Les traumatismes pénétrants du pelvis : accueil, bilan et prise en charge chirurgicale en urgence

Penetrating trauma of the pelvis (PTP) is defined as a wound extending within the bony confines of the pelvis to involve the vascular, intestinal or urinary pelvic organs. The gravity of PTP is related to initial hemorrhage and the high risk of late infection. If the patient is hemodynamically unstable and in hemorrhagic shock, the urgent treatment goal is rapid achievement of hemostasis. Initial strategy relies on insertion of an intra-aortic occlusion balloon and extraperitoneal pelvic packing, performed while volume resuscitation is ongoing before proceeding to arteriography. If hemodynamic instability persists, a laparotomy for hemostasis is performed without delay. In a hemodynamically stable patient, contrast-enhanced CT is systematically performed to obtain a comprehensive assessment of the lesions prior to surgery. At surgery, damage control principles should be applied to all involved systems (digestive, vascular, urinary and bone), with exteriorization of digestive and urinary channels, arterial revascularization, and wide drainage of perirectal and pelvic soft tissues. When immediate definitive surgery is performed, management must address the frequent associated lesions in order to reduce the risk of postoperative sepsis and fistula.