Pre-Peritoneal Pelvic Packing with Bilateral Ligation of Internal Iliac Arteries for 
Exsanguinating Pelvic Trauma Hemorrhage  
Dinesh Bagaria, Subodh Kumar 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Retroperitoneal hemorrhage secondary to 
pelvic fractures is a significant contributor to trauma 
hemorrhage-related preventable deaths. The origin 
of hemorrhage is primarily venous origin in 85% and 
arterial in 15% of such patients. The treatment 
options are:  
• Pelvic circumferential compression devices 
• External fixator application 
• Pre-peritoneal pelvic packing  
• Angioembolization,  
• Bilateral ligation of the internal iliac arteries  
 
Most hospitals will use various combinations 
of the above based on availability and expertise. 
Pelvic 
circumferential 
compression 
device 
application is a noninvasive intervention and helps in 
reducing bleeding by giving a tamponade effect. 
External fixators are becoming less popular as they 
failed in various studies to provide a better impact 
over pelvic circumferential compression devices. 
The 
available 
literature 
recommends 
using 
angioembolization as a principal treatment option: 
trauma centers in high-resource settings often have 
“hybrid operating rooms” where surgeons and 
interventional radiologists can perform percutaneous 
and open interventions simultaneously. 
In settings like ours, the combination of 
pelvic compression, pre-peritoneal packing, and 
bilateral ligation of the internal iliac is an alternative 
that may be used in such situations. This combination 
addresses both venous and arterial sources of 
bleeding. Our group and Choi et al. have showed 
applicability and acceptable outcomes using this 
technique. 
The steps of preperitoneal packing and 
bilateral ligation of the internal iliac arteries are:  
• Midline laparotomy and exclusion/dealing with 
other sources of hemorrhage. 
• Entry into Zone 3 hematoma and pelvic pre-
peritoneal packing. 
• Retroperitoneal dissection at common iliac artery 
bifurcation 
and 
internal 
iliac 
artery 
ligation/clipping.  
• Closure of Laparotomy or management as the 
open abdomen. 
 
Steps: 
1. A trauma victim with hemodynamic instability 
will undergo a primary survey and simultaneous 
resuscitation as per standard protocols. A pelvic 
circumferential compression device will be 
applied in suspected pelvic fracture patients. 
Those deemed non-responders will be wheeled 
into the operating theatre for surgery. A variety 
of strategies can be used for pelvic compression. 
Patients with an “open book” pelvic fracture with 
pubic symphysis diastasis will respond best to the 
treatment described here. Iliac wing fracture is an 
absolute contraindication to pelvic compression. 
Every method of pelvic compression applies 
pressure on the greater trochanters of the femurs 
(not the iliac wings) and leaves all of the 
abdomen exposed, allowing for laparotomy.  
 
A bedsheet is used as a pelvic circumferential compression 
device when commercial devices are not available. 
 
Pre-Peritoneal Pelvic Packing with Bilateral Ligation of Internal Iliac Arteries for 
Exsanguinating Pelvic Trauma Hemorrhage  
Dinesh Bagaria, Subodh Kumar 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
A commercially available pelvic binder in a high-resource 
setting: the mechanism on the front allows it to be pulled tight 
evenly. Source: DOI: 10.1038/s41598-021-82835-8 
 
2. Once the patient is in the operating room and 
undergoing simultaneous resuscitation, midline 
laparotomy will be done with the intention of 
stopping all bleeding.  
3. After entering the peritoneal cavity, a quick 
exploration of the abdomen viscera will be done 
to rule out any other simultaneous source of 
hemorrhage.  Around 15% of patients with pelvic 
fracture may have a second important bleeding 
source besides the pelvis, requiring some 
intervention.  
4. Once this second source is ruled out or addressed, 
the perivesical space is entered (“Space of 
Retzius”- called Zone 3 in trauma nomenclature.) 
Manually separate the peritoneum from the inner 
aspects of the pubic symphysis and pelvic ring.  
The hematoma is evacuated to create space for 
packing, and two to three surgical pads are 
packed on either side of the bladder from 
posterior to anterior. 
 
The zone 3 hematoma is evacuated, and 2-3 laparotomy pads 
are placed as packs on either side of the bladder. The forceps 
on the left side of the photo holds the peritoneum that has been 
dissected off of the pubic symphysis. 
 
5. To augment the tamponade effect, the stripped 
peritoneum will be sutured back to the rectus 
muscle edges.  
 
The peritoneum is sutured to the rectus muscle edges. 
 
6. Starting from the bifurcation of the aorta, follow 
the common iliac artery until its bifurcation. The 
Pre-Peritoneal Pelvic Packing with Bilateral Ligation of Internal Iliac Arteries for 
Exsanguinating Pelvic Trauma Hemorrhage  
Dinesh Bagaria, Subodh Kumar 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
peritoneum is dissected at the common iliac 
bifurcation to expose internal and external iliac 
arteries and adjacent ureter.  
 
Shown here on the patient’s left side, the posterior peritoneum 
is dissected at the bifurcation of the common iliac artery to 
expose its division into internal and external iliac arteries, with 
the adjacent ureter carefully preserved. 
 
7. The internal iliac artery will be separated 
carefully from the underlying vein and ureter.  
Now, it can be suture ligated, or clipped if clips 
are available. Clipping is preferable, because the 
clips can be removed at a later time, such as 
during abdominal re-exploration.  
 
Shown here on the patient’s right side, the internal iliac artery 
is dissected from surrounding structures (shown here, encircled 
with a blue vessel loop) and clipped or ligated. 
 
8. The same dissection and clipping will be done to 
the other side. 
 
Shown here on the patient’s left side, the internal iliac artery is 
dissected from surrounding structures and clipped or suture-
ligated. 
 
Pre-Peritoneal Pelvic Packing with Bilateral Ligation of Internal Iliac Arteries for 
Exsanguinating Pelvic Trauma Hemorrhage  
Dinesh Bagaria, Subodh Kumar 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
9. If the fascia can be sutured closed, this will 
increase the pressure effect of the pelvic packing. 
If the patient is hemodynamically unstable or the 
fascia cannot be closed due to edema, perform 
Temporary Abdominal Closure. Now, the patient 
will be shifted to the ICU for further resuscitation.  
The patient will be taken back to the operating 
theatre within 24-48 hours but not later than 72 
hours to remove the packs. Our practice is to 
obtain a contrast-enhanced CT scan before re-
exploration to find any missed injuries that may 
require intervention.  
 
Open abdomen treated with “Bogota bag,” one of the options 
for when the fascia cannot be closed. In the situation of pelvic 
fracture, this closure maintains tension on fascia and may 
maintain better pressure on the packing within the pre-pelvic 
space. See the chapter on Temporary Abdominal Closure in this 
Manual for further details.  
 
Pitfalls 
• Due care needs to be taken to avoid injuries to the 
underlying veins. Dissect very carefully. Such 
venous injuries in already compromised patients 
might be fatal. 
• Inadvertent ligation/clipping of external iliac 
arteries. Always make sure the anatomy is clear 
through careful dissection. If it isn’t clear, 
occlude the vessel that you plan to ligate with 
finger pressure and feel for the femoral pulse. 
Have an assistant check pulses in the bilateral 
lower limbs manually, or use Doppler in 
hypotensive patients. 
• Iatrogenic ureter injuries are to be avoided by 
careful dissection and awareness of their usual 
course. Be aware that a pelvic hematoma may 
displace them.  
• Perineal ischemic necrosis is a theoretical 
possibility after bilateral internal iliac artery 
ligation. The incidence is lower than was 
originally thought. If the patient has perineal 
injuries these may have difficulty healing. 
However this concern should not prevent you 
from applying this life-saving intervention. 
 
Dinesh Bagaria MS FACS 
All India Institute of Medical Sciences 
New Delhi, India 
 
Subodh Kumar MS MNAMS FAMS FACS FRCS 
(Glasgow) 
All India Institute of Medical Sciences 
New Delhi, India 
 
April 2024 
