GS18 - High Velocity Penetrating Abdominal Injury Secondary to a Motorized Wire Brush in the Workplace

Introduction/Purpose: Penetrating injuries are one of the most common types of workplace accidents. The majority of these injury patterns are due to non-missile type, low velocity sharp objects. We present an uncommon presentation of subacute abdominal pain secondary to non-missile type, high velocity workplace injury. It is important to keep a wide differential in mind when evaluating patients with lingering abdominal pain without an obvious case. Additionally, important is eliciting the patient's employment history, occupational exposures, and job tasks when a workplace injury is suspected. We present a 59 year old male with abdominal pain for five weeks. Outpatient CT scan of the abdomen/pelvis demonstrated a metallic foreign body within the abdominal cavity. The patient underwent laparoscopic removal of the intra-abdominal foreign body while utilizing fluoroscopy. He recovered without sequelae and he was free of abdominal pain at six months postoperatively. Overall, it is important to maintain a wide differential when evaluating atypical abdominal pain.

Methods or Case Description: Our patient was an otherwise healthy 59-year-old male who presented to the general surgery clinic with almost five weeks of mainly right sided abdominal pain. He stated he was cleaning with a motorized wire brush wearing a shirt on his upper body. Since that time he has had intermittent sharp, stabbing pain to his right abdomen. He was afebrile and denied any night sweats, bowel changes, nausea, or episodes of emesis. Focused abdominal exam elicited tenderness to palpation to the right hemiabdomen. There was no evidence of rebound, guarding, or generalized peritonitis. In addition, there were no obvious changes to the abdominal wall skin, no signs of puncture, wound, or erythema. A CT scan of his abdomen/pelvis demonstrated a likely wire metallic object in his right hemiabdomen. His white blood cell count was 7.4 K/uL, no left shift.



At this time diagnostic laparoscopy was discussed and the patient agreed to proceed. On the day of surgery the patient underwent a pre-op abdominal radiograph. After informed consent was obtained from the patient he was brought to the operating room and placed in supine position. General endotracheal anesthesia was administered via the anesthesia team. Bilateral lower extremity SCDs were on and working. Patient received 2 g of Ancef IV prior to incision. Patient's abdomen was prepped and draped in the usual sterile fashion. A time-out was completed which consisted of confirmation of the correct patient, correct procedure, and other pertinent information to today's case was discussed. All team members were in agreement prior to proceeding. A Veress needle was utilized to insufflate the abdomen, access was obtained in the left upper quadrant. 10 cc of saline was easily able to be flushed through the Veress needle. The abdomen was insufflated. Just left and lateral to the Veress insertion point a skin incision was created with a 15 blade scalpel large enough to accommodate an 8 mm robotic trocar. This was advanced into the abdominal cavity. The robotic camera was advanced into the abdominal cavity and a general survey revealed no entrance trauma and the Veress needle was removed. Two additional trocars were placed under similar manner and under direct visualization in the left hemiabdomen. Two laparoscopic bowel graspers were utilized to reflect the small intestine medially. Fluoroscopy was utilized to identify the metallic foreign body within the abdomen. A metallic foreign body appearing that of a likely wire was appreciated adhered to the small intestine mesentery. A Maryland dissector was utilized to grasp and remove the foreign body from the mesentery which was removed from the abdominal cavity and passed off the field and sent for gross pathology only. The rest of the abdominal cavity appeared benign, there were some what appeared to be abrasions of the small intestine serosa without evidence of leak or perforation. The small intestine appeared viable. The laparoscopic instruments were removed from the abdominal cavity which was allowed to deflate. 15 cc of 0.5% Marcaine without epinephrine was evenly split amongst the three incisions. Skin was approximated with inverted and interrupted sutures of 4-0 Monocryl. Steri-Strips were applied. Telfa was applied and secured with Steri-Strips.



Operative findings:

1. Single metallic appearing foreign body within the abdominal cavity. This was adhered to the small intestine mesentery. Easily able to be removed through one of the 8 mm robotic trocar ports. Preoperative fluoroscopic images obtained as well as postprocedure which demonstrated absence of the metallic foreign body at conclusion of procedure. .

2. There were some serosal abrasions to the small intestine without any overt serosal defect. These appeared only a couple of mm in diameter

3. No evidence of entrance trauma on general survey of the abdomen. The appendix was nondilated, pain, without any signs of active inflammation. The liver appeared smooth without any gross nodularity. Both inguinal canals visualized without any evidence of gross hernia defect.



Gross pathology demonstrated a 3 cm x 0.1 cm gray/silver metallic wire.

Outcomes: The patient tolerated the procedure and was discharged. At 6 months followup patient was doing well without any recurrence of his abdominal pain.

Conclusion: Penetrating abdominal injuries continue to be one of the leading causes of workplace injuries presenting to the emergency department. For patients presenting with undifferentiated abdominal pain and working in at-risk occupational environments, there should be a high index of suspicion for underlying traumatic injury. In this case, we described a patient presenting with a penetrating injury to the small bowel mesentery secondary to a missile type, high velocity metallic wire from a metal wire brush. This case emphasizes the importance of a detailed history and broad differential in cases of undifferentiated abdominal pain and illustrates the need for increased workplace safety to protect from possible device malfunction.