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 surgeon’s urgent goals are hemostasis and control of contamination; 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 10–12 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 transported 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 unexpectedly, 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 facilitate exposure in the pelvis. Likewise, have the appropriate sutures (4–0 Prolene for the iliac artery, 3–0 for the aorta, and 6–0 for the iliac vein), grafts, and vascular shunts available. 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 penetrating 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 borders the extremities, and injuries to the pelvis can also involve the groins or more distal structures. When more distal 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 hematoma 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 vessels 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 inferior Vena Cava (IVC) can also be achieved with simple compression.