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Introduction: Traumatic abdominal wall hernias (TAWHs) are uncommon and result from a high-energetic blunt trauma to the abdomen. These hernias are not always apparent in initial trauma evaluation. No consensus exists regarding optimal timing and surgical approach. Case Presentation: A 68-year-old Caucasian woman was involved as a passenger in a high-energetic head-on collision motor vehicle accident. In the initial assessment a sternal fracture, four rib fractures, a small pneumothorax, and a medial malleolus fracture were found. A small abdominal wall hernia was missed. Six months later she presents with a painful mass in her left flank. Computed tomography (CT) showed a large hernia containing colon. An elective hybrid repair was done. Laparoscopically, a preperitoneal mesh was placed. Afterward, using open access, the abdominal wall musculature was re-fixated on the iliac crest. Discussion: Emergent surgical management of TAWH is often preferred due to high incidence of associated intra-abdominal lacerations. These settings are not always favorable for mesh placement. Some data suggest a higher recurrence rate for hernias without mesh augmentation and repair within the acute posttraumatic period. Conservative management poses the risk of incarceration and hernia defect enlargement. A delayed repair can be considered if the patient is hemodynamically stable, no associated visceral lacerations are present and the defect is large enough to reduce the risk of incarceration. It has the advantage of mesh placement in healthy tissue.Conclusions: A delayed laparoscopic repair seems a safe and valid option allowing larger mesh placement. Additional fascia closure of muscle fixation can be done granting more reinforcement and smaller incision needs and thus less postoperative pain. Keywords: Case report, hernia, laparoscopy, trauma, traumatic abdominal wall hernia
| Introduction | |  |
A traumatic abdominal wall hernia (TAWH) is a hernia occurring after a blunt low- or high-velocity impact to the abdominal wall. A sudden and large impact gives shearing stress and an elevated intra-abdominal pressure, leading to a disruption of abdominal wall musculature and fascia.[1] The skin is typically intact, and no preexisting hernia defect should be present.[2] It is a rare type of hernia with a prevalence of approximately 1% recorded in trauma center series.[3],[4] TAWHs have mostly only been discussed in multiple case reports and limited series and there is no consensus regarding timing and approach of surgical repair. Most repairs are done in initial hospitalization requiring laparotomy to assess other intra-abdominal lacerations. Delayed procedures have been done but remain controversial regarding the risk of strangulation.
We report a case of TAWH in a 68-year-old woman following a high-energetic motor vehicle accident. In the initial assessment, the hernia was missed. In this case, a delayed repair combining a laparoscopic and open access is presented addressing the benefits and rationale of this approach.
| Case Report | | |
A 68-year-old Caucasian woman with a body mass index (BMI) of 23.67 kg/m2 and no significant medical history presented at the surgical consultation with complaints of progressive swelling and discomfort in her left flank.
Six months earlier she was involved as a passenger in a motor vehicle accident. She had a high-energetic head-on collision with a ghost rider. She was transported to the emergency department at a different center. Upon arrival, she was conscious with a Glasgow Coma Scale of 15 and hemodynamically stable. She complained of shortness of breath with sternal and at he left rib cleft thoracic pain. Her abdomen was soft and nontender. Her left ankle was painful and swollen. A computed tomography (CT) scan was done of her head, neck, thorax, and abdomen.
Radiological assessment proved four rib fractures and a small pneumothorax left sided, a nondisplaced sternal fracture, and a displaced medial malleolus fracture. She was admitted to the intensive care unit (ICU) for hemodynamic monitoring. The pneumothorax was treated conservatively with oxygen and analgesics. Her ankle fracture was operated and fixated. Trauma CT of her abdomen showed a contusion zone anterior of the left iliac crest. In retrospect, a fascial dehiscence and thus a hernia was already seen on this CT but not treated [Figure 1]. After 3 days she was discharged from the ICU and a week later she left the hospital in good clinical condition. | Figure 1: Initial contrast-enhanced CT showing bruising and fascial dehiscence at left iliac crest
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In following months, she noticed a painless, reducible swelling in her left flank. The swelling was progressive in nature and caused a significant discomfort in supine position.
Clinically a soft, nontender mass was seen above her lift iliac crest. Ultrasonography could not show a hernia. An additional CT scan was done which showed a large hernia of 63 mm × 55 mm × 60 mm containing colon [Figure 2]. Because of its symptomatic and progressive nature, a surgical repair was proposed in two stages. | Figure 2: CT scan after 6 months showing enlargement of hernia in left flank, now containing colon
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First, a laparoscopy was done. The large defect above the iliac spine, containing sigmoid colon, was visualized [Figure 3]A and B]. Peritoneum around the defect was incised and the hernial sac, including the sigmoid, was reduced [[Figure 3C]. A BIOMESH® P1 (Duomed, Aartselaar, Belgium) polypropylene mesh of 15 cm × 13 cm was placed with an overlap over the defect. Anteriorly the mesh was fixated using tackers. Posteriorly it was fixated using synthetic surgical glue (IFABOND®, Peters Surgical, Boulogne-Billancourt – France) because of the risk of nerve damage [Figure 3D]. The peritoneum was closed over the mesh using a nonabsorbable suture. In the second stage, an incision was made above the iliac crest following skin lines. When opening the external oblique fascia, the hernial orifice and the mesh were visualized. The orifice was closed with the external oblique muscles by re-fixation on the superior iliac spine using a thick polyester nonabsorbable suture (Ti-Cron™, Medtronic, Dublin, Ireland). A subcutaneous drain was placed. All wounds were closed. The total operation time was 2 h 45 min. The patient had adequate pain control with oral analgesics, the drain was removed, and she was discharged on the third postoperative day. | Figure 3: Laparoscopy images: (A) hernial defect, (B) sliding sigmoid colon, (C) reduction of hernial sac, and (D) mesh placement preperitoneal
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On postoperative control, after 6 weeks the patient was free of the preoperative complaints. She had a zone of hypoesthesia at her left flank and left thigh, transient in nature. No swelling or underlying recurrent hernia was found. A control CT was performed 3 months later which showed no recurrence of hernias [Figure 4].{Figure 4}
| Discussion | | |
The exact definition of a TAWH has differed over the years. Various authors have proposed diagnostic criteria. The history of blunt abdominal wall trauma and the absence of preexisting abdominal wall hernia is the common criteria according to Liasis et al.[2] Typically, in these cases the shearing stress of the blunt impact leads to disruption of muscle and fascia. The skin remains usually intact because of its elasticity, although bruising is frequently seen. In pediatric patients, this kind of hernia is called a “handlebar hernia” because of the bicycle handlebar, which is typically the object of blunt force in the abdomen. In adults, motor vehicle collisions are the most common cause.
Dennis et al.[5] devised a grading system of abdominal wall disruptions. In our case, we are dealing with a grade IV abdominal wall hernia due to the herniation of visceral abdominal content [Table 1]. In initial clinical assessment, it is possible for a hernia not to be apparent, and only a delayed presentation is possible. The ongoing theory is that pain and subsequent muscle spasm from the initial trauma masks the defect. Afterward muscle relaxation and bowel dilatation raise intra-abdominal pressure, which aggravates the muscle defect and herniation.[6],[7] Most TAWHs are seen in the lower abdomen. This is due to its presence of natural orifices and general weakness of the abdominal wall. In our case, the hernia was located above the iliac crest which is consistent with the deceleration trauma of the seatbelt in motor vehicle collisions.[3] In a supine, immobilized trauma patient, besides some bruising and ecchymosis, a hernia may not be present. A high index of suspicion should be present, and a CT scan should be performed to visualize an underlying abdominal wall hernia and rule out visceral organ damage.[8],[9] | Table 1: Grading of abdominal wall disruptions according to Dennis et al.[5]
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A TAWH remains a rare type of hernia and has been frequently discussed in multiple case reports and limited case series. No consensus has been reached regarding the best timing for treatment. In a trauma setting the stability of the patient takes priority. When other intra-abdominal lacerations are present, an emergency laparotomy is usually necessary. At the same time, a hernia repair can be considered. Early repair reduces the risk of bowel obstruction, incarceration, and strangulation.[6],[10] However, trauma-related stress and a higher risk of surgical site infections in initial exploration do not favor concomitant mesh placement.[2] In the case of intra-abdominal soiling due to hollow organ lacerations, bio-mesh usage has been proposed. These meshes however are more expensive and less durable compared to polypropylene mesh.[11] A systematic review of Karhof et al.[12] showed that 70% of recurrences occurred without mesh augmentation and in repairs within the first 2 weeks after trauma. However, no statistically significant difference could be noted in their pooled analysis. A high recurrence rate is seen in a traditional layered suture repair up to 54% for incisional hernia repair. In comparison, mesh repair has a lower recurrence rate between 15% and 30%.[13] Patients with large hernia defects and thus low chances of strangulation can be managed conservatively. In delayed repairs, the defect may enlarge, and muscles may atrophy making a primary suture more difficult.[14],[15] Otherwise, the patient is usually in a better clinical condition and the hernia sac will be more developed, facilitating mesh placement.[4]
In our case, at initial presentation and imaging the hernia was missed. Over time the hernia defect enlarged, and a primary suture would not have been favorable. We chose a combined approach. First laparoscopy to visualize the extent of the hernia, reduce it and place a preperitoneal polypropylene mesh. In this manner, a larger mesh could be placed compared to an open approach. Afterward an open approach but with a smaller incision was done to fixate the external oblique musculature to the iliac crest. A laparoscopic defect closure did not seem possible because laparoscopic instruments would not be able to exert enough force to fixate the musculature into bone.
Tulloh and de Beaux[16] reported the theoretical importance of the mesh:defect area ratio in which the general 5-cm overlap rule seems to be illogical in larger defects. Instead, the mesh radius size (R) should increase proportionally with the defect radius size (r) to maintain a balance between mesh displacement and mesh fixation. The following formula has been proposed: r2/R2. In our case, we approximately have mesh:defect area ratio of 5:4. Tulloh and de Beaux stated that a defect of 6 cm × 6 cm is the largest that can be attempted laparoscopically and maintain an adequate mesh:defect area ratio. This is about the defect size in our case. We do believe that we had adequate coverage as we additionally closed the defect. The defect was not circular in the midline as theoretically proposed but had an elliptical shape. This might give a more uneven force on the mesh at the level of the bony iliac spine and abdominal wall musculature.
When assessing literature, in only three cases a laparoscopic repair of a TAWH was done. Our case is the first in which a hybrid procedure is done with mesh placement and re-fixation of abdominal wall musculature. Our patient was satisfied with the outcome and no recurrence was seen in the first three-month follow-up.
This case presentation has some limitations. Treatment strategy was based on surgical experience and a patient-tailored approach thus we are unable to generalize this data. Together with the retrospective design of this study a certain amount of publication bias is present.
| Conclusions | | |
TAWH is fairly uncommon and seems to be easily missed in an acute trauma setting. A high index of suspicion is necessary, and a CT could facilitate the diagnosis. No consensus exists regarding the optimal management of TAWH. Treatment should be individualized based on hemodynamically stability, risk of incarceration, and associated intra-abdominal injuries. Repair with mesh augmentation is the preferred method. A delayed treatment with laparoscopy seems a safe and valid alternative to a laparotomy, allowing placement of a larger mesh and minimizing incisions for an additional open fixation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Correspondence Address:
Dries Dorpmans,
Postbaan 47, 3290 Diest, Vlaams-Brabant
Belgium
 Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figur 4]
[Table 1] |
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