Page 23 - Delaware Medical Journal - March 2017
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CASE REPORT
CASE PRESENTATION
A 22-year-old man presented after suffering a gunshot wound to the abdomen. He had a previous gunshot and had undergone an exploratory laparotomy
and ileo-colonic resection. A review of the record revealed he had a protracted post-operative course, having developed multiple wound infections and operative intervention. He was known to have bullet fragments in the right iliac bone.
At presentation, his chief complaint was pain at the bullet entry site in the right lower quadrant. He had
no generalized abdominal pain. His vital signs were normal and although he had tenderness at the right lower quadrant wound, the wound was hemostatic and he did not have peritonitis. A hypertrophic midline scar and umbilical incisional hernia were noted. An upright chest x-ray showed no free intra-peritoneal air and showed a projectile in the mid-abdomen (Figure 1). A CT scan of the abdomen was inconclusive for peritoneal entry (Figure 2).
He underwent diagnostic laparoscopy with removal of
a foreign body. Abdominal access was performed with Veress needle in the left upper quadrant. Two additional trocars were placed in the left hemi-abdomen (Figure 3). Dense midline adhesions were encountered and taken down with sharp dissection. A hematoma cavity within the adhesions was entered and the projectile
was discovered within the hematoma. There were no intra-abdominal injuries. The superior-most trocar
was exchanged for a larger size and the projectile was removed with an improvised atraumatic grasper (Figure 4). The patient had an uneventful post-operative course and was discharged on post-operative day number two.
The role of laparoscopy in trauma surgery has remained limited, reserved for select cases in hemodynamically normal patients.1 In such cases, diagnostic laparoscopy laparotomy, thereby avoiding unnecessary morbidity. The Eastern Association for the Surgery of Trauma (EAST) has published practice guidelines regarding
FIGURE 2
FIGURE 2
Abdominal CT scan demonstrating projectile in anterior abdomen with no clear intra-abdominal injury.
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