The blade within: Successful surgical management of a retained knife in abdomen

INTRODUCTION

Penetrating abdominal injury (PAI) is a significant cause of morbidity and mortality worldwide, accounting for a considerable proportion of emergency surgical admissions. Stab wounds, in particular, present unique challenges due to the potential for injury to vital organs and vascular structures, especially when the trajectory involves both the thoracic and abdominal cavities.^1,2 The complexity of such injuries requires a systematic approach to evaluation and management to ensure optimal outcomes.^2,3 The liver and diaphragm are among the critical structures frequently injured in penetrating trauma involving the upper abdomen.^3,4 Management strategies range from selective non-operative management (SNOM) in select cases to surgical exploration when hemodynamic instability, peritonitis, or retained foreign objects are evident.² The advanced trauma life support (ATLS) protocol serves as a cornerstone for the initial evaluation and stabilization of trauma patients, guiding subsequent decision-making.^2,3

This case report describes the case of a young male who sustained a stab injury to the right thoraco-abdomen, resulting in a hemothorax and penetration of the diaphragm and liver by a retained foreign object. The prompt diagnosis, adherence to ATLS protocols, and surgical intervention led to an uneventful recovery, underscoring the importance of a multidisciplinary approach in managing such injuries. The knife was removed under direct visualization, and the diaphragm was repaired successfully.

CASE REPORT

A 25-year-old male arrived in the Trauma emergency department (ED) of our hospital with an alleged history of stab injury with a knife to over right side chest. He was initially treated at a private hospital where he underwent intravenous fluid resuscitation with securing peripheral lines, one liter of Ringer's lactate, and a chest X-ray. He was administered one dose of 1 gm ceftriaxone and 500 mg of tranexamic acid. An attempt to remove the impaled object was unsuccessful due to a sudden breakdown. He was then referred to a higher center for further management. He arrived after 12 hours of injury at our hospital. ATLS protocol was followed for evaluation. The primary survey was unremarkable. Secondary survey on his chest examination revealed a sutured wound on the right side chest of 3cm over the 7^th intercostal space midaxillary line, reduced air entry on the right side base, and a dull note on percussion. Abdominal examination revealed diffuse tenderness, absent guarding or rigidity, and normal bowel sounds. Chest x-ray revealed right hemothorax and a foreign object in the right upper quadrant of the abdomen [Figure 1]. Intercostal tube drainage (ICTD) was put on the right side in the 5^th intercostal space to evacuate hemothorax, and about 200ml blood was drained. He was resuscitated with a maintenance dose of intravenous fluids. A sample was sent for blood group routine and cross-matching. He was planned for urgent exploratory laparotomy and taken to the operating room within half an hour. He was administered a third-generation cephalosporin antibiotic just before the incision. A midline laparotomy was done extending from the xiphisternal region to below the umbilicus. There was 200 ml of collected blood in the abdomen, which was evacuated. Intraoperative findings revealed part of the knife poking into the right lobe of the liver and a rent of size 2x1cm over the right crus of the diaphragm [Figure 2]. The liver was retracted inferiorly. The falciform ligament and right coronary ligament were divided, followed by the right triangular ligament to detach hepatic attachments from the diaphragm. Then we divided the hepatorenal ligament, freeing the right lobe from the kidney and bare area for complete right lobe mobilization.

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Figure 1:

Chest X-ray showing right-sided hemothorax and the retained knife blade in the right upper quadrant abdomen.

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Figure 2:

Intraoperative image showing the retained knife penetrating the right lobe of the liver.

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The Pringle maneuver was done for vascular control. The knife was removed under vision, and no active bleeding was noted. There was a 4 cm superficial laceration on the segment five anterior surface of the liver {Figures 3 and 4]. Hemostasis achieved. All other structures were found to be normal. Drain kept in Morrison pouch. Abdominal wound closed in layers. Ceftriaxone and metronidazole were advised and continued for five post-operative days. A repeat chest X-Ray on day 3 showed complete expansion of the lung with 50 ml serosanguinous output, and hence was removed. He made an uneventful postoperative recovery, and sutures were removed on the tenth postoperative day. He was discharged on the 11^th postoperative day. He was regularly followed up on and was stable and healthy. The work has been reported in line with the Surgical case report (SCARE) criteria.⁵

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Figure 3:

Intraoperative image after repair of liver defect; defect reinforced with an omental patch.

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Figure 4:

Extracted knife blade measuring approximately 12 cm, removed under direct visualization.

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DISCUSSION

Penetrating trauma to the thoracoabdominal region, particularly with retained foreign objects such as knives, presents unique clinical and surgical challenges. The management of such injuries requires meticulous adherence to trauma principles, including stabilization, appropriate imaging, and timely surgical intervention.^3,6 Adhering to advanced trauma life support (ATLS) protocols is critical in evaluating and managing penetrating injuries.^2,6 Our case exemplifies the importance of a thorough primary survey, which was unremarkable, and a focused secondary survey that identified significant findings, including reduced air entry and dullness on percussion, consistent with hemothorax. Appropriate Imaging confirmed the presence of hemothorax and a foreign object, emphasizing the importance of diagnostic tools in guiding management.^3,7 In stable patients, imaging plays a pivotal role in assessing the trajectory of the foreign object and potential injuries. While plain radiographs are often the first line, contrast enhanced computed tomography (CECT) of the torso provides detailed anatomical insights and aids surgical planning.^3,8 In our case, the chest X-ray was sufficient to identify the hemothorax and foreign object, allowing prompt decision-making. The principles of surgical management in penetrating trauma with retained objects emphasize controlled removal under direct visualization in an operative setting to prevent catastrophic hemorrhage and other complications.^5,7 In this case, Intercostal tube drainage (ICTD) effectively managed the hemothorax, while exploratory laparotomy revealed a knife penetrating the liver and diaphragm. A midline laparotomy should be done extending from the xiphisternum to the pubis.To mobilize the right lobe of the liver, retract the liver inferiorly. Divide the falciform ligament and right coronary ligament, followed by the right triangular ligament, to detach hepatic attachments from the diaphragm. Then divide the hepatorenal ligament, freeing the right lobe from the kidney and creating a bare area for complete right lobe mobilization. To mobilize the left lobe of the liver, retract the liver inferiorly and to the right. Divide the falciform ligament up to the left coronary ligament, then incise the left triangular ligament to release diaphragmatic attachments. Finally, divide the ligamentum teres (round ligament), completing mobilization of the left lobe for adequate exposure and access.

The Pringle maneuver was employed for vascular control, highlighting its utility in managing liver injuries.^7,8 The knife was removed under direct visualization, and the diaphragm was repaired successfully. The literature consistently demonstrates high morbidity and mortality rates associated with penetrating injuries involving vital organs. However, timely intervention and adherence to trauma protocols significantly improve outcomes.^3,8 Studies show that uncontrolled removal of foreign objects outside the operating room leads to catastrophic outcomes, as illustrated by mortality rates in such scenarios.^3,6 Our patient had an uneventful recovery, reinforcing the efficacy of controlled surgical intervention.

Diagnostic laparoscopy plays an important role in managing hemodynamically stable patients with penetrating abdominal trauma when clinical findings are equivocal.⁹ It allows direct visualization of the peritoneal cavity, accurately detects peritoneal or diaphragmatic injury, and significantly reduces unnecessary laparotomies, postoperative morbidity, and hospital stay.^10,11 However, its sensitivity for hollow-viscus injury remains limited, and it is contraindicated in patients with hemodynamic instability, evisceration, or peritonitis. Proper case selection and surgical expertise are crucial for safety and efficacy.¹²

Prophylactic antibiotics are used to manage penetrating abdominal injuries to prevent infectious complications within the first 24 hours.^6,7 In our case, a combination of ceftriaxone and metronidazole was administered, aligning with established guidelines. Regular follow-up and monitoring ensured a stable postoperative course.

CONCLUSION

This case highlights the critical importance of a structured and multidisciplinary approach to managing penetrating thoracoabdominal trauma with retained foreign objects. Adherence to ATLS protocols, timely imaging, and surgical intervention are paramount to achieving favorable outcomes. Controlled removal of the foreign object under direct visualization, combined with appropriate vascular control, proved effective in managing injuries to the liver and diaphragm in this case.