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Li H, Ai T, Huang GB, Yang J, Wei GB, Gao JM, He P, Cao XM, Du DY. Internal iliac artery ligation as a damage control method in hemodynamically unstable pelvic fractures: A systematic review of the literature. Chin J Traumatol 2024; 27:288-294. [PMID: 39025704 DOI: 10.1016/j.cjtee.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 06/20/2024] [Accepted: 07/02/2024] [Indexed: 07/20/2024] Open
Abstract
PURPOSE Internal iliac artery ligation (IIAL) has been used as a damage control procedure to treat hemodynamically unstable pelvic fracture for many years. However, there is ongoing debate regarding the effectiveness and safety of this hemostatic method. Therefore, we performed a systematic literature review to assess the efficacy and safety of IIAL for pelvic fracture hemostasis. METHODS Three major databases, PubMed, Embase, and Google Scholar, were searched to screen eligible original studies published in English journals. Two reviewers independently read the titles, abstracts, and full texts of all literature. Articles were included if they reported the use and effects of IIAL. RESULTS A total of 171 articles were initially identified, with 22 fully meeting the inclusion criteria. Among the analyzed cases, up to 66.7% of patients had associated abdominal and pelvic organ injuries, with the urethra being the most frequently injured organ, followed by the bowel. The outcomes of IIAL for achieving hemostasis in pelvic fractures were found to be satisfactory, with an effective rate of 80%. Hemorrhagic shock was the leading cause of death, followed by craniocerebral injury. Notably, no reports of ischemic complications involving the pelvic organs due to IIAL were found. CONCLUSION IIAL has a good effect in treating hemodynamically unstable pelvic fracture without the risk of pelvic organ ischemia. This procedure should be considered a priority for hemodynamically unstable pelvic fracture patients with abdominal organ injuries.
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Affiliation(s)
- Hui Li
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Tao Ai
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Guang-Bin Huang
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Jun Yang
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Gong-Bin Wei
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Jin-Mou Gao
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Ping He
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Xue-Mei Cao
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
| | - Ding-Yuan Du
- Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China.
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Madsen JE, Flugsrud GB, Hammer N, Puchwein P. Emergency treatment of pelvic ring injuries: state of the art. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05447-7. [PMID: 38970673 DOI: 10.1007/s00402-024-05447-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 06/29/2024] [Indexed: 07/08/2024]
Abstract
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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Affiliation(s)
- Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Kirkeveien 166, 0450, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Klaus Torgårds Vei 3, 0372, Oslo, Norway.
| | | | - Niels Hammer
- Division of Macroscopic and Clinical Anatomy Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
- Department of Orthopaedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
- Division of Medical Technology, Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Dresden, Germany
| | - Paul Puchwein
- Department of Orthopaedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
- Division of Medical Technology, Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Dresden, Germany
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
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Kostov S, Kornovski Y, Watrowski R, Slavchev S, Ivanova Y, Yordanov A. Internal Iliac Artery Ligation in Obstetrics and Gynecology: Surgical Anatomy and Surgical Considerations. Clin Pract 2023; 14:32-51. [PMID: 38248429 PMCID: PMC10801552 DOI: 10.3390/clinpract14010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 12/13/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
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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Affiliation(s)
- Stoyan Kostov
- Research Institute, Medical University Pleven, 5800 Pleven, Bulgaria;
- Department of Gynecology, Hospital “Saint Anna”, Medical University, 9002 Varna, Bulgaria (S.S.); (Y.I.)
| | - Yavor Kornovski
- Department of Gynecology, Hospital “Saint Anna”, Medical University, 9002 Varna, Bulgaria (S.S.); (Y.I.)
| | - Rafał Watrowski
- Department of Obstetrics and Gynecology, Helios Hospital Müllheim, 79379 Müllheim, Germany;
- Faculty Associate, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Stanislav Slavchev
- Department of Gynecology, Hospital “Saint Anna”, Medical University, 9002 Varna, Bulgaria (S.S.); (Y.I.)
| | - Yonka Ivanova
- Department of Gynecology, Hospital “Saint Anna”, Medical University, 9002 Varna, Bulgaria (S.S.); (Y.I.)
| | - Angel Yordanov
- Department of Gynecologic Oncology, Medical University Pleven, 5800 Pleven, Bulgaria
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Moeng MS, Viljoen F, Makhadi S. The Role for Preperitoneal Pelvic Packing in Low-to-Middle-Income Countries: A 16-Year Experience at a Johannesburg Trauma Unit. World J Surg 2023; 47:2651-2658. [PMID: 37716931 PMCID: PMC10545629 DOI: 10.1007/s00268-023-07173-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/18/2023]
Abstract
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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Affiliation(s)
- Maeyane Stephens Moeng
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Francois Viljoen
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Shumani Makhadi
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa.
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Choi K, Kim JT. Reply to the Letter to the editor concerning "Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma". Injury 2023; 54:110901. [PMID: 37595487 DOI: 10.1016/j.injury.2023.110901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/12/2023] [Indexed: 08/20/2023]
Affiliation(s)
- Kyunghak Choi
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea
| | - Jihoon T Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, Republic of Korea.
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Bagaria DK. Letter to Editor: Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma. Injury 2023; 54:1015. [PMID: 36628815 DOI: 10.1016/j.injury.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023]
Affiliation(s)
- Dinesh Kumar Bagaria
- JPN Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
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