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 27-year-old male with no past medical history was the driver and sole occupant of a car which crashed through a fence at 80 kph and hit a lamp post. He was wearing a seatbelt, the airbags did not deploy and despite the significant intrusion into the passenger space, he extricated himself unaided. He was resuscitated according to Advanced Trauma Life Support® principles. The primary survey identified decreased air entry at the base of the right lung and right-sided abdominal and lower chest tenderness. Abrasions were evident over the anterolateral abdominal wall and a large, right-sided abdominal swelling was noted.\nTrauma series computed tomography (CT) scans demonstrated a flail segment between the sixth and eight ribs with disruption of the intercostal muscles and a small right haemothorax (Fig. a). In the abdomen, there was hepatic contusion with an intrinsic liver injury (Fig. b). Blood was noted around the liver with minor active haemorrhage. The right abdominal wall was ruptured—the right rectus abdominis muscle had been torn from its costal attachments to the midpoint. The hepatic flexure of the colon had herniated through the intercostal muscles of the eighth and ninth ribs and was lying adjacent to the fractured ribs (Fig. c). Both small and large bowel had herniated through the abdominal wall lateral to rectus abdominis, but remained covered by external oblique (Fig. d). Herniation of small and large bowel immediately adjacent to the fractured ribs raised the suspicion of occult bowel injury not detected on CT.\nThe operative management was undertaken by both thoracic and abdominal surgeons. The ribs were re-opposed with absorbable polyglycolic acid sutures and a chest drain inserted. At laparotomy, it was noted that the hernia sac contained omentum, the bowel having reduced spontaneously under general anaesthesia. A small rent in the mesentery of the proximal small bowel was noted. The abdominal defect was repaired with a 20 × 30 cm sheet of cross-linked acellular porcine dermal collagen (Permacol™, Covidien, Gosport, Hants, UK) which was sutured to the margins of the fascial defect with interrupted nylon sutures, using a ‘bridge’ technique, with a 5-cm underlay on the left.\nPost-operatively, the patient was managed in the intensive care unit for 24 h. A seroma that developed at the hernia site after 1 week was treated conservatively. Impaired abdominal wall function, particularly reduced mobility, was noted post-operatively. Sitting up from lying down position and hip flexion caused difficulty, but improved with intensive physiotherapy. He was discharged home 9 days after admission.\nSix weeks after discharge, he was well with good mobility. He had a persistent seroma at the hernia site. A repeat CT of the thorax and abdomen at 10 weeks demonstrated no residual defect in the anterior abdominal wall and resolution of the seroma (Fig. ).