Preperitoneal Packing for Pelvic Hemorrhage Control

Preperitoneal packing is an emergency surgical technique in which laparotomy sponges are placed directly against the bleeding surfaces inside the pelvis to create pressure, or tamponade, that slows or stops life-threatening hemorrhage from unstable pelvic fractures. The procedure targets a specific problem: most bleeding from severe pelvic injuries comes from fractured bone surfaces and torn veins rather than from arteries, and this diffuse, low-pressure bleeding does not respond well to the catheter-based clot-sealing technique (angioembolization) that works on arterial bleeds. Because it can be performed quickly in an operating room without specialized radiology equipment, preperitoneal packing has become a central tool in damage-control resuscitation for patients who are crashing from pelvic blood loss.

Who Needs Preperitoneal Packing

Not every pelvic fracture requires this procedure. The vast majority of pelvic breaks are stable enough to manage with blood transfusions, pelvic binders, and close monitoring. Preperitoneal packing is reserved for the subset of patients whose blood pressure stays dangerously low despite aggressive fluid and blood replacement. One widely used threshold is persistent systolic blood pressure below 90 mmHg during initial resuscitation despite receiving at least two units of packed red blood cells.¹ These patients are typically in hemorrhagic shock, often with Injury Severity Scores in the high range, meaning they have sustained major trauma to multiple body systems.

The decision to pack rather than pursue angioembolization depends on the suspected source of bleeding and what resources are available. Angioembolization, in which an interventional radiologist threads a catheter to a bleeding artery and seals it, is effective for arterial hemorrhage and is supported by established trauma guidelines. But the majority of pelvic fracture patients bleed primarily from veins and bone, not arteries. For these patients, packing addresses the actual source of blood loss more directly.² And in hospitals where interventional radiology is not available around the clock, packing can be a lifesaving fallback that any trained trauma surgeon can perform.

How the Procedure Works

The word “preperitoneal” describes the anatomical space targeted. The peritoneum is the thin membrane lining the abdominal cavity. In a standard abdominal surgery, the surgeon opens through the peritoneum to access organs. In preperitoneal packing, the surgeon deliberately stays in front of that membrane, working in the narrow space between it and the pelvic bones. This matters because the bleeding from pelvic fractures collects in this space, and staying out of the abdominal cavity avoids disturbing organs and potentially worsening things.

The procedure begins with stabilizing the pelvis externally. A pelvic binder, external fixator, or C-clamp is applied to reduce the volume of the pelvis and provide a rigid surface for the packing to press against.³ Reducing the pelvis and stabilizing the ring creates a self-tamponade effect, which alone can slow bleeding substantially.⁴ The surgeon then makes a small midline incision below the navel, identifies the preperitoneal space, and pushes the peritoneum and its contents upward and backward. Laparotomy sponges are packed firmly into the space on each side of the bladder, pressing against the fractured bone and torn vessels. The goal is direct compression: the sponges create enough pressure to slow or stop the venous and bony bleeding that makes up most of the hemorrhage.

When packed tightly, this approach can also help control some arterial bleeding, though its primary strength is against the lower-pressure venous and bony sources.⁵ The incision is then closed temporarily, and the patient is moved to the intensive care unit for ongoing resuscitation. The sponges are typically removed within 24 to 72 hours in a planned return to the operating room.

The Speed Advantage Over Angioembolization

In a patient who is hemorrhaging, every minute counts. One of the strongest arguments for preperitoneal packing is how much faster it can be performed compared to angioembolization. A systematic review and meta-analysis comparing the two approaches found that the average time from admission to operating room for packing was about 60 minutes, while the average time to intervention for angioembolization was about 131 minutes, a difference of roughly 71 minutes.⁶ That gap is not trivial when blood pressure is dropping and organs are being starved of oxygen.

A separate quasi-randomized trial of 56 severely injured patients reported similar findings: median time from admission to intervention was 77 minutes for packing versus 102 minutes for angioembolization, and actual procedure time was shorter too, at 60 minutes versus 84 minutes.⁷ The delay with angioembolization stems from needing an interventional radiology suite, assembling a specialized team, and navigating catheters to the bleeding vessels under fluoroscopy. Packing requires only a standard operating room, a surgeon, and laparotomy sponges.

This does not mean packing replaces angioembolization entirely. After initial stabilization with packing, a subset of patients still need angioembolization for arterial bleeding that packing alone cannot control. In one series, about 13% of patients who underwent packing went on to angioembolization, typically several hours later once they were stable enough to tolerate the procedure.⁸ The two methods are increasingly seen as complementary rather than competing, with packing buying time for the more targeted arterial intervention.

Mortality and Transfusion Outcomes

Without hemorrhage control, unstable pelvic fractures carry devastating mortality rates. One study noted mortality as high as 52% in hemodynamically unstable patients who did not receive preperitoneal packing. In a cohort that did receive packing, that rate dropped to about 30%.⁹ A 30% mortality rate is still high, but these are patients who would otherwise face even longer odds. The improvement reflects not just the packing itself but the overall damage-control approach it is embedded in, including early blood products, pelvic stabilization, and intensive-care management.

Packing also appears to reduce the ongoing need for blood transfusions. One early study of the technique found that transfusion requirements dropped significantly after the procedure: patients needed an average of about 12 units of blood before reaching the intensive care unit, but only about 6 units in the 24 hours afterward.¹⁰ That halving of blood use matters enormously in trauma settings where blood products are a finite resource and massive transfusion itself carries risks.

Combining Packing With REBOA

One of the more recent developments in managing catastrophic pelvic bleeding is pairing preperitoneal packing with REBOA, short for resuscitative endovascular balloon occlusion of the aorta. REBOA involves inserting a balloon catheter into the aorta and inflating it to temporarily block blood flow to the lower body. This buys time by reducing hemorrhage while the surgical team works, though it cannot be left inflated for long without risking damage to tissues downstream.

A study comparing patients who received packing alone versus packing combined with REBOA found that the combination was used in more severely injured patients with worse physiological states going in. Despite that disadvantage, there were no deaths from acute pelvic hemorrhage in the group that received both, suggesting the combination provides a level of hemorrhage control that neither technique achieves alone.¹¹ The REBOA patients did require more blood transfusions overall, consistent with the severity of their injuries, but the fact that none bled to death from their pelvic fractures is a striking result. This “inflate and pack” strategy is gaining traction at major trauma centers, though it requires familiarity with both techniques.

Complications and Risks

Packing is not without downsides. Leaving foreign material in a wound creates conditions favorable for infection. The most concerning complication is pelvic infection, and the risk factors are fairly well defined. A study examining infection after preperitoneal packing found that patients with open fractures (where bone has broken through the skin) had much higher infection rates, with 55% of patients who developed pelvic infections having open fractures compared to 17% of those who did not get infected. Undergoing angioembolization in addition to packing, needing repeat packing, and having sponges in place longer were also associated with higher infection rates.¹²

This is why timely removal matters. The standard approach is to return to the operating room within 24 to 48 hours to remove the sponges once the patient is more stable. Leaving packing in place beyond that window increases infection risk and can contribute to other problems. There is also a theoretical risk of increased pressure within the abdomen from the packing material, particularly in patients who are already receiving large volumes of fluid resuscitation, which itself causes tissue swelling. The interplay between packing, massive fluid resuscitation, and abdominal pressure is something trauma teams monitor closely in the ICU.

Hemostatic Gauze as a Refinement

Standard laparotomy sponges provide mechanical compression, but researchers have explored whether sponges treated with clotting agents could improve results. Kaolin-impregnated hemostatic gauze, which promotes blood clotting on contact, has been tested against regular gauze in preperitoneal packing. A propensity-matched analysis found that patients packed with hemostatic gauze needed significantly fewer blood transfusions in the 12 hours after the procedure compared to those packed with standard gauze (roughly 4 units versus nearly 8 units). Mortality from hemorrhage did not differ significantly between the two groups, but the reduced transfusion burden is clinically meaningful, as fewer transfusions mean lower risk of transfusion-related complications and less strain on blood banks.¹³

This kind of incremental improvement illustrates how the technique continues to be refined even as its basic concept remains the same. The core idea of compressing bleeding surfaces with sponges is straightforward; the details of what the sponges are made of, how many to use, and exactly where to place them are where the technique continues to evolve.

Uses Beyond Pelvic Trauma

While unstable pelvic fractures from blunt trauma are the primary indication, the same principle of preperitoneal packing has been adapted for other situations. One notable application is in obstetric hemorrhage. After a hysterectomy performed for uncontrollable postpartum bleeding, the resulting pelvic cavity can hemorrhage from diffuse venous sources in much the same way a fractured pelvis does. Case reports and small series have described packing the pelvis in these patients using the same technique, with authors arguing it should be included in obstetric hemorrhage protocols as a life-saving option.¹⁴

The technique has also been applied in children. Pediatric pelvic fractures with hemodynamic instability are rare, which means most surgeons will encounter them infrequently. A case report describing the successful use of preperitoneal packing combined with external fixation in a child with an unstable pelvis highlighted its potential as a management strategy in this population, where the small body size makes angioembolization technically more challenging and specialized pediatric interventional radiology may not be available.¹⁵

Training and Simulation

One challenge with preperitoneal packing is that the patients who need it are relatively uncommon. Even at busy trauma centers, a surgeon might perform it only a handful of times per year, which makes building proficiency difficult. This has driven interest in simulation-based training. A pelvic emergency simulator designed to mimic the anatomy and active bleeding of a pelvic fracture allows trainees to practice the technique in a controlled setting. In one study using such a simulator, participants achieved bleeding control through packing in an average of about 6 minutes, with total simulated blood loss during the training session averaging around 1,300 mL.¹⁶

The 6-minute figure for achieving bleeding control is encouraging because it suggests the technical steps, once learned, can be executed rapidly. The larger challenge is recognizing when the technique is indicated and integrating it smoothly into a trauma team’s workflow alongside pelvic binding, blood transfusion, and the decision about whether to pursue angioembolization afterward. Simulation gives surgeons the muscle memory for the procedure itself, but the decision-making framework around it requires broader institutional protocols and team-based training that go beyond any single surgeon’s hands.

Where the Field Stands

The evidence base for preperitoneal packing has grown substantially over the past two decades, but it remains composed mostly of retrospective case series and single-center studies rather than large randomized trials. The nature of the injury makes classic trial design almost impossible: you cannot randomize a dying patient to a delayed intervention, and the patients who need packing are too sick and too variable for clean comparisons. The meta-analyses that exist are limited by the quality of the underlying studies, and the numbers are smaller than what you would see in, say, a cardiovascular drug trial.

What the available evidence does show fairly consistently is that preperitoneal packing is faster to perform than angioembolization, reduces ongoing blood loss, and is associated with lower mortality than historical controls who did not receive it. Whether it is better than angioembolization in a head-to-head comparison is harder to say, partly because the two techniques address different bleeding sources and are increasingly used together rather than as alternatives. The trend in major trauma centers is toward a protocol-driven approach where packing is the first step for hemodynamically unstable patients, with angioembolization reserved for persistent arterial bleeding identified after initial stabilization. The question is no longer really “packing or embolization” but rather “in what order and for whom.”

Many trauma centers outside of major academic hubs still rely primarily on angioembolization when it is available, and some lack the institutional experience with preperitoneal packing to offer it confidently. Broader adoption depends on training programs, simulation availability, and institutional protocols that give surgeons a clear decision pathway when a patient arrives in hemorrhagic shock from a pelvic fracture. The technique itself is not complicated, but the situation in which it is needed is among the most chaotic and high-stakes in all of surgery.