Presentation
Post trauma laparotomy for stabbing.
Patient Data
Injury to the superior mesenteric artery approximately 18 mm past its origin with extravasation and pooling of contrast around the SMA, extending and large volume of pooling (5.4 x 2.6 x 5.5 cm) in the left psoas muscle, which is grossly expanded. Distal to the injury the SMA opacifies.
Early filling of the left renal vein on arterial phase imaging, which is also immediately adjacent to extravasated contrast.
No aortic, celiac axis, renal artery or splenic artery injury identified. IVC, SMV and portal vein appear uninjured.
Multifocal areas (approximately 5) of active bleeding in the left psoas as well as within left quadratus lumborum. Gas and mild swelling of the left paraspinal muscles with overlying surgical clips.
Jejunum is thickwalled and hyperenhancing compared to distal small bowel and colon. No obvious penetrating bowel injury but this is difficult to exclude given the free fluid and free gas.
Evidence of arterial active bleeding from the inferior splenic pole from a presumed laceration, which is difficult to see. Multiple linear hypodensities through the pancreatic head, which also appears swollen. Hyperenhancing adrenal glands.
Liver appears uninjured but difficult to exclude small subcapsular injury with adjacent surgical packing. Kidneys and adrenal glands appear uninjured. IDC in collapsed bladder.
Case Discussion
The patient proceeded directly to trauma laparotomy from the trauma bay being haemodynamically unstable post-stabbing. Operative findings were right upper quadrant bleeding and an expanding retroperitoneal hematoma. The abdomen was packed and closed with a vacuum dressing and the patient proceeded to CT.
CT demonstrated multiple injuries:
- superior mesenteric artery injury with active bleeding into the retroperitoneum and left psoas muscle
- multifocal active bleeding points in the left psoas and quadratus lumborum muscles
- traumatic arteriovenous fistula between the superior mesenteric artery and left renal vein
- active arterial bleeding from the lower splenic pole
- possible pancreatic head laceration
Endovascular treatment of the superior mesenteric artery was considered but thought to be higher risk than open operative management, and the patient proceeded to successful open surgical repair of the SMA injury.
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