Successful open repair of a civilian low-energy ballistic suprarenal abdominal aortic injury: Case report and literature review

Background: Civilian suprarenal abdominal aortic injuries are exceptionally rare and highly lethal, with mortality rates exceeding 80% in high-energy firearm mechanisms. Most patients die before hospital arrival or within the first 24 h. In contrast, low-energy handgun injuries may occasionally be survivable when prompt recognition, damage-control resuscitation, and immediate operative intervention are achieved. Case presentation: A 45-year-old man sustained a low-energy ballistic wound from a civilian handgun, with entry in the lower right basithoracic region and exit in the posterior left lumbar area. On arrival, he was haemodynamically unstable, intubated, and managed with massive transfusion under damage-control principles. Computed tomography angiography revealed a posterolateral suprarenal aortic laceration with active extravasation, peri-aortic haematoma, and hepatic dome laceration; the projectile was lodged in the left lumbar subcutaneous tissue. Emergency thoraco-phreno-lumbotomy provided direct retroperitoneal supraceliac control (cross-clamp time: 5 min), followed by primary repair with polypropylene suture. A complementary midline laparotomy allowed diaphragmatic closure and hepatic haemostasis. Results: The patient was discharged from the intensive care unit on postoperative day 3 with restored intestinal transit. The postoperative course was uneventful, and at one-month follow-up he remained clinically stable. Conclusion: In unstable patients with complex anatomy, immediate supraceliac control via a dual surgical approach can be life-saving when endovascular options are not feasible.