Perineal trauma, the diaphragm was not far!

Abstract

Perineal injuries may occur in association withpenetrating and blunt pelvic injuries. Life-threatening injuries should beaddressed first, including laparotomy for hemorrhagic solid organ injuries,major arterial injuries and hollow viscus injuries. We report the case of a youngmale patient who suffered from a penetrating perineal trauma with rectal,gastric and diaphragmatic injuries.Perineal injuries may occur in association with penetrating and blunt pelvic injuries. Life-threatening injuries should be addressed first, including laparotomy for hemorrhagic solid organ injuries, major arterial injuries and hollow viscus injuries. We report the case of a young male patient who suffered from a penetrating perineal trauma with rectal, gastric and diaphragmatic injuries. BACKGROUND Perineal traumas are seen rarely in emergency conditions and can be blunt or penetrating. We report the case of a young male patient who suffered from a penetrating perineal trauma with rectal, gastric and diaphragmatic injuries. CASE REPORT We report the case of a 26-year-old man, mason of profession, without particular pathological antecedents, who had fallen on a metal bar fixed on the ground from 5m height, with perineal impact. On admission, the patient had no respiratory or hemodynamic disorders. On examination, his abdomen was totally sensitive. Perineal examination in gynaecological position showed a wound of approximately 2.5cm paraanally at twelve o’clock. Rectal examination was very painful and revealed a rectal wound 5cm of the anal margin; the anal sphincter was intact. Abdominal and thoracic x-rays were normal. Abdominal echography showed a small liquid abundance in the pouch of Douglas. At median laparotomy, a left para-rectal hematoma under the peritoneum was found, fusing up along the left mesocolon. After mobilisation of the left colon and mesosigmoid dissection, a wound was discovered in the posterior region of the middle part of the rectum as well as a wound of the transverse mesocolon on the level of its insertion in the lower edge of the pancreas (figure 1). The exploration of the sub-mesocolic region showed a transfixing wound of the stomach and a 2cm wound on the cupola of the left diaphragm (figure 2). Figure 1 Figure 1: Wound of the transverse mesocolon in the level of its insertion on the lower edge of the pancreas (indicated by the grip), and wound of the posterior face of the stomach (marking sutures). Perineal trauma, the diaphragm was not far! 2 of 3 Figure 2 Figure 2: Wounded left diaphragmatic cupola We sutured the diaphragmatic wound on a thoracic drain, then the anterior and posterior gastric wounds. A left iliac colostomy was performed as a protection after suturing the two rectal wounds and washing of the rectum. The follow-up was good. Re-establishment of continuity was performed 3 months afterwards. COMMENTS Only five percent of the pelvi-perineal traumas are penetrating. Their frequency is relatively low, contrasting with their potential gravity. The death rate associated with these traumas varies from 8 to 58% [1]. The emergency management is to dry up the haemorrhage by the way of an endovascular or surgical treatment. During this initial phase, we should not ignore an anorectal or urogenital wound that can require specialized treatment [1-2]. This observation underlines the importance of an exhaustive exploration in the case of a penetrating perineal trauma in order to identify all the lesions. All these measurements, associated with an attentive monitoring of the wound and suitable treatment of the sepsis, reduce mortality.