Laparoscopic-first approach for treating a small bowel injury in a patient stabilized after initial hemodynamic shock: a case report and video.

Introduction: Laparotomy is the standard treatment for penetrating abdominal trauma; however, the role of laparoscopy is expanding. We report the case of a penetrating jejunal injury in a patient who initially presented with shock but was successfully managed using a laparoscopic-first approach. Case presentation: A 61-year-old male with a history of distal gastrectomy presented with a self-inflicted abdominal stab wound and had ingested antihypertensive drugs and cigarettes. He was initially diagnosed with hemorrhagic shock (systolic blood pressure, 60-70 mmHg), which stabilized after fluid resuscitation. Computed tomography revealed a hemoperitoneum, free air, and omental herniation. A laparoscopic-first approach identified 1200 mL of hemoperitoneum and a full-thickness jejunal perforation. The small bowel was inspected using the "running the bowel" technique, and the perforation was repaired with a two-layer handsewn technique. Therefore, the hybrid laparoscopic/anterior open approach was deemed useful. The patient recovered uneventfully. Discussion: This case suggests that a laparoscopic-first approach can be safely applied to select patients who initially present with transient hemodynamic instability but stabilize after resuscitation. Careful patient selection and systematic exploration are critical to avoid missed injuries. A pragmatic hybrid approach preserves the benefits of minimal invasion. Conclusion: The laparoscopic-first approach is a safe and feasible option for treating small-bowel injuries in selected patients who achieve hemodynamic stability after resuscitation. This strategy facilitates faster recovery and is particularly beneficial in selected patients requiring rapid postoperative recovery, such as those with psychiatric comorbidities.