PMC7422010_01
(a) CT scan of the abdomen/pelvis with bullet entrance point. (b) CT scan of the abdomen/pelvis with bullet exit point.
CRIS2020-8861270.001.jpg
PMC7422010_01_CRIS2020-8861270.001.jpg
fig1
On physical exam, the patient's abdomen was rigid and tender with a presumed entry point in the periumbilical area (Figure 1(a)) and a presumed exit point in the left posterior superior buttock (Figure 1(b)). Computed tomography (CT) was performed and showed a mild amount of free fluid and air in the abdomen and pelvis (Figure 1(a)).
(a) Intraoperative laparoscopic visualization of stool contamination adjacent to the sigmoid colon. (b) Intraoperative laparoscopic visualization of first sigmoid perforation. (c) Intraoperative laparoscopic visualization of the sigmoid colon after repair of first perforation; second perforation visualized on the right. (d) Intraoperative laparoscopic visualization of the sigmoid colon during repair of second perforation. (e) Intraoperative laparoscopic visualization of the sigmoid colon following repair of second perforation. (f) Intraoperative laparoscopic visualization of rectal wall laceration. (g) Intraoperative laparoscopic visualization of the rectal wall following repair of laceration. (h) Intraoperative laparoscopic visualization of bladder laceration. (i) Intraoperative laparoscopic visualization of the bladder following repair of laceration. (j) Intraoperative laparoscopic visualization of the bladder with distillation for assessment of leak. (k) Intraoperative laparoscopic visualization of midsmall bowel perforation. (l) Intraoperative laparoscopic visualization of midsmall bowel following repair of perforation.
CRIS2020-8861270.002.jpg
PMC7422010_01_CRIS2020-8861270.002.jpg
fig2
Upon laparoscopic entrance, a small amount of blood and stool was noted in the left lower quadrant (Figure 2(a)). Initial inspection of the sigmoid colon revealed a perforation with minimal contamination from stool spillage (Figure 2(b)). This was cleared and washed out followed by intracorporeal repair using 2-0 V-Loc  suture in a running fashion done in 2 layers (Figure 2(c)). A second sigmoid perforation was found in the 4-5 cm distal to the first perforation as was repaired in a similar fashion (Figures 2(d) and 2(e)). The sigmoid was followed systematically to the pelvis, and a rectal wall laceration was noted (Figure 2(f)). This was again repaired using 2-0 V-Loc  suture in 2 layers (Figure 2(g)). After advancing down the rectum, a laceration was noted in the peritoneum over where the bladder was located (Figure 2(h)). The on-call urologist was contacted intraoperatively, and it was agreed upon for the primary surgeon to repair it in 2 layers with 2-0 V-Loc  sutures and leave a Foley in place for 2 weeks postoperatively (Figures 2(i) and 2(j)). Another perforation was found approximately midsmall bowel with an enterotomy measuring less than 1 cm in size (Figure 2(k)). This was closed in 2 layers using 2-0 V-Loc  suture (Figure 2(l)).