High-impact technical and patient management tips from the 2024 AAST Continuous Certification Course - Practical insights for trauma and acute care surgery

Sep 29, 2026

Uploaded by McQueen

Trauma and acute care surgeons balance rapid intervention with evolving technique and cutting-edge technology. This article compiles practical, experience-driven guidance from a lunch session at the American Association for the Surgery for Trauma Annual Meeting 2024, covering preperitoneal pelvic packing, trauma video review, video-assisted thoracic surgery for retained hemothorax, and laparoscopic common bile duct exploration. Across topics, the shared focus is refining technical precision, strengthening team performance, and improving patient outcomes through deliberate practice, including detailed operative steps and key pitfalls for preperitoneal pelvic packing.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages7

Reading Time18 min

AccessFree to download

Summary

Preperitoneal pelvic packing and control of pelvic fracture-associated hemorrhage

Technique

Major pitfalls

Operative timing and follow-up

Additional topics from the course session

Trauma video review

Video-assisted thoracic surgery for retained hemothorax

Laparoscopic common bile duct exploration

Open access Review High-impact technical and patient management tips from the 2024 AAST Continuous Certification Course: preperitoneal pelvic packing, trauma video review, video-assisted thoracic surgery for retained hemothorax, and laparoscopic common bile duct exploration Clay Cothren Burlew Emma Gilman Burke Matthew J Martin 6 , 1 Whitney Renee Jenson ,2 Katherine Cironi ,3 ,4 Ryan Peter Dumas ,4 Rachel D Appelbaum ,5 1Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA 2Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA 3University of Southern California, Los Angeles, California, USA 4Surgery, Baylor College of Medicine, Houston, Texas, USA 5Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA 6Division of Acute Care Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA Correspondence to Dr Whitney Renee Jenson; whitney.jenson@cuanschutz. edu Received 2 May 2025 Accepted 23 November 2025 © Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. To cite: Burlew CC, Jenson WR, Cironi K, et al. Trauma SurgAcute Care Open 2025;10:e001910 . SUMMARY Trauma and acute care surgeons are constantly balancing the need for rapid, decisive intervention with the ongoing evolution of surgical technique and cuttingedge technology. This article presents a collection of practical, experience-driven insights across four topics that reflect the modern breadth of trauma and acute care surgery presented during a lunch session at the American Association for the Surgery for Trauma Annual Meeting 2024: preperitoneal pelvic packing, trauma video review, video-assisted thoracic surgery for retained hemothorax, and laparoscopic common bile duct exploration. Although seemingly disparate, these topics are united by a common goal: enhancing technical precision, team performance, and patient outcomes through deliberate, refined practice. PACK LIKE A PRO: PREPERITONEAL PELVIC PACKING AND CONTROL OF PELVIC FRACTUREASSOCIATED HEMORRHAGE While the majority of pelvic fractures result from low energy mechanisms and do not result inhemodynamic instability, a subgroup of patients will experience significant pelvic fracture-related hemorrhage resulting in mortality rates as high as 32%–41%.1–3 There are multiple options for the management of patients with serious bleeding secondary to pelvic fractures, primarily consisting of preperitoneal pelvic packing (PPP), angioembolization (AE), and resuscitative balloon occlusion of the aorta (REBOA). PPP has repeatedly been demonstrated to have a shorter time-to-intervention as well as time required for intervention compared with AE2 4–7 and, as such, should be in the armamentarium of all surgeons. Technique PPP is performed by first externally stabilizing the pelvis to both reduce the pelvic volume and provide a stable surface against which tamponade can be created. Pelvic stabilization is ideally performed with an external fixator or a c-clamp. The specific conformation of the external fixator should be discussed with the orthopedic team prior to placement, particularly if an exploratory laparotomy is to be performed so that the crossbar does not obscure the operative field. If external fixators orc-clamps are not available, the pelvic binder should be repositioned so that the superior margin is below the pubic symphysis and out of the operative field. When extrapelvic sources of hemorrhage exist, these may be addressed while the pelvis is stabilized by the orthopedic team. A midline incision is made from the pubic symphysis superiorly extending approximately 6–8 cm. The subcutaneous tissue and the midline fascia are divided, leaving the underlying peritoneum intact. At this point, the pelvic hematoma is usually encountered. If the

FAQs

Why is preperitoneal pelvic packing important in pelvic fracture hemorrhage?

A subset of pelvic fracture patients develops significant hemorrhage with high mortality risk. Preperitoneal pelvic packing has demonstrated shorter time-to-intervention and shorter time required for intervention compared with angioembolization, supporting its inclusion for serious bleeding management.

What are the core steps of preperitoneal pelvic packing?

The pelvis is externally stabilized to reduce volume and provide a stable tamponade surface. A midline incision is made to access the preperitoneal space, the pelvic hematoma is unroofed, and laparotomy pads are placed posteriorly in the presacral space then moved anteriorly around the bladder; placement is repeated on both sides with suprapubic catheter placement when needed.

What is the main pitfall of preperitoneal pelvic packing and how is it avoided?

A major pitfall is decompression of the pelvic hematoma into the peritoneal cavity or externally. The text advises using a separate, more lateral stab incision for suprapubic catheter needs and creating a cranial separate incision above the umbilicus if a laparotomy is required.

Sep 29, 2026

Uploaded by McQueen