PENETRATING INJURY

ABDOMEN
 56 year old male came
with alleged history of
Case history fall from height (about
10ft) influence of
alcohol from terrace
of his residence in
Rameswaram On
10.6.23 around 11pm
He landed up on the
spear shaped Grills and
sustained a penetrating
injury – entry from RT
gluteal region, exit from
suprapubic region
extending to the RIF
Rescued by Fire
service,As they
were unable to pull
the patient due to
severe pain,they cut
the rod using metal
cutter and patient
was referred to our
hospital by 108 on
11.6.23 at 2.30AM
Penetrating injury

• Entry wound
Exit wound
On examination :

Pt consious
. Oriented
. Afebrile
Not anaemic
Hydration fair
BP 140/90
PR 106/min
SpO2 98%
• CVS : S1 S2+
• RS. : BAE +
• CNS : B/L PERL +
• P/A : soft
No distension
Tenderness + in supra pubic region
No guarding / no rigidity
. Entry wound : at right Gluteal region
Exit wound : right suprapubic region
• Routine investigation were done : all are within normal limits

• CT abdomen was not able to take

• Bladder catheterization done : drained blood stained urine

• Usg abdomen and pelvis done :

1. Mild free fluid in abdomen and pelvis
2. Foreign body seen penetrating through posterior abdominal wall
gluteal region into anterior abdominal wall in right iliac fossa
3. Sugg : CECT
• Pt was taken up for
emergency exploratory
laparotomy
• Intubation found to be
difficult

• In right lateral position , pt

was intubated
• Under ETGA ; spear
shaped foreign body
removed and
proceeded with
laparotomy
Inverted T shaped
incision with
transverse limb
including exit
wound
• Findings:
1. Posterior wall of Bladder rupture extending upto dome transversely
2. Rectal rent in posterior wall
3. Ileal perforation of about 3*2cm about 30cm proximal to ileocecal
junction and another perforation of 2*1cm about 40cm proximal to
ileocecal junction with surrounding ileal ischemia
4. No intraperitoneal / retroperitoneal hematoma
5. B/L iliac pulsation +
6. Blood of about 250ml +
Ileal perforation
Ruptured bladder

Vertical rent present over

the posterior wall and
transverse rent present
over the done of the
bladder

Thorough wash given

Both ureteric orifice

appears to be normally
functioning , so ureteric
exploration not done
Bladder closed
in 2 layers with
SPC insertion
• Muscle found to be unhealthy on right iliac region
• Subcutaneous tissue found to be necrosed near the exit wound which
was excised
• Primary closure of bladder done in 2 layers with SPC insertion
• Rectal rent closure done
• About 10cm of ileal loop resection done with double barrel ileostomy
placed in left iliac fossa
Double barrel ileostomy
POST OPERATIVE PERIOD
Pt vitals stable

Pt started on Higher antibiotics

Stoma functioning from POD 2

Orals started on POD 4

Stoma functioning
• Urology opinion
• To continue same line of management
Suggested CBD care
Clamp SPC

Ortho opinion
No bony injury
Nil orthopedic intervention needed
CECT abdomen and pelvis
• Soft tissue injury with minimal air pockets in subcutaneous and
intramuscular plane in RIF
• Soft tissue injury with minimal air pockets and collection in left gluteal
region
• Minimal presacral collection measuring 5*2.7cm
• No significant free fluid / free air in peritoneum at present
• No bowel dilatation
• Long segmental abdominal aorta circumferential atheromatous
plaque with minimal aneurysmal changes seen
Wound on POD 17