|CASE SERIES IN POINT - CLINICS IN SURGERY
|Year : 2018 | Volume
| Issue : 4 | Page : 256-258
Management of posttraumatic abdominal hernia
Ajay Rajyaguru, Vikrant Patel, Jatin Bhatt
Department of General Surgery, Pandit Deendayal Upadhyay Medical College and Hospital, Rajkot, Gujarat, India
|Date of Web Publication||29-Oct-2018|
Department of Surgery, P. D. U. Medical College and Hospital, Rajkot - 360 001, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Traumatic abdominal wall hernias (TAWHs) are extremely uncommon type of abdominal wall hernia as far as the etiology is concerned. Materials and Methods: We encountered 10 cases of TAWHs during a period of 5 years at the PDU Medical College. The study duration of 5 year included 1 year of follow up for wound dehiscence and incisional hernia. After routine investigations all undergone primary surgical treatment under spinal or general anaesthesia. All the patients were discharged successfully without any major complication. Discussion: TAWH should be suspected in a patient with tender, localized swellings of the abdominal wall following blunt trauma. USG and computed tomography of the abdominal are the helpful investigations to diagnose the hernia and associated intra-abdominal injuries. In all cases of wall defects with bowel herniation, one must take up urgent surgical measures to prevent further bowel injury and to avoid complications. Incisions directly over the defects, instead of midline incisions are preferred for proper repair of the defect. Mesh repair is desirable in the elderly with weak anterior abdominal wall so as to prevent the long-term complications of recurrences.
Keywords: Abdominal wall, blunt trauma, bowel herniation, management, perforation
|How to cite this article:|
Rajyaguru A, Patel V, Bhatt J. Management of posttraumatic abdominal hernia. Astrocyte 2018;4:256-8
| Introduction|| |
Traumatic abdominal wall hernias (TAWHs) are extremely uncommon type of abdominal wall hernia as far as the etiology is concerned. Although TAWH was first described by Selby a century ago, fewer than 100 cases have been reported in the English literature. Blunt traumatic abdominal hernia is defined as a herniation through disrupted musculature and fascia, without skin penetration with no evidence of a prior hernia defect at the site of injury. Contrast-enhanced computed tomogram (CECT) and ultrasonography (USG) can be used to evaluate the associated intra-abdominal injuries, particularly for early presentation, while late presentation is usually a clinical diagnosis. Such hernias, if missed, can result in high morbidity and may prove fatal.
| Materials and Methods|| |
We encountered 10 cases of TAWHs from January 2011 to December 2015 at PDU Medical College Rajkot, Gujarat, India, which were retrospectively analyzed. Only patients with a history of trauma and who simultaneously had hernia at the trauma site over abdomen without any skin breech were included in the study, as per the definition. Only patients with isolated traumatic hernia without any intra-abdominal injuries were included in the study. The diagnosis was based on clinical examination and USG. CT scan was performed only in cases where the diagnosis was difficult.
All patients underwent operative management at the same institute but by different surgeons. The actual size of the defect was determined preoperatively by USG and intraoperatively. Depending upon the mode of presentation and condition of the patient as well as the size of the defect, either primary repair or primary repair with open onlay meshplasty was performed.
| Results|| |
We encountered 10 cases of TAWHs during a period of 5 years at the PDU Medical College. The study duration of 5 years included 1 year of follow-up for wound dehiscence and incisional hernia.
Out of 10 patients, 8 were males and 2 were females. The mean age was 32 ± 12.2 years with the maximum age of 45 years and minimum age of 7 years. As per patient's history, 7 patients had delayed presentation (>3 days after trauma) while 3 patients presented early (up to 72 hours of trauma over abdomen). The most common mode of trauma was blunt trauma due to road traffic accident (seat belt injuries) in 7 patients while 3 had other modes such as fall from height over a blunt object and hit and run by an animal. The most common presentation in early presentation patients was bruise and abrasion over the trauma site with pain and swelling, while those with late presentation had complains of painless reducible swelling over the trauma site with a healed scar and increasing size of swelling on straining. All patients had no intraabdominal solid or hollow viscous injuries. Each patient underwent local USG and only 1 had CT scan done to rule out other injuries on clinical suspicion.
After routine investigations, all underwent primary surgical treatment under spinal or general anesthesia. Out of 10 patients, those with early presentation, young age and small defect size (<4 cm) underwent open primary repair with nonabsorbable suture material. While patients with delayed presentation, old age, and large defect size (>4 cm) underwent open primary repair with onlay mesh reinforcement.
All patients were discharged successfully without any major complications. Only 1 patient had seroma formation which was treated conservatively while 1 had superficial wound infection which required laying open the wound and healed secondarily.
| Discussion|| |
Herniation is a rare occurrence following blunt abdominal trauma. Most herniations are diagnosed at presentation by physical examination or on abdominal CECT, and most authors have advocated immediate laparotomy with repair of the defect because of the high incidence of associated intra-abdominal injury. The criteria for TAWH include immediate appearance of the hernia through the disrupted muscle and fascia after blunt abdominal trauma, and failure of the injury to penetrate the skin were defined by Clain It can occur after blunt trauma abdomen which can be classified into low- or high-energy injuries. Low-energy injuries occur after the impact on a small blunt object. High-energy injuries are sustained during motor vehicle accidents or automobile versus pedestrian accidents. The pathophysiology of TAWH involves the application of a blunt force to the abdomen over an area large enough to prevent penetration of the skin; the tangential forces resulting in a pressure-induced disruption of the abdominal wall muscles and fascia, allowing subcutaneous herniation of abdominal viscera through the defect, as proposed by Ganchi. As the skin is more elastic than the other layers of the abdominal wall, it remains intact even though the underlying musculature and fascia are disrupted which gives rise to TAWH. In particular, the forces directed tangentially to the abdominal wall can easily produce shearing stresses to the underlying muscles, fascia, and peritoneum. Associated intra-abdominal injuries are infrequent. Damschen et al. found that 17 of 28 patients had no associated injury in their review. The other 11 patients had associated injuries, including five in the small intestine (45.5%), three in the colon (27.3%), two in the liver (18.2%), and one in the kidney (9.1%).
Three types of TAWH were described by Wood et al. according to the mechanism and size of injury., Type I are small defects caused by blunt trauma. In Type II, larger defects occurring during motor vehicle crashes. In Type III, there are abdominal wall defects with bowel loop herniation following deceleration injuries, which are extremely rare., Our cases fulfil the criteria of type III, especially the second case which had associated bowel perforation.
CECT and USG of the abdomen are the investigations of choice. However, CECT is not a reliable investigation to diagnose hollow viscous injury and mesenteric tear. Once the diagnosis of TAWH is made, prompt surgery is required to avoid the complications such as incarceration or strangulation and subsequent morbidity. The incision should be given directly over the traumatic swelling for proper enforcement of the herniated contents and defect. The repair of small defects with clear borders is straightforward. In contrast, more prominent disruptions require a variety of factors to be considered, such as the patient's overall condition, associated intra-abdominal injuries, the defect's size and site, and available surgical expertise., Primary approximation of the traumatic defect can be done by nonabsorbable sutures with or without mesh, as most case reports indicate. Mesh repair is contraindicated in the contaminated wall defects because of the high risk of mesh infection. TAWHs are uncommon, and it remains controversial whether such patients require urgent laparotomy.
| Conclusion|| |
TAWH should be suspected in a patient with tender, localized swellings of the abdominal wall following blunt trauma. Ultrasonography and computed tomography of the abdomen are helpful investigations to diagnose hernia and associated intra-abdominal injuries. In all cases of wall defects with bowel herniation, one must take up urgent surgical measures to prevent further bowel injury and to avoid complications. Incisions directly over the defects, instead of midline incisions, are preferred for proper repair of the defect. Mesh repair is desirable in the elderly with weak anterior abdominal wall to prevent the long-term complications of recurrences.
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Conflicts of interest
There are no conflicts of interest.
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