Combined fragment wound of the chest and abdomen with tension pneumothorax, right kidney injury, and inferior vena cava damage: A clinical case

Introduction. Combined fragment wounds of the chest and abdomen are among the most severe types of combat trauma. Injuries to the inferior vena cava (IVC) and renal vessels are associated with massive retroperitoneal hemorrhage and high mortality rates, reaching 50–70%. In a mobile medical group (MMG) (Level 2+ of medical care), located close to the combat zone, treatment success depends on rapid decision‑making, a well‑organized multidisciplinary approach, and the performance of complex vascular reconstructions.

Case description. A 32‑year‑old serviceman was delivered to the MMG 30 min after sustaining a fragment wound. The condition was extremely severe, characterized by profound hemorrhagic shock grade II and severe anemia. A penetrating abdominal wound with injury to the right kidney and retroperitoneal hemorrhage, as well as a right‑sided pneumothorax, were diagnosed. The consultation team decided on emergency surgery. Pleural cavity drainage and a midline laparotomy were performed, revealing a massive retroperitoneal hematoma (2 L of blood evacuated). Exploration demonstrated an injury to the right renal hilum with avulsion of the renal artery and vein, alongside two defects of the IVC: avulsion of the right renal vein from its confluence and a through‑and‑through defect of the anterior wall. After intravenous heparin administration, the IVC was clamped, the vein defects were closed with a parietal suture, and the renal vein stump was oversewn. Due to fragmentation of the renal hilum, a right‑sided nephrectomy was performed. The operation was completed with a laparostomy. Intraoperative hemotransfusion amounted to 2000 mL of blood components. The postoperative condition was stable, and the patient was evacuated to a rear hospital.

Conclusions. This case demonstrates the possibility of successfully providing specialized surgical care to wounded patients with critical major vessel injuries in a MMG (Level 2+ of medical care). The key success factors were rapid evacuation, coordinated work of a multidisciplinary team, correct choice of damage control tactics with temporary hemostasis and subsequent vascular defect closure under systemic heparinization.

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