Introduction

The gluteal region is anatomically located between iliac wings, inferior gluteal folds and bilateral greater trochanter.¹ Penetrating sharp object injuries (PSOIs) in the gluteal region are rare and constitute 2-3% of all injuries.² These injuries generally do not pose serious health problems. However, visceral and vascular injuries leading to life-threatening events can be observed in one-quarter of the cases.³ To the best of our knowledge, little research has been conducted on visceral and vascular injuries in the gluteal region. In this study, we present a case of small bowel perforation arising from an injury in the gluteal region. We hope our study will bring more interest to the subject and contribute to the scarce literature.

Case Report

A 24-year-old male patient was admitted to the Emergency Department of Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital with a PSOI in the gluteal region. Physical examination of the patient revealed 1 cm incision in the superior zone of the left gluteal region at 10 o’clock and eviscerated gangrenous ileum loop in the superior zone of the right gluteal region at 9 o’clock (Figure 1). The vitals were stable. A urinary bladder catheter was inserted and no macroscopic hemorrhage was observed. Lower extremity peripheral pulses were normal by palpation on both sides. There was no motor deficit in both lower extremities. No abnormality was found in the digital rectal examination.

Abdominal examination revealed muscular guarding and rebound tenderness. Abdominal examination findings and gangrenous prolapse of the ileal segment mandated surgical intervention. Laparotomy was performed via a midline abdominal infraumbilical incision. At exploration, approximately 200 cc hemorrhagic fluid was present in the abdomen. It was observed that approximately 15 cm incarcerated small intestinal loop, 20 cm proximal to the ileocaecal valve, had slipped out through the penetrated obturator canal during the injury. The incarcerated intestinal loop was taken back into the abdominal cavity, and three perforated areas and necrosis were observed (Figure 2). The injured segment was resected and end-to-end anastomosis was performed.

In further exploration, no injury was detected to the iliac, femoral and obturator arteries or veins, aorta and vena cava inferior. The urinary bladder and ureter were intact. After rectal tube placement, it was concluded that the rectum was not injured. The abdominal cavity was irrigated with copious isotonic fluid. The peritoneum in the injured area was debrided and repaired. A drain was placed in the right pararectal space. The injured areas in the gluteal region had already been explored preoperatively, and the operation was completed by placing a Penrose drain in both injury sites (Figure 3).

On postoperative day 2, the possibility of a rectal injury was re-evaluated by rectoscopy. No injury was detected. Neurosurgery consultation recommended electromyography to rule out possible sciatic nerve damage and no deficit was detected by EMG. The bowel movements started on postoperative day 2 and he started oral feeding on day 3. At the end of postoperative day 6, he was discharged by surgical healing.

Discussion

PSOIs are as old as the history of humanity. Nowadays, PSOIs occur with the use of different objects in our country and around the world. According to the study conducted by Üstüner et al.,⁴ PSOIs are usually performed by young men (16-35 years old), most often in summer, during may and between 12.00-04.00 a.m. Among these injuries, gluteal injuries are the third most common injuries following thoracic and abdominal injuries.⁵ Depending on the type of injury, patients are generally discharged with antibiotics after closure of the wound with primary suture. However, there may be vascular, intestinal, genitourinary and sciatic nerve injuries depending on the depth and trajectory of penetration.⁶ The upper zone and the lower zone are formed when the gluteal region is divided into two from the inter-trochanteric line. Mortality and morbidity of the upper zone injuries are higher than the lower zone.³ Angiography and surgical intervention may be required for diagnosis and treatment.⁷ In our case, the injury occurred in the upper zone and the patient was operated.

There is no consensus on the treatment algorithm of penetrating injuries to the gluteal region and the management is still to be evolved. Treatment begins with ABCDE. First, CT is performed to investigate the presence of intraperitoneal fluid in patients with shock. If positive, laparotomy is performed and the localization of the bleeding is determined if negative. Packing and angioembolization are performed depending on the bleeding site, and surgery is performed if the bleeding could not be stopped. In patients without shock, CT is also the initial imaging method. Surgery, angioembolization or observation could be preferred according to the observed bleeding and abdominal injuries.²

In 2014, Lunevicius et al.,⁸ updated the algorithm and recommended evaluation in the following order: general inspection of the patient, controlling the femoral pulse, neurological examination of the lower extremities, examination of urethra and rectum, and then rectoscopy was suggested after the patient became stable.⁹ Radiologists recommend contrast-enhanced rectal CT if there is still clinical suspicion of rectal injury despite rectoscopy.⁶ There is no standard treatment for pelvic wounds.¹⁰

In our case, the examination of the rectum, genital organs, femoral and distal pulses were performed. Since there was an incarcerated intestinal loop seen outside of the gluteal region and findings of acute abdomen, the surgery was performed. On the postoperative day 2, rectum was checked using rectoscopy. In PSOIs, the mortality rate is 0-2% in the posterior abdomen region, 0-4.4% in the anterior abdomen region, 2.1% in the thoraco-abdominal region, and 2.5-5.6% in the thorax region. The mortality rate in gluteal injuries is 2.9%, which is quite high compared to other parts of the body.²

Conclusion

In conclusion, PSOIs in the gluteal region may lead to life-threatening damages. Small bowel perforation is one of these damages and should be kept in mind though it is rarely observed.

Ethics

Informed Consent: Informed consent was obtained from the patient.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: E.Y., A.K., Concept: M.A.Ü., Design: M.A.Ü., L.D., Data Collection or Processing: A.K., Analysis or Interpretation: M.A.Ü., L.D., Literature Search: E.Y., Writing: M.A.Ü.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.