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A 40-year-old man was transferred to our trauma center by helicopter after being injured in an explosion in a factory. He presented with unstable vital signs and a Glasgow Coma Scale of 11. His left arm was nearly amputated, and his left lung was visible because of a crush injury to his chest wall. After intubation and blood transfusion, a log rolling maneuver was performed for inspection of his back. Bowel evisceration was noted at the posterolateral area of the thoracic cavity, and diaphragmatic rupture was suspected (Fig. 1). After wrapping the wound, the patient was moved to the operating room without undergoing any imaging study.

We ligated the brachial vessels that had already been transected, and performed amputation of his arm. Because the bowel was observed to have already eviscerated through the wound in his lateral chest wall, we decided to perform exploration using the lateral position/approach. The left diaphragm showed complete rupture, and the intra-abdominal organs were visible through the ruptured diaphragm (Fig. 2). The spleen was also observed to have ruptured, and splenic vessel ligation was performed (Fig. 3). The splenectomy was much easier than the anterior approach, but the ligament of Treitz was not easily accessible. Inspection of the small bowel revealed small bowel injury, and primary repair was performed.

Approaching the right-sided colon and the liver was impossible—we had to rely on tactile sensation for the procedure. A closed drain could be inserted though the lateral abdominal wall, although we had to rely upon tactile sensation to confirm the position of this drain. After the abdominal procedure had been completed, we inspected the thoracic area and identified lung laceration and air leakage. Stapler sutures were placed, and plates were used for fixation of multiple ribs. The diaphragm was repaired using 1-0 Vicryl sutures via a supra-diaphragmatic approach (Fig. 4). We closed the chest wall after the amputated lesion had been inspected by an orthopedic surgeon (Fig. 5).

The patient developed an acute kidney injury secondary to rhabdomyolysis, and continuous renal replacement therapy was needed. Several plastic surgeryprocedures were required to manage necrosis observed in a part of the chest wall. However, the patient did not need to undergo further abdominal or thoracic surgery and was discharged without complications.