Acute Laparoscopic Management of Thoracoabdominal Gunshot Wound

Siddarth Kudav, MD, Roger de la Torre, MD, Jacob A Quick. University of Missouri – Columbia

Introduction: Penetrating thoracoabdominal trauma is often associated with hemodynamic instability, precluding laparoscopic management. However, in hemodynamically stable patients, laparoscopy has the ability to both effectively characterize injuries not reliably diagnosed via imaging techniques, as well as provide a viable treatment modality. We present a case of a thoracoabdominal gunshot wound treated acutely with laparoscopic techniques.

Case presentation: A 27 year old male was evaluated in the emergency department after sustaining a high-velocity gunshot wound to the right chest. Physical exam revealed diminished breath sounds over the right hemithorax, mild tachycardia, with a normal blood pressure and pulse pressure.  Focused assessment with sonography for trauma (FAST) revealed hemopneumothorax with no evidence of hemoperitoneum. Tube thoracostomy was performed with return of air and 400 mL blood.  The patient remained hemodynamically stable and underwent contrasted CT imaging of the chest, abdomen and pelvis, revealing right lung injury with hemopneumothorax, multiple rib fractures, and a Grade 2 liver laceration. On imaging, the missile was seen with the right flank soft tissue. The presence of a liver laceration in the face of a gunshot wound to the right chest was suggestive of diaphragmatic injury. The patient was taken emergently for diagnostic laparoscopy. Upon identification of the diaphragmatic injury, pneumoperitoneum was decreased to 10 mmHg and thoracostomy collection container suction was confirmed. Our working ports were placed in a similar configuration to a laparoscopic cholecystectomy, with the exception of a 10 mm epigastric port to allow sutures to be passed. The laparoscope was inserted through the diaphragmatic injury and the chest examined and hemothorax evacuated. The right lower lobe was contused, and the lung adequately inflated without evidence of tension physiology. Ventilator peak pressures were kept under 30 mmHg. Hepatorrhaphy was performed laparoscopically with application of a topical hemostatic agent. Addressing the diaphragm injury, two sutures were placed at the lateral edges of the injury and pulled through opposite ports to allow the injury to be aligned properly, and was then repaired with interrupted nonabsorbable sutures. No complications occurred and the patient was discharged following tube thoracostomy removal.

Conclusion: Selective acute laparoscopic management of penetrating thoracoabdominal wounds is safe and effective in hemodynamically stable patients. Attention to pulmonary physiology is crucial to successful laparoscopic completion.

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