelvic and perineal injuries and their surgical exposure.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Describe the approach to complex injuries of the pelvis and perineum.
2. Describe the role of angiography and angioembolization to control pelvic hemorrhage.
3. Demonstrate preperitoneal packing.

Considerations

• Traumatic pelvic injuries result from very high- energy mechanisms, placing the patient at risk of associated life-threatening and devastating injuries.
• The combination of potential vascular, genitourinary, rectal, nerve, soft tissue, and bony injuries requires a multispecialty care team typically found in a trauma center (Figures 1 and 2).

Initial Management

• Hemodynamically unstable pelvic fractures are very challenging to treat. Patients can easily exsanguinate from a pelvic fracture.
• Patients with suspected or proven severe pelvic fractures are likely to require initiation of massive transfusion protocol for optimal outcomes. A low threshold for resuscitation with blood products should be maintained.
• If the pelvic fracture is unstable, particularly in the case of an open-book fracture, the pelvic ring should be closed to assist with hemorrhage control. This can be accomplished with minimal equipment, such as wrapping a sheet snugly around the pelvis at the level of the greater trochanters (Figure 3).
• Several commercial devices, such as the T-pod (Figure 4), are also available and are generally more effective when used properly (centered over the greater trochanters) than using a sheet to wrap the pelvis.
• Field-expedient and commercial pelvic binders help control hemorrhage from the pelvis by decreasing the pelvic volume (Figure 5). An open-book fracture with separation of the pubic symphysis can increase the pelvic volume with potential for significant blood loss into the resultant space.

• Following initial stabilization and closure of the pelvic ring with a binder, several paths for the further management of these injuries are available and will be dictated by the presence of other life-threatening injuries, the patient’s hemodynamic and physiologic stability, and access to specialty services such as interventional radiology and orthopaedics.
• The management of hemodynamically unstable high-energy pelvic injuries remains controversial, and there are a number of proposed modalities.
• Alternatives for temporizing and/or definitive management of hemorrhage from pelvic fractures are as follows:
  • Pelvic binding, as described above, is a temporizing measure.
  • Pelvic packing can be either temporizing or definitive, depending on the source of hemorrhage.
  • Resuscitative endovascular balloon occlusion of the aorta (REBOA), as described in Chapter 22, is a temporizing measure that will allow for subsequent definitive management.
  • Intravascular embolization of hemorrhage using coils or gelfoam is done either in an interventional radiology suite or, preferably, in a hybrid operating room. This allows for definitive control of hemorrhage and is strongly supported by available literature (Level 1 recommendation) and 2011 EAST guidelines (east.org/education/practice- management-guidelines/pelvic-fracture- hemorrhageupdate-and-systematic-review).
  • Ligation of bilateral internal iliac arteries.
  • External (or delayed internal) fixation of the pelvic fracture is described in Chapter 28. Early fixation of the pelvic ring may assist with bleeding control and will help subsequent patient care and mobilization. In patients with hypotension, pelvic fixation should not delay the implementation of the other procedures described above.

Pelvic Packing

Considerations

• Timing and sequence of intervention for patients with hemorrhage from pelvic fractures is very dependent on local institutional practice, but hemodynamically unstable patients are best managed in the operating room (ideally a hybrid room). There, external fixation, preperitoneal packing, and angiographic embolization can be performed. If interventional radiology is not available or will be delayed, patients who are hemodynamically unstable should be considered for pelvic (retroperitoneal) packing.
• Classically, pelvic packing is performed through a dedicated incision in the lower abdomen. However, it must be remembered that patients who have significant pelvic trauma also have a high likelihood (roughly 35 percent) of associated intra-abdominal injuries, necessitating a laparotomy.
• Pelvic packing can serve as a temporizing measure, but in small series it has been shown to be definitive in up to 83 percent of patients.

Technique

• In patients in whom a concomitant trauma laparotomy is not indicated (ruled out by CT scan or other means), a midline incision is made between the umbilicus and the pubis (Figure 6).
• The rectus sheath is divided and the space of Retzius (preperitoneal space) is entered, taking care not to enter the peritoneum, which is displaced posteriorly along with the bladder (Figure 7).
• In the presence of a large pelvic hematoma, dissection of the retroperitoneal space will have been accomplished by the hematoma. The hematoma is evacuated by hand, and packs are placed on either side (usually three or four per side) as far posteriorly as possible to tamponade bleeding (Figure 8). Be mindful of bony shards when placing the packs.

• The fascia is then closed over the packs (Figure 9), which will be removed once the patient’s physiology has been corrected and any bleeding controlled.
• If the patient has intra-abdominal injuries that require a laparotomy as well as an unstable pelvic fracture, pelvic packing can still be performed. This requires that the lower portion of the peritoneum be left intact. This can be accomplished by stopping the laparotomy incision just below the umbilicus and making a second incision inferiorly along the midline (Figure 10).
• Alternatively, the pelvis can be packed through a standard single-incision trauma laparotomy in which the lower portion of the peritoneum is left intact and the space of Retzius is entered above the peritoneum to allow placement of packs (Figures 11 and 12).

Evaluation of Injuries to the Perineum

• After abdominal sources of bleeding have been controlled, the next step is a detailed examination for injuries of the perineum, genitalia, and rectum. A speculum and rigid sigmoidoscopy should be used to evaluate for injury of the vagina and rectum, respectively. The patient may also require evaluation with retrograde urethrogram.
• Removal of debris and foreign bodies, as well as debridement of devitalized tissue followed by copious irrigation, can be helpful in delineating the extent of injury. Complex injuries such as those seen in Figures 1 and 2 are examples of complex soft-tissue injuries of the perineum that require careful evaluation, irrigation, debridement, and packing.
• If the injury involves the anorectal region, or if the injury is so extensive that there will be possibility of significant ongoing contamination during defecation, a diverting-loop colostomy may be needed to divert fecal flow from the injury site. This does not always have to be done at the initial operation.
• Reconstruction of extensive soft-tissue injuries should be delayed due to the risk of ongoing contamination, necrotizing infection, and sepsis. Involvement of subspecialty expertise is advisable for the reconstruction of these difficult injuries.
• All fractures should be immobilized as soon as possible.