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Home > Case Presentation

Woman, 30 y old, sustained a gunshot wound to the right upper quadrant. She was and remained hemodynamically normal in the emergency room.


At laparotomy, the bullet was found to have penetrated the anterior and posterior surfaces of the stomach. There was minimal intraperitoneal blood but there was a right retroduodenal haematoma.  A medial visceral rotation was performed. 

Right medial visceral rotation

The head of the pancreas was injured (without injury to the main pancreatic duct) and the inferior vena cava was injured just below the junction with the right renal vein. The infrarenal vena cava was controlled with a vascular clamp and cephalad control achieved with compression of the reno-caval junction.  The bullet was found lying in retroperitoneal tissues between the IVC and right kidney.

Lateral Repair


Bullet in retroperitoneum

The gastric wounds were repaired by simple suture. Repair of anterior gastric wound

Total intraoperative blood loss was 400ml, and she had no post-operative complications. Submitted by:Luis Pinheiro. Viseu, Portugal

Comments

On 08/24/2007, anthonysh commented:

You commented that the main pancreatic duct was not injured.  How did you evaluate it?

On 08/25/2007, Luis Pinheiro commented:

Thanks for the question. In fact I “presumed” the lack of duct injury after a complete Kocher’s manouver. The posterior tear was located about 1 cm from the superior border of the pancreatic head. There was no bleeding or leaking from the tear. The subsequent evolution proved that I was rigth in this case. In doubt, (and depending on the patient condition) an intraoperative ERCP or, alternatively, a cannulation via a dudonenotomy can be done. I never did any!

On 12/27/2007, alsayali commented:

Is it ivolve the anterior and posterior side of the IVC?
If it is involve the posterior side would you repair it ?

On 12/27/2007, Luis Pinheiro commented:

Thank you for your questions, doctor Alsayali.The lesion was just in the right edge of the IVC in the origin of the right renal vein (see 4th image). If the lesion would interest the posterior aspect of the VCI, I don’t think it could be easily repaired. Not in this location! I would not repair it, unless I would be forced to (uncontroled bleeding). “Let the sleeping dogs lie”.

On 05/03/2008, Dr. Pachy commented:

of course you should repair that, one way of exposing the posterior injury is to enlarge the anterior vena cava injury and repair the posterior injury inside the lumen of the vena cava.  thank you

On 05/04/2008, alsayali commented:

I do agree with luis that if there is uncontrolled bleeding then I will repair it.
In exposing the post IVC will increase the icidences of stenosis and more harm than the bullet injury .
thanks

On 05/06/2008, Luis Pinheiro commented:

Thank you for you comment Dr. Pachy. In fact any good book of trauma recomends the technique you described above . Also any surgeon who deals with trauma patients must know it. I think it can be very helpfull in other locations (below renal veins)  where it’s application can be far easier, and proximal and distal control can be achieved with no major problems. I continue agreeing with Dr. Alsayali: in this location, and without evidence of continuing posterior bleeding, this technique should be more harmfull than beneficial.

On 05/12/2008, Tim Hardcastle commented:

To Drs Alsayali, Pinheiro and Pachy

If the Anterior and posterior IVC is injured the technique you describe works - repair through the anterior hole. However, if the injury is BELOW the renal veins and there is EXTENSIVe blood loss - just ligate the IVC. There is good experience that this is often the Damage Control manoeuvre of choice.

I have repaired about 10 IVC injuries over the past 3 years and ligated 4. 3/4 ligated ones survived to discharge.

Tim - South Africa

On 01/22/2009, husen commented:

They are good images. Thanks.
This is the ideal injuries with low velocity missiles like you have it here. These missiles usually cause penetration of great vessels without much bleeding so you can get them in emergency room alive. While with high velocity missiles like Kalashnikov or fragments from explosions such injuries are rare because most of the die before reaching hospital. The reason for low velocity missiles to cause minimal bleeding is the low power so the adventitia and tissue of the retro peritoneum remain intact and contain the hematoma which press of the cava or even aorta and stops bleeding.
Husen

On 02/14/2010, Youssef commented:

if the patient had only injury to IVC, HD stable with contained hematoma. would anyone suggest non-operative management

On 05/30/2015, Rodrigo Hernández Orduña commented:

This case was an example of a successful gunshot wound control. May be there isn’t some information we´d use in most cases of penetrating abdominal trauma (according to the ATLS).

This information is useful to improve medical care (just like the time between the bullet hit and her arrival to the emergency room, the distance where the shot was made from and the type and caliber of the bullet).

There is also information missing to estimate her systemic response to the bullet hit (like the estimated amount of blood that was found in the retroduodenal hematoma in spite of the normal hemodynamics, the antibiotics used to avoid necrotizing pancreatitis and the pancreatic function evaluations made after a certain time passed the surgery to be sure there was not important pancreatic injury).

After expressing the above, I have to say that due to the minimum hemodynamic changes at that moment (bleeding degree I according to the description given) it is understandable to mention only the abnormal findings when writing an article, but I still think this information could be useful to study this kind of cases in the future.

Finally, we saw once more that an early response to the bullet hit and the proper management of penetrating wounds are still the determinant factors to avoid a greater loss of blood.

Cadet RODRIGO HERNANDEZ ORDUÑA
Military Medical School, Mexico City

On 06/17/2015, 2 Via commented:

Great example of a gunshot wound control. There may be some insight into the procedures and other methods, but it was very well done.

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