A case of traumatic abdominal wall hernia

1.  DR. PRAMEYRATNA KADAM (JUNIOR
RESIDENT)
 DR. CHINMAY GANDHI (ASSOCIATE
PROFESSOR)
 DEPARTMENT OF GENERAL SURGERY
 BHARATI VIDYPEETH DEEMED UNIVERSITY
MEDICAL COLLEGE & HOSPITAL

2.  63 year old male gives history of accidental fall in
well from 60 feet at 2 pm on 24/05/2016.(H/O FALL
ON STAIRS BEFORE FALLING IN WATER)
 Patient arrived in emergency at 4pm with chief
complaint of pain in abdomen.
 On examination patient was conscious, oriented
with vitals stable.
 BP. 150/90
 PULSE. 88 per minute
 R.Rate 22 per minute
 RS,CVS,CNS were normal

3. PICTURE CLINICAL EXAMINATION
 Per. Abdominal
examination revealed Right
Lower abdominal swelling,
contusion and ecchymosis.
 There was localized
tenderness and guarding
 There were no major extra
abdominal injuries noted

4. HB% 14 gm%
Total counts 5400 P.70% L 26%
B. Urea 42 mg %
S. Creatinin 1.8 mg %
All other lab. Reports were normal
ABDOMINAL USG : Suggested
Abdominal wall defect with bowel
herniation with no intraabdominal free
fluid.

6.  We did early
laparotomy through
the defect to prevent
incarceration and
strangulation of
herniated bowel.

7.  We found intestinal
(ileum) perforation in
subcutaneous bowel
loop.

8.  Lacerated perforated
and gangrenous
bowel loop inside
abdomen.

9.  Mesenteric tear with
mesenteric
hematoma with
appendicular tip
gangrene.

10.  We did small bowel
resection and anastomosis,
appendicectomy and
mesenteric tear closure.
 TAWH repair was done
after intra abdominal repair
of injured bowel.

11.  Anatomical repair with
proline suture was done for
transverse 5cm tear in
posterior rectus sheath and
2 cm tear in anterior rectus
sheath.
 Due to risk of
contamination mesh was
not used.
 Subcutaneous fat and skin
required debridement
because of necrosis and
contamination

12. Blunt abdominal trauma is common injury, but traumatic
abdominal wall hernia occurs only in 1% of these cases.
First reported by Selby in 1906.
Dimyan described relationship of handlebar of cycle with
abdominal wall hernia in 1994.
Only 250 TAWH are reported in literature till date.
Dennis proposed grading for abdominal wall disruption in
2009.

13.  Grade 1:subcutaneous tissue contusion
 Grade 2: AW muscle hematoma
 Grade 3: single AW muscle disruption
 Grade 4: complete AW muscle disruption
 Grade 5: complete AW muscle disruption with
herniation
 Grade 6 : complete AW disruption with
evisceration

14.  Tangential forces leading to disruption of abdominal
muscles, fascia and peritoneum with raised intraabdominal
pressure is the main cause of TAWH.
 Skin being more elastic , hence it remains intact in most
cases.
 Woods classified TAWH in 3 major types.
 Type 1: is associated with high energy injuries like motor
vehicle, motorcycle accidents and are associated with
intraabdominal injuries and are less common.
 Type 2: is associated with Low energy injuries like bicycle
handle bar injuries in young children, mostly without
intraabdominal injuries and are more common.
 Type 3 :Results from deceleration injuries like seat belt
injuries.

15.  TAWH may be associated with extra abdominal injuries like
pelvic, lumbar and rib fractures involving significant kinetic
injuries.
 Many a times herniation is seen at anatomically weak points
due to blowout, near iliac crest, inguinal region, lateral to
rectus muscle away from site of primary impact.
 Tension of abdominal musculature between pelvic and rib
bones increases potential for disruption in right lower
abdomen lateral to rectus muscle through oblique and
transverse muscle after blunt abdominal trauma.
(common site of TAWH is Rt. infraumbilical region)

16. Traumatic abdominal wall hernia presents as tender
palpable lump with ecchymosis of overlying skin.
One should advice CECT scan of the abdomen
immediately for early accurate diagnosis and to
differentiate it from hematoma and to identify other
intra abdominal injuries.
CECT will show bowel herniation through defect, but is
not reliable investigation to diagnose hollow viscous
injuries and mesenteric lacerations.
CECT helps in grading abdominal disruption.

17.  First Mechanism of injury should be deciding
factor whether a patient with TAWH needs urgent
laparotomy.(high energy injuries need urgent
laparotomy)
 Secondly clinically apparent hernia appear to
have high rate of associated injuries and need
urgent laparotomy.
 Occult TAWH diagnosed only by CT may not
require urgent laparotomy or hernia repair.

18.  High index of clinical suspicion of TAWH is
essential as an accompanying hematoma often
compound the diagnosis.
 In Occult TAWH surgery should not be delayed
too much as defect may enlarge, muscle may
undergo disuse atrophy, primary approximation
may become difficult.
 Also large hernias repaired under tension may
cause abdominal compartment syndrome.

19. Early repair is techniquely easier and
layered closer of disruptured muscle and
fascia with nonabsorbable suture usually
have excellent results.
 It also shortens hospitalization and
disability.

20.  72% patients with TAWH reported immediately for repair.
 84% cases were repaired with suture only.
 25 to 75% patients with TAWH had intra abdominal injuries.
 Diaphragmatic hernia is a more common than Traumatic
abdominal wall hernia after blunt abdominal trauma.
 Occult TAWH and handlebar hernias without intraabdominal
injuries or hernia with large defect unlikely to be
strangulated can be repaired in delayed setting with mesh
and laparoscopicaly if expertise available.

21. Recurrence rate of 26% for TAWH in
recent literature review.
Acute repair was associated with
majority of the recurrences.

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