Damage Control Surgery in Obstetrics and Gynecology: Abdomino-Pelvic Packing in Multimodal Hemorrhage Management

Damage control surgery (DCS) is a staged surgical strategy for rapid control of life-threatening bleeding, followed by physiological stabilization and delayed definitive repair. Abdomino-pelvic packing (APP)-placing compressive material within the pelvis and/or abdomen to tamponade bleeding-is a cornerstone of DCS as a temporizing measure to achieve hemostasis and stabilization in critically unstable patients. This narrative review synthesizes current evidence on DCS with a focus on APP-a technique historically developed in trauma and orthopedic surgery for exsanguinating pelvic bleeding but adaptable to gynecologic and obstetric emergencies. We outline the historical evolution, physiological basis, and stepwise protocol of DCS, adapted to specialty-specific conditions such as postpartum hemorrhage, placenta accreta spectrum, uterine rupture, and hepatic rupture in HELLP syndrome, as well as oncologic surgeries (debulking, exenteration, lymphadenectomy) and benign procedures (trocar-entry injuries in laparoscopy, presacral bleeding in sacrocolpopexy, and retroperitoneal hemorrhage in deep-infiltrating endometriosis). Modern adjuncts-including early tranexamic acid, topical hemostatic agents, and multidisciplinary coordination-have transformed packing from a last-resort maneuver into an integrated component of staged hemorrhage control. In OB/GYN, APP allows for successful hemostasis in 75-90% of cases, with significantly lower mortality rates than trauma surgery. In conclusion, APP as a potentially life-saving maneuver within DCS requires integration into standardized, institution-wide hemorrhage protocols in OB/GYN. Training, simulation, and guideline adoption are critical, particularly in resource-limited settings where advanced interventions for catastrophic bleeding are inaccessible.