Title : Through the body, beyond the organs: Surviving transperineal abdomino-thoracic impalement
Abstract:
Presentation: A male in his twenties was brought to the emergency department after slipping and falling onto an erect iron rod at a construction site. The rod had been cut from the concrete pillar by co-workers, and the patient was transported with the rod still impaled in his perineum. Upon arrival, the diagnosis of perineal impalement was evident.
The patient was hemodynamically stable but exhibited reduced breath sounds on the right side of his chest. His abdomen was soft and non-tender. The rod had entered through the anal canal without lateral perineal injuries or active bleeding. The rod was palpable subcutaneously near the 7th and 8th ribs on the right side in the mid-axillary line.
Two wide-bore intravenous lines were established, and the patient received intravenous
fluids, broad-spectrum antibiotics, and a tetanus toxoid injection.
Investigations: A CT scan of the thorax, abdomen, and pelvis revealed a metallic foreign body entering through the perianal region, traversing the right ischioanal fossa, and extending into the extraperitoneal space posterolateral to the bladder and prostate. The rod entered the retroperitoneal space, and coursed anterolaterally to the right psoas muscle and exited the abdominal cavity through the 10th and 11th intercostal spaces and terminated in the subcutaneous plane of the right posterolateral chest wall. The scan also showed pneumoretroperitoneum and significant pelvic free fluid. No actively bleeding vascular injuries were identified. Routine blood tests were normal.
Treatment: A multidisciplinary surgical team comprising a general surgeon and a vascular surgeon performed a midline laparotomy. A large hematoma was identified in the right iliac fossa, but no active bleeding was noted. The superior portion of the rod was palpable intraperitoneally, lateral to the liver, and had penetrated the diaphragm. The hematoma was evacuated. The cecum, ascending colon, and small bowel were mobilized medially to expose the rod. The right common, external, and internal iliac arteries were secured with vascular loops. The rod traversed behind the right psoas muscle without injuring the bowel or solid organs. The rod was carefully removed from the perineal side under direct visualization. After removal, bleeding from the right internal iliac vein was noted and controlled with sutures.
The diaphragmatic rent was repaired with interrupted non-absorbable sutures, and a right intercostal drain was inserted. The abdomen was irrigated and drained, and a de functioning sigmoid loop colostomy was created in the left lower abdomen. The procedure lasted three hours, with an estimated blood loss of one litre. The patient received multiple blood transfusions intraoperatively.
Outcome and follow up: The patient received post-operative care in the intensive care unit. He retained normal anal tone and had an uneventful recovery. He was discharged on post-operative day eight.
On follow up after 6 weeks patient came with abscess near right 6th and 7th ribs in posterior axillary line(impalement site). Incision and drainage was done and foreign body (cloth piece) was retrieved.
