Small bowel herniation through ballistic wound resulting in small bowel obstruction

Small bowel obstruction (SBO) is often a result of post-operative adhesions and sometimes herniation of small bowel through a fascial defect. Obstruction secondary to herniation through a ballistic wound is exceedingly rare. This case report discusses a 40-year-old male who presented with multiple gunshot wounds to the abdomen, right axilla, and extremities who was taken for exploratory laparotomy and underwent cecal resection, small bowel resection with anastomosis, cholecystectomy, hepatorrhaphy with omental patch, and primary right diaphragm repair. His post-operative course was complicated by herniation of small bowel through a right lower quadrant ballistic wound requiring return to the operating room for reopening and repair of the fascial defect with delayed closure. His hospital course also included bile leak requiring endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct stent and biliary sphincterotomy, hepatic necrosis with abscess, and right empyema requiring additional tube thoracostomy and subsequent thoracotomy. Closure of ballistic fascial defects during initial trauma laparotomy may prevent this rare complication of small bowel herniation requiring return to the operating room.