Avulsion of thegall abdominal trauma Masud
bladder in blunt
General Hospital, Sligo, Ireland TRAUMATIC avulsion of the gall bladder, and its subsequent dislodgement into the pelvis has not previously been reported. The case described records severe damage to the biliary system without much damage to other viscera. CASE REPORT* A 23-year-old male was admitted to Sligo General Hospital at about 1.30 am following a road traffic accident. He was conscious, and said that he was the driver of the car, but had not worn the seat belt. He was intoxicated, and complained of severe colicky abdominal pain, occuring every 5 to 10 minutes. There was no external sign of injury. On examination, he was pale and shocked with a pulse rate of 110 per minute diminished in volume, and his blood pressure 90/60 mm per Hg. The abdomen was rigid all over, but four quadrant aspiration was negative, and X-ray films of the chest and abdomen demonstrated nothing abnormal. A diagnosis of blunt abdominal trauma was made, immediate resuscitation started, and vital signs recorded. Intravenous Ringer’s solution was commenced, followed by blood transfusion, but although pulse and blood pressure were steadily maintained, the abdominal rigidity remained, and discoloration of the skin over the umbilicus was apparent within a few hours. Laparotomy was performed through a midline incision 8 hours after admission, and a large amount of clotted blood mixed with bile was evacuated. The liver was mobilized after division of the falciform ligament, and a tear 2 inches in length *This case was presented at the Western Surgical Club in Sligo.
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was found in its anterosuperior border. The gall bladder was found missing from the liver bed, but there was no leakage of bile from the common bile duct or bleeding from the torn cystic artery. The stomach, duodenum, small and large intestine were contused, but intact, as were the remaining abdominal viscera. A search revealed the gall bladder lying freely amongst the clotted blood in the pelvis. Exploration of the porta hepatis revealed a tiny hole at the junction of cystic and common bile duct. The common bile duct was therefore opened, washed out, and drained with a T-tube, but the proximal part of the cystic artery could not be located. The abdomen was closed with drainage of the subhepatic area. The postoperative recovery was uneventful, and a T-tube cholangiogram showed dye passing freely into the duodenum. The patient was discharged on the 27th day, and was reviewed later in the surgical outpatient clinic when he was found to be in excellent health. Acknowledgements I wish to thank Mr T. T. Swan, M.Ch., F.R.C.S., for his encouragement and help, and Mr J. B. McDevitt, M.Ch., F.R.C.S., for allowing me to treat this case.
BIBLIOGRAPHY BROWN, H. P. (1932), ‘ Traumatic Am. Surg., 92, 952. ‘ Avulsion of HALKER, E. (1963), Dan. Meri. Bull., 10,8, 262. ROBBINS, R. F. (1953), ‘ Traumatic bladder without a wound of the Ann. SlUg 139,915.
of gall wall ‘,
Sligo General Hospital, Sligo,