Complete small bowel and mesenteric avulsion following rope-compression blunt abdominal trauma after a fall from height: a case report

Introduction and importance: Complete small bowel and mesenteric avulsion is an exceptionally rare consequence of blunt abdominal trauma. We report a case associated with a massive traumatic abdominal wall hernia (TAWH) following rope-compression injury after a fall from height. Presentation of case: A 75-year-old man sustained severe blunt abdominal trauma after a 15-m fall during a logging accident. The fall was abruptly arrested by a rope compressing the upper abdomen, producing a marked seatbelt sign and hemorrhagic shock. Contrast-enhanced CT demonstrated active mesenteric bleeding, bowel ischemia, and a large TAWH. Emergency damage-control laparotomy revealed complete avulsion of approximately 2 m of distal small bowel and mesentery up to the ileocecal valve. Management included hemorrhage control, temporary abdominal closure with negative-pressure wound therapy (NPWT), second-look laparotomy with ileocolic anastomosis, and abdominal wall reconstruction. Approximately 100 cm of proximal small bowel remained. The postoperative course was complicated by skin necrosis, acute cholecystitis, and short bowel syndrome requiring prolonged nutritional support. Clinical discussion: The combination of complete bowel and mesenteric avulsion with massive TAWH represents an extreme form of blunt abdominal trauma. CT imaging provided valuable diagnostic information in a transiently responsive patient and facilitated operative planning. Staged damage-control surgery was critical to survival. Despite extensive abdominal wall destruction, the linear pattern of muscular avulsion facilitated definitive anatomical reconstruction. Conclusion: Recognition of a seatbelt sign should prompt suspicion of severe intra-abdominal injury. CT evaluation may assist operative planning in transiently responsive patients, and staged damage-control surgery can achieve favorable outcomes even after catastrophic abdominal trauma.