World J Surg (2012) 36:2761–2766
DOI 10.1007/s00268-012-1745-3
The 1–2–3 Approach to Abdominal Packing
Carlos Ordoñez • Luis Pino • Marisol Badiel • Alvaro Sanchez • Jhon Loaiza •
Oscar Ramirez • Fernando Rosso • Alberto Garcı́a • Marcela Granados •
Gustavo Ospina • Andrew Peitzman • Juan Carlos Puyana • Michael W. Parra
Published online: 6 September 2012
Ó Société Internationale de Chirurgie 2012
Abstract
Background Abdominal packing (AP) in damage-control
laparotomy (DCL) is a lifesaving technique that controls
coagulopathic hemorrhage in severely injured trauma
patients. However, the impact of the duration of AP on the
incidence of re-bleeding and on intra-abdominal infections
in penetrating abdominal trauma is not clear. The objective
of the present study was to evaluate the complications
related to the duration of AP and to determine the optimal
time for AP removal.
Methods Prospectively collected/retrospectively analyzed
data at an urban level I trauma center from January 2003 to
C. Ordoñez (&)
L. Pino
A. Garcı́a
Departamento de Cirugı́a, Fundación Valle del Lili, Avenida
Simón Bolivar, Carrera 98 Número 18-49, Cali, Colombia
e-mail: marisolbadiel@yahoo.com.mx;
ordonezcarlosa@gmail.com
C. Ordoñez
L. Pino
F. Rosso
A. Garcı́a
M. Granados

G. Ospina
Unidad de Cuidado Intensivo, Fundación Valle del Lili, Cali,
Colombia
C. Ordoñez
L. Pino
A. Garcı́a
Departamento de Cirugı́a, Universidad del Valle, Cali, Colombia
M. Badiel
J. Loaiza
O. Ramirez
Instituto de Investigaciones Clı́nicas, Fundación Valle del Lili,
Cali, Colombia
A. Sanchez
A. Peitzman
J. C. Puyana
Department of Surgery, University of Pittsburgh, Pittsburgh, PA,
USA
M. W. Parra
Division of Trauma Critical Care, Broward General Level I
Trauma Center/Delray, Provisional Level I Trauma Center,
Ft. Lauderdale, FL, USA
December 2010 were used as the basis for this study.
Inclusion criteria were adults (C18 years old) with pene-
trating abdominal trauma, who had survived both the initial
DCL procedure and their first re-laparotomy. All initial
DCL patients included in the study underwent abdominal
packing for coagulopathic hemorrhage control. The out-
come measures of this study were re-bleeding after packing
removal, intra-abdominal infection, and 30-day cumulative
mortality. We considered time after packing as an inde-
pendent variable. This was defined as the total amount of
time (in days) that the packs were left in the patient’s
abdomen. Patients were grouped according to the duration
in days of their AP in \1, 1–2, 2–3, and [3 days.
Results Of 503 patients with penetrating abdominal
trauma, 121 underwent DCL and AP. The mean age was
30.1 ± 11.5 years, and the male to female ratio was 9:1.
The mean Acute Physiology and Chronic Health Evaluation
(APACHE II) score was 17.6 ± 7.2. The mean Injury
Severity Score (ISS) score was 24.9 ± 9.1. The right upper
quadrant was packed in 39 (32.2 %) patients, retroperito-
neum in 70 (57.8 %), pelvis in 13 (10.7 %), and left upper
quadrant in 9 (7.4 %). Fifty-one patients (42.1 %) had
associated colon injuries and 58 (47.9 %) had small bowel
injuries. Twenty-six patients (21.5 %) had AP \1 day, 42
patients (34.7 %) had AP between 1 and 2 days, 35 patients
(28.9 %) had AP between 2 and 3 days, and 18 patients
(14.8 %) had AP [3 days. The re-bleeding rate in patients
packed for 1–2 days compared to those packed for \1 day
was a third lower, 14.3 %, (95 % confidence interval
[95 % CI]: 8.06, 20.5) versus 38.5 % (95 % CI: 25.4, 51.5).
Conversely, an increasing trend toward intra-abdominal
infection occurred as time after packing increased. The
infection rate tripled from 16.7 % (95 % CI: 6.6, 26.7) to
44.4 % (95 % CI: 31.03, 57.7) when comparing 1–2 days
versus [3 days. Overall mortality was 16.5 %. Of these
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deaths, 8.26 % were attributable to re-bleeding, and 13.2 %
to intra-abdominal infection. Deaths secondary to
re-bleeding seemed to decrease with time of AP, whereas
intra-abdominal infection deaths increased with time of AP
(Chi square for trend p value = 0.04).
Conclusions The present study suggests that AP used in
the setting of DCL for coagulopathic hemorrhage control
should not be removed prior to the first postoperative day
because of the increased risk of re-bleeding. The ideal
length of AP is 2–3 days, and AP left in longer than 3 days
is associated with a significantly increased risk of infec-
tious complications.
Introduction
Damage-control laparotomy (DCL) is a potentially life-
saving surgical strategy for critically injured patients. One
of the cornerstones of DCL is the immediate arrest of
severe bleeding from intra-abdominal parenchymal, major
vessel, and/or retroperitoneal injuries to avoid the devel-
opment of the lethal triad of hypothermia, acidosis, and
coagulopathy [1–4]. Hemostatic control during this early
phase of DCL usually requires abdominal packing (AP),
especially in the setting of destructive parenchymal injuries
in severe abdominal penetrating trauma. In cases where
surgical time is a crucial determinant of the patient’s sur-
vival, AP represents the fastest and most effective method
of hemorrhage control. This has made AP a lifesaving
technique that controls hemorrhage in severely injured
trauma patients [5–7]. However, the impact of the duration
of AP on the incidence of re-bleeding and on intra-
abdominal infections (IAI) in penetrating abdominal
trauma is not clear. Our study objective was to evaluate the
complications related to the duration of AP and to deter-
mine the optimal time for AP removal.
Materials and methods
Study population and design
The study was designed as a prospectively collected and
retrospectively analyzed data analysis at an urban level I
trauma center registry from January 2003 to December
2010. Inclusion criteria were adults (C18 years old) with
penetrating abdominal trauma, who had survived both the
initial DCL procedure and their first re-laparotomy. All
initial DCL patients included in the study underwent
abdominal packing for coagulopathic hemorrhage control.
This study was approved by the Institutional Review
Board.
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World J Surg (2012) 36:2761–2766
Variable definitions and measurements
The outcome measures of this study were re-bleeding after
packing removal, intra-abdominal infection, and 30-day
cumulative mortality. Re-bleeding was defined as bleeding
from the packed injury site that occurred after pack
removal and required re-packing. Intra-abdominal infection
was defined as either the development of a purulent intra-
abdominal collection identified at re-laparotomy or the
development of positive intra-abdominal cultures with
associated signs of systemic inflammatory response syn-
drome (SIRS). We considered time after packing as an
independent variable. This was defined as the total amount
of time (in days) that the packs were left in the patient’s
abdomen. Patients were grouped according to the duration
in days of their AP into four categories: \1, 1–2, 2–3, and
[3 days. All groups were compared by age, gender,
mechanism of injury, Injury Severity Score (ISS), New
Injury Severity Score (NISS), Abdominal Trauma Index
(ATI), Trauma Score (RTS), and Acute Physiology and
Chronic Health Evaluation (APACHE II).
Intervention
On each admission to our trauma center a standardized
damage-control resuscitation (DCR) guideline with a pre-
established institutional massive transfusion protocol
(MTP) with a 1:1:1 transfusion ratio of packed red blood
cells, fresh frozen plasma, and platelets was carried out by
a trained trauma team prior to transfer of the patient to the
operating room. The trauma surgeon on call decided
intraoperatively whether to perform a DCL with or without
AP according to the extent of the intra-abdominal injuries
found at initial laparotomy. Subsequently, the decision to
remove the AP was made by the same trauma surgeon
based on the following criteria:
1. Hemodynamic stability
2. Core temperature [36 °C
3. Corrected coagulopathy
4. Corrected metabolic acidosis
Intra-abdominal pressure was measured periodically in
all DCL with AP patients during their stay in the trauma
intensive care unit (ICU). Intravenous prophylactic anti-
biotics were given to all patients during AP. The most
commonly used prophylaxis was a combination of a third-
generation cephalosporin and metronidazole.
Statistical analyses
Data were collected from a DAMACON registry, which is
a World Wide Web database on a MySQL platform
(Hughes Technologies, Australia). We estimated absolute
World J Surg (2012) 36:2761–2766 2763

and relative frequencies of re-bleeding, intra-abdominal Table 2 Injury scores

infections, and death. Chi square for trend was performed. Time of N ATI median ISS NISS median
Graphical trends by time after packing were constructed. abdominal (IQR) median (IQR)
Statistical analyses were performed with STATA (version 8) packing (IQR)
software. (days)

\1 26 32 (17–43) 27 (20–34) 44 (37.5–51)

1–2 42 24 (17–35) 20 (16–25) 34 (27–50)
Results 2–3 35 30 (23–39) 25 (20–29) 38.5 (34–48)
[3 18 25.5 (19.5–37.5) 25 (16–29) 41 (32–57)
Of 503 patients with penetrating abdominal trauma, 121
underwent DCL and AP. The mean age of the patients was
30.1 ± 11.5 years, and the male to female ratio was 9:1. Table 3 Length of stay and number of re-laparotomies
The mean APACHE II score was 17 ± 7.3, and the mean Time of N ICU length of Hospital length Number of re-
ISS was 24.9 ± 9.1 (Table 1). These trauma scores reveal abdominal stay, days, of stay, days, laparotomies,
the extreme nature and severity of injuries of the patients packing median (IQR) median (IQR) median (IQR)
enrolled in this study. The right upper quadrant was packed (days)
in 39 (32.2 %) patients; retroperitoneum, in 70 (57.8 %); \1 26 3 (1–8) 7.5 (1–15) 1 (1–2.5)
pelvis, in 13 (10.7 %); and left upper quadrant, in 9 1–2 42 7 (5–10) 11 (8–22) 2 (1–3)
(7.4 %). As shown in Table 2, trauma severity scores were 2–3 35 9 (6–14) 13 (7–25) 3 (2–5)
similarly distributed among the different groups. As [3 18 6.5 (3–12) 12 (7–21) 2 (1–3)
expected, time in the ICU was greater for those patients
IQR interquartile range
with longer packing times and also with more surgical
re-interventions (Table 3).
Table 4 Re-bleeding and infection rates
Re-bleeding and infection rates
Time of abdominal N Re-bleeding Intra-abdominal
packing (days) ratea % (n) infection rateb % (n)
Patients were grouped according to the duration of the AP
in days (Table 4). Twenty-six patients (21.4 %) had AP \1 26 38.4 (10) 3.84 (1)
\1 day, 42 patients (34.7 %) had AP for 1–2 days, 35 1–2 42 14.28 (6) 16.6 (7)
patients (28.9 %) had AP for 2–3 days, and 18 patients 2–3 35 11.4 (4) 22.8 (8)
(14.8 %) had AP [3 days. The relationship between [3 18 0 44 (8)
re-bleeding and infection rates by AP duration is shown in a
For re-bleeding rate, Chi square for trend 6.83, p = 0.009
Fig. 1. A decreasing trend toward re-bleeding after pack b
For intra-abdominal infection, Chi square for trend 12.85,
removal can be seen with time. This trend seems to decline p \ 0.001
abruptly after 1 day of packing. The re-bleeding rate in
patients packed for 1–2 days compared to those packed for
\1 day was a third lower, 14.3 %, (95 % CI: 8.06, 20.5)
versus 38.5 % (95 % CI: 25.4, 51.5). Conversely, an

Table 1 Damage-control laparotomy—abdominal packing (AP)

Demographics (n = 121)

Age (years) 30.1 ± 11.5

Male (%) (n) 92.5 (112)
ATI 29.3 ± 14.35
ISS 24.9 ± 9.1
RTS 6.57 ± 1.64 Fig. 1 Re-bleeding and intra-abdominal infection rates after abdom-
APACHE II 17.65 ± 7.23 inal packing removal

NISS 39.5 ± 12.05

ATI abdominal trauma index, ISS injury severity score, RTS trauma
increasing trend toward intra-abdominal infection occurred
score, NISS new injury severity score, APACHE II acute physiology as time after packing increased. The infection rates almost
and chronic health evaluation (APACHEII) tripled, from 16.7 % (95 % CI: 6.6, 26.7) to 44.4 % (95 %

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Table 5 Mortality
Time of abdominal N Bleeding Infectious
packing, days mortality n (%) mortality n (%)
\1 26 6 (23.1) 1 (3.8)
1–2 42 3 (7.14) 2 (4.76)
2–3 35 1 (2.85) 4 (11.4)
[3 18 0 (0) 8 (44.4)
Mortality at 30 days (%) 16.5
Chi square for trend, p value = 0.04
CI: 31.03, 57.7) when comparing 1–2 days of AP versus
[3 days of AP.
Mortality
Overall mortality was 16.5 %, 8.26 % of which was
attributable to re-bleeding, and 13.2 % to intra-abdominal
infection. Deaths secondary to re-bleeding seemed to
decrease by time of AP, whereas intra-abdominal infection
deaths increased by time of AP (Chi square for trend,
p = 0.04; Table 5). There were no statistical differences
between 30-day mortality rates when comparing the
2–3 day group and the[3 day group. There were 6 patients
who died after premature removal of AP, indicating that
the risk of mortality associated with inappropriate early
removal is high. Furthermore, those patients who re-bled
required packing for a longer time and ended up with a
higher incidence of septic complications.
Discussion
During the last two decades, abdominal packing has been
progressively recognized as an accepted surgical technique
in DCL patients [8, 9]. When surgeons and their patients
are faced with threatened exsanguination from massive
hemorrhage or coagulopathy, abdominal packing has
become an essential and lifesaving maneuver [10, 11].
Nevertheless, there appears to be little consensus on the
optimum timing for re-look and removal of the abdominal
packs. Thus the aim of the present study was to determine
when abdominal packs should be removed following
packing for complex penetrating abdominal trauma from
gunshot wounds and whether the total duration of AP is
related to the development of subsequent complications.
The appropriate timing for AP removal should logically
be determined by the correction of the patient’s lethal triad.
After trauma, a window of time, usually 12–36 h, is nec-
essary to reach this coagulopathic correction, yet abdomi-
nal packs have been removed as long as 7 days after the
initial packing [12, 13]. When AP is removed too early the
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World J Surg (2012) 36:2761–2766
chance of re-bleeding increases, and if left too long, the
potential for infectious complications may increase.
Abdominal packing has resulted in satisfactory control
of hemorrhage in more than 90 % of patients. There is
obviously a desire to remove the abdominal packs as soon
as possible but the benefits of AP removal have to be
weighed against the risk of a re-bleed requiring repeat
abdominal packing. Caruso et al. [14] demonstrated that
re-bleeding was greater when abdominal packs were
removed within 36 h. Likewise, Nicol et al. [15] demon-
strated that if abdominal packs were removed at 24 h in the
stable patient the risk of re-bleeding requiring repacking
was significantly higher than if the packs were left in closer
to the 48 h point. This would seem to indicate that in the
majority of patients, AP for a period of at least 48 h is
required to achieve hemostasis. Our study confirms this
assumption that the first re-look laparotomy following AP
should only be performed after 2 days and when hypo-
tension, hypothermia, coagulopathy, and acidosis have
likely been corrected. We also found that an early re-look
at 1 day is associated with a high incidence of re-bleeding
and does not lead to the successful removal of the
abdominal packs. The re-bleeding rate in patients packed
for 1–2 days compared to those packed for \1 day was a
third lower, 14.3 % (95 % CI: 8.06, 20.5) versus 38.5 %
(95 % CI: 25.4, 51.5).
The use of AP to control hemorrhage indicates a very
severe abdominal injury with massive blood loss, both of
which may increase the risk of infection. The major reason
for removing packs within the first 24–48 h is the elimi-
nation of a foreign body, which might predispose to the
formation of late postoperative intra-abdominal abscesses
[16]. Feliciano et al. [17] reported a 49 % abscess rate in
patients in whom packs were used. Similarly, AP has been
associated with a 20–30 % incidence of intra-abdominal
sepsis, but early pack removal, along with the evacuation
of intra-peritoneal clots would appear to lessen the inci-
dence of this problem [18]. Krige et al. reported an 83 %
risk of intra-abdominal sepsis in patients who required AP
for [3 days. In contrast, Nicol et al. [15] pointed out that
there was no association between the total duration of
packing and the development of infectious complications,
but the presence of concomitant small bowel or colon
injury was found to be an important factor with regard to
the development of an intra-abdominal fluid collection. In
the present study we observed an increasing trend toward
intra-abdominal infections as time after packing increased;
there was also a high association with hollow viscus injury:
51 patients (42.1 %) had associated colon injuries and 58
(47.9 %) had small bowel injuries. Also, the frequency of
infection sharply increased after the third day of AP. The
infection rate almost tripled, from 16.7 % (95 % CI:
World J Surg (2012) 36:2761–2766
6.6, 26.7) to 44.4 % (95 % CI: 31.03, 57.7) when com-
paring 1–2 days versus [3 days of AP (Fig. 2).
Sepsis is a major cause of morbidity/mortality following
AP, and this has led to the recommendation that abdominal
packs be removed as soon as possible. Abikhaled et al. [19]
demonstrated an increased morbidity and mortality with
AP for more than 72 h in otherwise similar groups of
injured patients. Fabian et al. [20] used gauze packs in the
surgical management of 10 % of major abdominal injuries,
and they reported a 29 % mortality rate and a 30 % abscess
rate. Intra-abdominal abscesses have been noted to account
for 25 % of late deaths. In the present study, high infection
rates were seen after 3 days of AP and mortality attribut-
able to infection was appreciable. Overall mortality was
16.5 %, of which 8.26 % was attributable to re-bleeding,
and 13.2 % to intra-abdominal infection. Deaths secondary
to re-bleeding seemed to decrease by time of AP, whereas
intra-abdominal infection deaths increased by time of AP
(Chi square for trend p value = 0.04; Table 5). There were
no statistical differences between 30-day mortality rates
when comparing the 2–3 day AP group and the [3 day AP
group. Six patients died after the attempted removal of the
packing prematurely, indicating that the risk of death
associated with inappropriately early removal is high.
Consequently, we propose that there is a time window
between days 2 and 3 where the greatest benefits of AP can
be obtained and where AP removal is at its safest. It seems
that in this time period, a happy medium is achieved
between a low re-bleeding rate and an acceptable intra-
abdominal infection rate (Fig. 1). In contrast, after 3 days
of AP, the intra-abdominal infection rate increases notably,
exceeding [30 % among the surviving patients. That is
why our study suggests that AP used in the setting of DCL
for hemorrhage control should be approached in the fol-
lowing way:
1. Because of the increased risk of re-bleeding, abdom-
inal packing should not be removed prior to the first
postoperative day
2. The ideal duration of AP is 2–3 days
Fig. 2 Intra-abdominal infection rates in patients with abdominal
packing and associated bowel injury
2765
3. Abdominal packing left in longer than 3 days should
be avoided, as it is associated with a significantly
increased risk of infectious complications.
Conclusions
We are well aware that our study is limited by its design,
specifically referring to the lack of randomization and the
built-in trauma surgeon bias of patient allocation to
abdominal packing and subsequent removal. Our findings
suggest, however, that the ideal time for AP removal in
patients with DCL is after 2–3 days. At this point in the
treatment protocol the cumulative incidence of complica-
tions with re-bleeding and intra-abdominal infections is
optimal. Abdominal packing should not be removed prior
to the first postoperative day because of the increased risk
of re-bleeding, and if left in longer than 3 days, AP carries
a significantly increased risk of infectious complications.
Acknowledgments This work was funded in part by the Fogarty
International Collaborative Trauma and Injury Research Training
Program (ICTIRT) and NIH grant 1 D43 TW007560-01.
References
1. Sugrue M, D’Amours SK, Joshipura M (2004) Damage control
surgery and the abdomen. Injury 35:642–648
2. Rotondo MF, Schwab CW, McGonigal MD et al (1993) Damage
control: an approach for improved survival in exsanguinating
penetrating abdominal injury. J Trauma 35:375–382; discussion
382–383
3. Asensio JA, Petrone P, Roldan G et al (2004) Has evolution in
awareness of guidelines for institution of damage control
improved outcome in the management of the posttraumatic open
abdomen? Arch Surg 139:209–214; discussion 215
4. Burch JM, Ortiz VB, Richardson RJ et al (1992) Abbreviated
laparotomy and planned reoperation for critically injured patients.
Ann Surg 215:476–483; discussion 483–484
5. Fabian TC (2007) Damage control in trauma: laparotomy wound
management acute to chronic. Surg Clin North Am 87:73–93, vi
6. Lee JC, Peitzman AB (2006) Damage-control laparotomy. Curr
Opin Crit Care 12:346–350
7. Johnson JW, Gracias VH, Schwab CW et al (2001) Evolution in
damage control for exsanguinating penetrating abdominal injury.
J Trauma 51:261–269; discussion 269–271
8. Rumley TO (1983) Improved packing technique in the control of
diffuse hemorrhage of the abdomen. Surg Gynecol Obstet 156:82
9. Saifi J, Fortune JB, Graca L (1990) Benefits of intra-abdominal
pack placement for the management of nonmechanical hemor-
rhage. Arch Surg 125:119
10. Garrison JR, Richardson JD, Hilakos AS (1996) Predicting the
need to pack early for severe intra-abdominal hemorrhage.
J Trauma 40:923
11. Sharp KW, Locicero RJ (1992) Abdominal packing for surgically
uncontrollable hemorrhage. Ann Surg 215:467
12. Aydin U, Yazici P, Zeytunlu M et al (2008) Is it more dangerous
to perform inadequate packing? W J Emerg Surg 3:1
123
2766
13. Talbert S, Trooskin SZ, Scalea T (1992) Packing and re-explo-
ration for patients with non-hepatic injuries. J Trauma 33:121
14. Caruso D, Battistella F, Owings JT (1999) Perihepatic packing of
major liver injuries. Arch Surg 134:958–963
15. Nicol AJ, Hommes M, Primrose R et al (2007) Packing for
control of hemorrhage in major liver trauma. World J Surg
31:569–574
16. Bender JS, Geller ER, Wilson RF (1989) Intra-abdominal sepsis
following liver trauma. J Trauma 29:1140–1144; discussion
1144–1145
17. Feliciano DV, Mattox KL, Burch JM et al (1986) Packing for
control of hepatic hemorrhage. J Trauma 26:738–743
123
World J Surg (2012) 36:2761–2766
18. Pachter HL, Spencer FC, Hofstetter SR et al (1992) Significant
trends in the treatment of hepatic trauma. Ann Surg 215:492–502
19. Abikhaled JA, Granchi TS, Wall MJ et al (1997) Prolonged
abdominal packing for trauma is associated with increased
morbidity and mortality. Am Surg 63:1109–1112; discussion
1112–1113
20. Fabian TC, Croce MA, Stanford GG (1991) Factors affecting
morbidity following hepatic trauma. A prospective analysis of
482 injuries. Ann Surg 213:540–547; discussion 548