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House B, Pansky EL; Review of Gross Anatomy 2nd ed; p377; Macmillan New York 1970 |
We had an interesting pelvic bleed case this past week of three gunshot wounds of the right back extending caudad into the left pelvis. Laparotomy showed multiple small bowel and a sigmoid colon penetrations. These were managed by colon resection and colostomy and enterostomies. At the end of bowel repairs, a small hematoma at left pelvic brim started to expand. It was explored and massive uncontrolled hemorrhage required 28 units.
After packing, he was brought to the ICU for rewarming and resuscitation. Bleeding continued requiring 20 additional units of packed cells. Patient was reexplored about 12 hours after first exploration and extensive hemorrhage ensued after packs were removed. The surgeon placed a vascular clamp and vascular loops on the origin of the internal iliac artery. The abdomen was repacked and closed with clamp extending out of abdomen. He was then brought to angio.
At angio, aortography was normal. The catheter was then placed into the origin of the hypogastric but it could not go past the clamp. The clamp was released from the iliac artery and removed from the abdomen. The catheter then easily advanced deeper into the hypogastric artery.
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House B, Pansky EL; Review of Gross Anatomy 2nd ed; p377; Macmillan New York 1970 |
Angiography showed transection of the internal iliac artery as the anterior division divided into multiple branches. The vessel was then embolized with two coils. He had persistent bleeding so angiography was repeated. The hypogastric artery bleeding was still stopped. However, retroperitoneal bleeding from the right third lumbar artery was bleeding and this was controlled with gelfoam pledgets. Bleeding stopped and transfusion requirements stopped.
I thought that internal iliac artery clamping was a great option in this case once pelvic hemorrhage could not be controlled in the OR. This might also have applications for blunt pelvic fracture hemorrhage when a patient must undergo exploratory laparotomy prior to angiography.