Traumatic Abdominal Wall Hernia–A Series of 12 Patients and a Review of the Literature

Abstract

Background The traumatic abdominal wall hernia (TAWH) is strongly associated with blunt abdominal trauma. The importance of the CT scan cannot be underestimated—the diagnosis of TAWH is easy to miss clinically, but simple to spot radiologically. We report a case series of patients managed in a French‐level one trauma centre, to contribute our experience in the detection and management of associated injuries, and of the hernia itself. Methods All patients (n = 4238) presenting to a single‐level one trauma centre for trauma resuscitation (including systematic full‐body computerised tomography) from November 2014 to February 2020 were screened for the presence of TAWH and prospectively added to our database. Particular attention was paid to the late detection of associated intra‐abdominal injuries. Finally, the choice of management of the hernia itself was noted. A literature review of all case series and individual case reports until the time of writing was performed and summarised. Results We report 12 cases of TAWH amongst 4238 patients presenting to the trauma resuscitation bay between November 2014 and February 2020. All patients underwent a contrast‐enhanced CT immediately after stabilisation. No patients had clinically detected TAWH prior to CT. Intra‐abdominal injuries were found in 9 patients (75%), and urgent surgery was required in 7 patients (58.3%). Two (28.5%) of these seven patients had a missed diagnosis of intra‐abdominal injury at the time of the index CT scan, although the TAWH had been detected. Based on our literature review, 271 patients across 12 case series were identified. In total, 183 (67;5%) of these patients were reported to have ≥ 1 associated intra‐abdominal injuries. In total, 127 (46,8%) patients required an urgent laparotomy for management of these injuries. Five (3.9%) of the patients requiring urgent laparotomy had a missed CT diagnosis of intra‐abdominal injury but not of TAWH at the time of the baseline CT. Conclusions TAWH is a rare clinical entity that may alert to more significant, associated trauma lesions. The CT scan is the imaging modality of choice, to both diagnose and classify the hernia and to screen for other injuries. The presence of TAWH must lower the threshold to operatively explore or at least closely monitor these patients, in view of the high rate of false‐negative findings at index imaging.

Abdominal reconstruction in a patient with flank hernia after trauma, a case report and review of the literature

“…Management, as in the rest of hernias, consists of dissecting the sac to free it from the edges of the defect, reducing the sac with its contents, and repairing the defect. It is important to mention that, up to now, there is no consensus to determine the best management In most of the reported cases open approaches (preperitoneal) have been performed, through the midline in the case of blunt trauma or by extending the wound in the case of open trauma or post-incisional hernias [14][15][16][17][18][19] and laparoscopic approach in fewer cases 20,21 . The only indication found in the review for performing a laparoscopic approach is in the case of patients who did not receive immediate surgical treatment and developed symptomatic lateral hernias.…”

Traumatic abdominal wall hernia: a rare and often missed diagnosis in blunt trauma

“…[1,2] It is postulated that a high body mass index/obesity and seatbelt-related trauma, as noted in our patient, may also contribute to shearing deceleration forces, thus increasing the incidence of TAWH and associated mesenteric injury. [8,9] The diagnosis of TAWH requires a detailed physical examination and a high index of suspicion. The most common clinical feature on examination includes abdominal pain with a tender bulge in the abdominal wall at the site of traumatic hernia.…”

“…TAWH is an important predictor of associated intra-abdominal injuries in patients who suffer from severe trauma, especially radiologically occult mesenteric and serosal/mucosal shearing injuries. [1,7,8] Occasionally, the hernia can be discovered during a laparotomy performed for other indications, and this then poses a significant challenge to the surgeon who has to decide on the method of reconstruction. The appropriate timing of surgery for TAWH should be considered on a case-by-case basis, depending on the mechanism and severity of trauma, hemodynamic stability of the patient, the size of the abdominal musculature defect, clinical and radiological findings and other associated injuries.…”

Post-traumatic lateral abdominal wall hernia: a case report

“…Blunt abdominal trauma continues to be a frequent cause of emergency department visits 1 . It is strongly associated with high-energy injuries.…”

“…It was first described in 1906 3 and defined as the ‘herniation through disrupted musculature and fascia, associated with adequate trauma, without skin penetration and no evidence of a prior hernia defect at the site of injury’. Its incidence is less than 1% of all abdominal blunt trauma 1 , 4 , 5 . All patients with varying degrees of abdominal tenderness with either abdominal wall skin abrasions or ecchymosis could make easy misdiagnosed TAWH because the abdominal examination is difficult.…”