Traumatic abdominal wall hernias: a single-center case series of surgical management

Abstract

BackgroundTraumatic abdominal wall hernias (TAWHs) are a rare clinical entity that can be difficult to diagnose and manage. There is no consensus on management of TAWH due to its low incidence and complex concomitant injury patterns. We hereby present the largest single-center case series in the USA to characterize associated injury patterns, identify optimal strategies for hernia management, and determine outcomes.MethodsPatients who presented with a TAWH from blunt trauma requiring operative management were retrospectively identified over a 14-year period. Demographic data, Injury Severity Score (ISS), associated injuries, type of repair, durability of repair, and complications were collected, and descriptive statistics were calculated.ResultsFifteen patients were identified. The average age was 31±11 years, ISS 15±9, and body mass index 33.4±7.1 kg/m2. Mechanisms included falls (13%), motor vehicle collisions (60%), motorcycle accidents (20%), and pedestrian versus motor vehicle collisions (7%). The most commonly associated injuries included colonic injuries (53%), long bone fractures (47%), pelvic fractures (40%), and small bowel injuries (33%). Nineteen hernia repairs were performed: 6 underwent primary suture repair (32%) and 13 used mesh (68%). There were four recurrences. We could not find any significant relationship between contamination and mesh use or recurrence. There was one mortality related to sepsis.DiscussionTAWHs have an associated injury pattern involving fractures and abdominopelvic visceral injuries where a tailored approach is advisable. Without hollow viscous injuries and gross contamination, these hernias can be repaired safely with mesh in the acute setting. However, in patients with gross contamination or hemodynamic instability, the risk of recurrence with primary repair must be weighed against the risk of infection and prolonged surgery with mesh repair. In those cases, a delayed reconstruction in the elective setting may be optimal.

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.…”

Traumatic abdominal wall hernia after impact from handlebar: A case report

“…The use of mesh in an emergency TAWH repair is debatable, weighing the benefits of lower recurrence rate against the risk of surgical site or mesh infection. In small hernia defects, attempts for primary closure with non-absorbable monofilament sutures are recommended, but the risk of recurrence rate can be as high as 33 to 40% [6] . Techniques such as component separation and relaxing incisions can be used for successful closure of larger hernia defects.…”

Traumatic abdominal wall hernia in a patient with diastasis recti

“…Proponents of early repair state the decreased potential for incarceration or strangulation, as well as the fact that the defect may enlarge with time 8 . There has been no significant relationship found between recurrence and contamination or mesh use, bearing in mind that the sample size is very small 6 . The management of TAWH appears to be both patient and surgeon dependent, taking into consideration the acuity of a significant trauma, the stability of the patient and presence of other injuries, as well as access to emergency theatre.…”

“…The pathophysiology is thought to be due to blunt force causing an acute increase in intraabdominal pressure, distributed over a surface area large enough to prevent penetration of the skin 5 . TAWH are graded on a severity score from I to VI, ranging from subcutaneous tissue disruption (Grade I) to complete abdominal wall disruption with evisceration (Grade VI) 5,6 …”

“…5 TAWH are graded on a severity score from I to VI, ranging from subcutaneous tissue disruption (Grade I) to complete abdominal wall disruption with evisceration (Grade VI). 5,6 Motor vehicle accidents are the most common cause of TAWH, identified as the aetiology in up to 60% of cases. Other causes include falls, pedestrian versus motor vehicle accidents and motorcycle accidents.…”