Handlebar hernia with intra-abdominal extraluminal air presenting as a novel form of traumatic abdominal wall hernia: report of a case

Managing severe traumatic abdominal-wall injuries, a monocentric experience

PURPOSE

Abdominal wall injuries (AWI) is a clinical and radiological diagnosis of fasciomuscular and at times cutaneous defects after abdominal trauma. Their severity encompasses a spectrum of parietal defects, with the most severe being a burst abdomen with eviscerated organs. With the wide use of CT scans in trauma settings, their incidence is being more recognized. Especially in severe AWI, where associated intrabdominal lesions are highly prevalent, many questions about parietal reconstruction arise concerning the timing and type of surgery, and their final hernia recurrence rate.

METHOD

A list of severe AWI injuries have been retrieved, all of which were treated in our center. Type of trauma, clinical presentation, surgical technique and follow-up have been included.

RESULTS

Eight cases were found with severe abdominal injuries, with an age range of 11-85 years. Road traffic accidents, crush injuries, fall from height, stab and gunshot wounds are included. Seven out of the 8 cases had associated intrabdominal traumatic lesions. Mesh augmentation due to tissue loss was used in three cases. Recurrence rate was estimated around 25%.

CONCLUSION

Prompt surgical exploration is required as associated intrabdominal traumatic lesions are highly associated with severe AWI. Even when intrabdominal lesions are ruled out, fasciomuscular defects should be managed during the same hospitalization, to prevent intestinal strangulation and occlusion. Mesh augmentation should only be used when parietal defects include extensive tissue loss preventing tension-free parietal reconstruction.

Traumatic inguinal hernia: An uncommonly reported entity

Traumatic abdominal wall herniation, especially of the groin region, is a rare condition and typically results from a high-energy trauma to the abdominal wall. We report a fatal case of a road-traffic collision involving a young male motorcyclist who collided with a speeding lorry. The victim sustained multiple injuries over the chest and abdomen, with traumatic inguinal herniation causing gross distension of the scrotum. At autopsy, multiple lacerations of thoracic and abdominal organs were seen, along with traumatic disruption of the right inguinal canal. The contused terminal ileum was present in the scrotal sac. A literature search has revealed a limited number of reported cases of gross inguinal herniation following thoracoabdominal trauma. In cases of high-energy trauma to the thoraco-abdominal region with unilateral or bilateral distension of the scrotum, the possibility of herniation of the abdominal contents into the scrotal sac should be considered by the forensic pathologist.

Complete abdominal wall disruption with herniation following blunt injury: case report and review of the literature

Acute traumatic abdominal wall hernia (TAWH) is a rare type of hernia that occurs after a low- or high-velocity impact of the abdominal wall against a blunt object. With few cases reported, a consensus in diagnosis and management has not been established in the literature. A systematic review of the literature for adult cases of traumatic abdominal wall hernia due to blunt abdominal trauma was undertaken. All original articles were reviewed and data were compiled and tabulated qualitatively. Diagnostic imaging modalities and their reported description of the abdominal wall hernia were detailed correlated with the laparotomy findings. We also report a case of TAWH following blunt abdominal trauma, and describe integration of this management into clinical practice. Fifty-five cases of adult TAWH were found in the English literature. Most hernias contained either small bowel (69%) or large bowel (36%), with 16% of TAWH containing both. Concurrent intra-abdominal injuries were seen in 60% of cases, with an almost equal number of associated bowel (44%) and solid organ (35%) injuries. Twenty percent of diagnosis of TAWH was delayed, ranging from 2 days to 9 years. While TAWH is uncommon, a high index of suspicion is required in patients who present with blunt abdominal trauma. A staging system for TAWH can facilitate appropriate management priorities and treatment. CT scanning is crucial in the diagnosis of TAWH, and aids in definitive management of these patients. The literature supports immediate surgical exploration for most TAWH.

Traumatic abdominal wall hernia: Delayed repair: Advantageous or taxing

INTRODUCTION

Traumatic abdominal wall hernia (TAWH) is a rare entity. Most cases occur in children, following an injury from the bicycle handle bar. In adults, it usually results from road traffic accidents (RTA). We present one of the largest reported cases of TAWH following RTA managed by delayed mesh repair.

PRESENTATION OF CASE

A 35yr old obese male with RTA was diagnosed with TAWH with 19cm×15cm defect in left flank. As there were no intra abdominal injuries and overlying skin was abraded, he was planned for elective repair after 6 months. On exploration a defect of 30cm×45cm was found extending from midline anteriorly to 8cm short of midline posteriorly in transverse axis and costal margin to iliac crest in craniocaudal axis. After restoration of bowel into abdominal cavity, primary closure or even approximation of muscular defect was not possible thus a mesh closure using 60cm×60cm prolene mesh in subcutaneous plane was done. After 4 months follow up, patient is healthy and has no recurrence.

DISCUSSION

Emergent surgical management of TAWH is usually favoured due to high incidence of associated intra abdominal injuries. Delayed repair may be undertaken in selected cases.

CONCLUSION

TAWH, although rare, should be suspected in cases of RTA with abdominal wall swellings. With time, the hernia defect may enlarge and muscles may undergo atrophy making delayed repair difficult.

Delayed presentation of the traumatic abdominal wall hernia; dilemma in the management - review of literature

Traumatic abdominal wall hernia is a rare entity, and an uncommon type of abdominal wall hernia as far as the etiology is concerned. It is caused by blunt trauma and disrupts the fascial layers, but does not disrupt the elastic skin. In this study, we report the case of a 60-year-old female, diagnosed with traumatic abdominal wall hernia with delayed presentation. In this case, herniation of the bowels was present through the defect in the left iliac region. She was surgically well-managed. During the follow-up of 1 year, there was no recurrence. In the Western medical literature, only a few cases have been reported, especially with intra-abdominal injuries. Confusion still exists in the management of such a disease as to whether to treat the condition at an early or later stage.

Peritoneal free air due to evacuation of pneumobilia in blunt abdominal trauma

Pneumobilia is mostly observed on computed tomography (CT) following surgical biliary-enteric anastomosis and biliary manipulation through endoscopic procedures. Although pneumobilia can be seen in pathological conditions, post-surgical pneumobilia is typically not associated with morbidity. In the present article, we report a case in which blunt abdominal trauma led to the evacuation of pre-existing pneumobilia causing pneumoperitoneum. Given that the subsequent laparotomy proved to be non-therapeutic, this report adds to the few cases of intra-peritoneal free air not helped by surgical intervention.

Traumatic abdominal wall hernia (TAWH): a case study highlighting surgical management

We report a rare case of traumatic abdominal wall hernia (TAWH) caused by a traffic accident. A 47-year-old woman presented to the emergency room soon after a traffic accident. She complained of diffuse, dull abdominal pain and mild nausea. She had no history of prior abdominal surgery or hernia. We found a bulging mass on her right abdomen. Plain abdominal films demonstrated a protrusion of hollow viscus beyond the right paracolic fat plane. Computed tomography (CT) showed intestinal herniation through an abdominal wall defect into the subcutaneous space. She underwent an exploratory surgery, followed by a layer-by-layer interrupted closure of the wall defect using absorbable monofilament sutures without mesh and with no tension, despite the large size of the defect. Her postoperative course was uneventful.

Successful conservative treatment of a bicycle-handlebar hernia: report of a case

Handlebar hernia is a rare type of blunt traumatic abdominal wall hernia (TAWH). It involves a disruption of the abdominal wall muscles, with bowel loop herniation through the defect in the abdominal wall. We report a case of bicycle-handlebar hernia in a 9-year-old boy who had all layers of his abdominal wall disrupted after falling from his bicycle. He was brought to our hospital with lower abdominal pain and bulging. A physical examination revealed left lower quadrant bulging in a standing posture, and a palpable fascial defect, 3 cm in diameter. Computed tomography showed a disruption of the abdominal rectal muscle layer, but his skin and intra-abdominal organs were completely intact. The patient was treated conservatively with abdominal wall compression using a cotton cloth corset. Within 3 weeks, his abdominal wall hernia had healed without the need for any surgical intervention.

Handlebar hernia: a case report

A 36-year-old man fell from his bicycle and struck his lower abdomen on the end of the handlebar. Computed tomography (CT) showed a small bowel loop protruding into the subcutaneous fat layer of the abdominal wall. We present this case of handlebar hernia, a rare type of traumatic abdominal wall hernia, and the usefulness of CT in diagnosing such injuries.

A case of a traumatic abdominal wall hernia that could not be identified until exploratory laparoscopy was performed

Traumatic abdominal wall hernia (TAWH) is a rare condition secondary to blunt abdominal trauma in children. We herein report an 8-year-old boy who developed TAWH after falling onto a bicycle handlebar. Neither physical examination nor radiological findings suggested a diagnosis of TAWH at first presentation. TAWH in the right lower quadrant could not be identified until exploratory laparoscopy was performed. An open surgical repair was done, and the postoperative course was uneventful. The literature on pediatric TAWH is briefly reviewed and the findings discussed.

Traumatic abdominal wall hernia: a reappraisal

Traumatic abdominal wall hernia, a rare cause of hernia, has a confusing clinical picture and requires a high index of suspicion for prompt diagnosis and management. Such hernias, if missed, can result in high morbidity and may prove fatal. Distinction from a pre-existing hernia is important as well. We report our experience in two such cases, which had presented in a span of 9 months, and submit a brief analysis of 50 reviewed cases.