A 48-year-old male with no significant past medical history who was a restrained driver in a motor vehicle accident sustained multiple injuries in the crash () and had a prolonged and difficult extrication from the crash site before being brought to Ryder Trauma Center with a Glasgow Coma Scale of 15 approximately 1-2 hours after his accident. While in the resuscitation bay, bilateral chest tubes were placed for bilateral pneumothoraces and he had a positive FAST exam with tachycardia and severe hypotension (HR 128, BP 69/50). He was immediately brought to the operating room (OR) for emergency exploratory laparotomy, and splenectomy was performed for Grade V splenic injury, followed by abdominal packing without complete abdominal closure. His condition stabilized intraoperatively; no active abdominal bleeding or hematoma could be identified at that moment.\nA full-body CT scan was then requested to investigate other injuries. A list of numerous bone fractures that demonstrate the serious extent of the traumatic injury is shown in . The patient had also a scalp injury and needed additional workup to rule out traumatic brain injury. Head CT was negative. Chest CT demonstrated no further injuries other than minor pulmonary contusions and pneumothoraxes already being treated by the previously placed chest tubes. Abdominal contrasted CT identified a left renal artery injury and a nonenhancing ischemic left kidney but no other abdominal organ injuries (). In an attempt to salvage left kidney function despite over 4 hours of warm ischemia at that point, the patient was taken back to the OR for emergent repair of his left renal artery/in situ autotransplantation.\nAn occlusive 2 cm intra-arterial thrombus was removed, and a corresponding 2 cm damaged segment of the renal artery was excised. The kidney was flushed through the renal vein with histidine-tryptophan-ketoglutarate perfusion solution during the anastomosis of the renal artery. The left kidney was adequately perfused postreconstruction of the left renal artery ().\nDuring the two operations, the patient received a total of 7 units of packed red blood cells, 6 units of fresh frozen plasma, 2 units of cryoprecipitate, and 2 platelet transfusions. The patient was subsequently admitted to the Trauma Intensive Care Unit (TICU) for postoperative care. His hospital course was significant for worsening azotemia in the setting of decreased kidney function and falling urine output with a peak creatinine above 8 mg/dL. Dialysis and pressors were started on postoperative day 4. Eventually, his renal function improved, and his creatinine fell, and urinary output increased. He exhibited hypertension 2-3 weeks postrenal artery repair, but his systolic blood pressures eventually stabilized between 110 and 130 mmHg. He recovered in our TICU after multiple episodes of fungemia and bacteremia, was transferred to the trauma floor, and was discharged two months after admission. He is currently being followed in an outpatient clinic. After 18 months of follow-up, his serum creatinine level is 1.3 mg/dL and vital signs were within normal limits, without hypertension.\nOutpatient nuclear medicine renal scan indicated partial preservation of left renal function with a shrunken left kidney, and 16.3% () of split renal function attributed to the left kidney. Renal biopsy of the revascularized kidney was not performed. Left renal artery stenosis was not noted after its reattachment.
A 45-year-old man, gored by a cow was admitted in emergency department, within 2 h of injury. Patient complained of pain and swelling in the right lower quadrant with localized bruising. Vital signs were stable. On abdominal examination, a tender reducible bulge was present in the right fossa of size 5 × 8 cm2 with underlying fascial defect []. Routine blood tests and chest radiography were normal. USG of the abdomen revealed dilated bowel loops herniating through the defect with minimal fluid in the pelvis.\nOn laparotomy, there was minimal blood stained fluid and a large rent was present in right lower part of the rectus muscle. Ileal loops were reduced, and repair of the mesenteric tear was done. Rest of the intra-abdominal organs were normal. The muscular defects were repaired with absorbable sutures. Postoperatively patient recovered very well. Patient was discharged on 13th postoperative day. On follow-up at 6 months, patient is asymptomatic.