Case discussion

Abdominal Gun shot wound

KKH 6/1/2555

15 year-old boy
CC : 2 . . PI : 2 . . . resuscitation + x ray .

15 year-old boy
A : No drug allergy M : No medication P : No med/sx History L : Last meal 2 hr

E : 2 (9 )

15 year-old boy
BP 123/66 mmHg PR 96 tpm RR 20 tpm BT 36.9 c A : Patent airway, c-spine : intact B : Equal breath sound, O2 sat 99% C : No external bleeding D : E4V5M6, pupils 3 mm RTLBE

15 year-old boy
HEENT : pink conjunctivae Heart : no distant heart sound Lungs : equal breath sound Abdomen
Generalized guarding Max point of tenderness : lt upper abdomen Wound at left frank (as figure)

15 year-old boy

15 year-old boy
PR : good sphincter tone N/S exam
Motor power : 5 5 0 1 Sensation : decrease PPS at L2-3 both legs

15 year-old boy
Hct : 41% Foley catheter
Gross hematuria

NG tube
Gastric content

FAST
Positive at hepatorenal, splenorenal, CDS

15 year-old boy
Provisional Dx
1.Gun shot wound left frank (retained bullet) 2.Peritonitis (suspected hollow viscus inj) 3.Gross hematuria (suspected kidney inj) 4.Paraparesis (suspected nerve root inj)

15 year-old boy Management ?

15 year-old boy

 Hemoperitoneum 500 ml descending colon inj (through wall) lt retroperitoneal hematoma (zone2)no expanding

 transected lt lower pole kidney perirenal hematoma

15 year-old boy
Intraop findings
Gun shot wound lt frank Descending colon injury Lt lower pole kidney inj (transection)

Procedure
EL, repair descending colon, lt renorrhaphy, abdominal toilet

Colon injury

Colon injury
1. 2. 3. 4. Primary repair vs Diverting colostomy One- vs Two-Layer Anastomosis End vs Loop Colostomy Drainage vs No Drainage

1.Primary repair vs Diverting colostomy

Primary repair in absence of C/I
shock extensive fecal contamination multiple associated injuries significant blood loss and blood transfusions prolonged delays from injury to operation distracting colon injury left colon injury

A meta-analysis of 6 RCT concludes that

favors PR than DC for penetrating colon injuries

2.One- vs Two-Layer Anastomosis

There was no difference in anastomotic leaks between the two techniques
One-layer anastomosis was faster

Principle
well-vascularized tension-free adequately-sealed anastomotic

3.End vs Loop Colostomy

In trauma, never use permanent colostomy
Morbidity of the reconnection is essential Loop colostomy

An end colostomy is an alternative method to manage a colon injury following resection

The use of a linear stapler for definitive fecal diversion

Hartmann's procedure with end colostomy and a rectal pouch

4.Drainage vs No Drainage
Routine drainage is unnecessary
Drains are usually placed to facilitate drainage of residual fluid that is not suctioned, as well as new fluid that accumulates during resuscitation

Operative Mx Kidney injury

Kidney exploration
When exploration of an injured kidney in the absence of preoperative imaging
Palpate the contralateral kidney

Control of renal pedicle prior to renal exploration is controversy

Decrease rate of unnecessary nephrectomy

The posterior peritoneum is opened over the aorta medial to the inferior mesenteric vein

The colon is reflected medially exposing the perinephric hematoma

Thank you