PMC5835007_01
Gunshot wound trajectory. A - Posterior wound medial to the vena cava (arrow). B - Duodenal injury. C - Pancreatic head injury.
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No injuries were found in the middle colic, superior mesenteric or portal veins, followed by Cattell-Braasch and Kocher maneuvers with findings of a complex injury of the pancreatic head with bile duct and Wirsung duct injuries (grade V), and an injury of the second portion of the duodenum with the involvement of a > 75% narrowing and transfixing injury of the transverse colon with local contamination, indicating the need for a gastroduodenopancreatectomy with a right hemicolectomy (Fig. 1).
Resected surgical specimen.
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Immediately afterward, a right hemicolectomy with stapling and sectioning of the transverse colon and distal ileum was performed using a linear cutting stapler (Fig. 2).
5th postoperative day. A - Hepatic duct with Kehr drain. B - Pancreas with a catheter in the Wirsung duct. C - Stapled stomach.
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Surgical reopening occurred on the fifth postoperative day (Fig. 3), and the patient was subjected to single-loop reconstruction of the intestinal transit with telescoping pancreaticojejunal anastomosis, biliodigestive anastomosis with termino-lateral hepaticojejunal anastomosis with a Kehr drain (Fig. 4) and gastroenteroanastomosis in 2 planes.
Abdominal wall reconstruction with onlay mesh after relaxing Gibson incisions.
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On the second postoperative day after the single-loop reconstruction, the patient was subjected to abdominal wall closure without complications, which required relaxing Gibson incisions and wound closure with polypropylene mesh placement in a pre-aponeurotic position closed with multiple stitches (Fig. 5).
The patient was discharged on the 40th day of his hospital stay.
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The patient was discharged on the 40th post-trauma day without drains, with a functioning ileostomy and with a scheduled reconstruction of intestinal transit (Fig. 6).