Indirect ballistic injury to the liver: Case report and review of literature

AbstractIntroductionPenetrating injury due to gunshot wounds is a common problem seen in trauma centres around South Africa. Gunshot wounds can injure organs directly or may cause indirect injury. The temporary cavity is responsible for injury to organs distant to the wound tract. Organs with higher density such as bone or liver are more prone to injury due to the temporary cavity.Presentation of caseA 25 year old male patient sustained a gunshot wound to the right lower chest from a handgun. He was haemodynamically and metabolically stable with no evidence of peritonitis. CT scan of the abdomen revealed a Grade 2 injury of the liver. There was subcutaneous emphysema along the tract of the bullet. No injury to the lung or pleura was reported. The patient was explored laparoscopically to rule out diaphragmatic injury. At exploration the peritoneum was not breeched but the liver had a grade two laceration caused by an indirect ballistic injuryDiscussionPenetrating trauma to the right lower chest can potentially injure multiple organs. CT scan can reliably diagnose the bullet tract as well as solid organ injuries. In this case the diaphragm was contused and the liver was lacerated by energy created by the temporary cavity. The difference in severity of the injury of these organs is related to the pliability of the tissue.ConclusionGunshot wounds can injure organs directly as well as those located close to the bullet tract. These injuries may be found in adjacent cavities not traversed by the bullet. A high index of suspicion, as well as imaging, is important to diagnose and grade these injuries. The possibility of indirect ballistic injury should always be kept in mind when managing patients with gunshot wound even in the lower velocity handgun injuries

The use of laparoscopy in managing penetrating thoracoabdominal injuries in Africa: 83 cases reviewed

Abstract Background The use of laparoscopy in managing haemodynamically stable patients with penetrating thoracoabdominal injuries in developed countries is wildly practiced, but in Africa, the use of laparoscopy is still in its infancy stage. We reviewed a single centre experience in using laparoscopy in Africa for management of patients with both isolated diaphragmatic injuries as well as diaphragmatic injuries associated with intra-abdominal injuries requiring intervention. Methods A retrospective analysis of prospectively collected data of patients presenting with penetrating thoracoabdominal injuries was done. All patients offered laparoscopic exploration and repair from January 2012 to December 2015 at Dr. George Mukhari Academic Hospital were analysed. Means (±SD) were presented for continuous variables, and frequencies (%) were presented for categorical variables. All analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC). Results A total of 83 stable patients with penetrating thoracoabdominal injuries managed with laparoscopy met the inclusion criteria and were included in the study. The Injury Severity Score ranged from 8 to 24, with a median of 18. The incidence of diaphragmatic injuries was 54%. Majority (46.8%) of patients had Grade 3 (2–10 cm defect) diaphragmatic injury. Associated intra-abdominal injuries requiring intervention were encountered in 28 (62%) patients. At least 93.3% of the patients were treated exclusively with laparoscopy. The morbidity was encountered in 7 (16%) patients; the most common cause was a clotted haemothorax Clavien-Dindo III-b, but only 1 patient required a decortication. There was one non-procedure-related mortality. Conclusions A success rate of 93% in using laparoscopy exclusively was documented, with an overall 82% uneventful outcome. The positive outcomes found in this study when laparoscopy was used in stable patients with thoracoabdominal injuries support similar work done in other trauma centres. However, in addition, this study seem to suggest that the presence of peritonitis in stable patient is not a contra-indication to laparoscopy and thoracoscopy may be useful especially in right side diaphragmatic injury where the liver can preclude adequate visualization of the entire diaphragm and to thoroughly clean the chest cavity and prevent future complication such as residual clotted haemothorax. Clinical relevance: The presence of peritonitis in stable patients with penetrating thoracoabdominal injury is not a contra-indication to laparoscopy provided the operating surgeon has adequate laparoscopic skills