Traumatic abdominal wall hernia with concealed colonic perforation

Abstract

Traumatic abdominal wall hernia (TAWH) is a rare clinical entity in terms of aetiology. It occurs following a blunt abdominal injury with energy high enough to cause disruption of the musculoaponeurotic layer but not the elastic skin layer. It is often associated with underlying intra-abdominal injuries, which can be diagnosed either clinically or radiologically. We report a case of TAWH in a young man with associated large bowel transection, which remained undiagnosed in the preoperative period owing to its masked features. He was managed surgically, with no recurrence to date. Considering the high volume of blunt abdominal trauma cases that present to the accident and emergency department, only few cases of TAWH have been reported in the literature. Confusion still exists regarding the timing and mode of management of this condition. KEYWORDSAbdominal wall -Traffic accidents -Abdominal hernia -Aetiology -Motorcycles Traumatic abdominal wall hernia (TAWH) is an unusual type of hernia that occurs following a non-penetrating abdominal trauma resulting in breach of the musculoaponeurotic layers of the abdomen with an intact overlying skin. Although blunt abdominal trauma is very common, the incidence of TAWH is low. The diagnosis of TAWH is rarely straightforward owing to the various clinical presentations and management therefore varies substantially. 1 We report a unique case of TAWH following a road traffic accident with associated hollow viscous injury. Case historyA 30-year-old man presented to the accident and emergency department having sustained a high velocity blunt trauma injury over his left flank from a hollow metal pipe two hours earlier while driving a motorcycle. The patient was haemodynamically unstable. He had a tender, irreducible swelling of approximately 15cm x 10cm over the left flank with evidence of an overlying bruise and abrasions (Fig 1). There was no expansile cough impulse over the swelling and the swelling was soft in consistency. General abdominal examination was insignificant and there was no peritonitis. Focused assessment with sonography for trauma showed no intra-abdominal fluid collection. However, ultrasonography indicated a possible parietal breach at the site of the lump. Multidetector computed tomography (CT) of the abdomen revealed a full-thickness defect over the left lumbar region with small bowel herniation (Fig 2).The patient was posted for an exploratory laparotomy by a midline approach. A 20cm loop of jejunum was found to be herniating through a gap of 7cm over the left lumbar region. A complete transection of the descending colon was also noted (Fig 3). Both the proximal and distal ends of the transected colon were also seen to be herniating through the defect. There was collection of stool and blood clots in the ONLINE CASE REPORT Ann R Coll Surg Engl 2016; 98: e133-e135

Simplified Repair of Traumatic Iliac Crest Flank Hernias with Mesh Strips

“…Traumatic abdominal wall hernias are themselves rare entities, and descriptions of primary repair are largely limited to case reports. 23 , 33 , 35 , 57 – 59 While several factors contribute to the decision of primary versus mesh-supported repair, including defect size and presence of abdominal contamination, we find that our mesh strip technique provides some of the advantages of planar mesh while avoiding the difficulties and time required to place a large sheet of prosthetic material. Cases were completed on average under 2 hours for these surgeries.…”

“…In any patient with an acute traumatic abdominal wall hernia, there must be a high suspicion for associated intra-abdominal injuries, 8 , 11 , 27 – 33 as well as pelvic fractures, 27 , 34 , 35 as a high force is required to cause this herniation. These high-energy injuries have a high incidence of associated operative intra-abdominal injuries and thus the risk of a contaminated field.…”

Traumatic abdominal wall hernias: Classification, diagnosis and management

“…Traumatic abdominal wall hernias (TAWHs) are rare clinical conditions where muscular and fascial layers of the abdominal wall are disrupted while the skin remains intact after a blunt abdominal injury. 1,2 Only a handful of cases have been reported, therefore a consensus in management of TAWHs has not been established. 3 The purpose of this study was to investigate current literature regarding management of TAWHs, taking into consideration mainly circumstances of the occurrence and optimal timing for repair of hernias subsequent to blunt abdominal trauma.…”

“…The incidence of TAWHs is rather low in contrast to the more frequent blunt abdominal trauma. 1,[3][4][5] The incidence of TAWHs is estimated at 0.07 %. 3 Usually, a TAWH contains small bowel or large bowel, however a small percentage of TAWHs can contain both.…”

“…4,6 Unsurprisingly, a high number of handlebar hernias have also been reported in children as a result of a thinner abdominal wall and more elastic skin. 1 Risk factors known for TAWH are pre-existing hernias, old age and weak abdominal muscles. 3,8 TAWHs can be described as a "visible bulge" on the parietal wall associated with ecchymosis and subcutaneous fluctuant swelling.…”