A 27-year-old male with no past medical history was the driver and sole occupant of a car which crashed through a fence at 80 kph and hit a lamp post. He was wearing a seatbelt, the airbags did not deploy and despite the significant intrusion into the passenger space, he extricated himself unaided. He was resuscitated according to Advanced Trauma Life Support® principles. The primary survey identified decreased air entry at the base of the right lung and right-sided abdominal and lower chest tenderness. Abrasions were evident over the anterolateral abdominal wall and a large, right-sided abdominal swelling was noted.\nTrauma series computed tomography (CT) scans demonstrated a flail segment between the sixth and eight ribs with disruption of the intercostal muscles and a small right haemothorax (Fig. a). In the abdomen, there was hepatic contusion with an intrinsic liver injury (Fig. b). Blood was noted around the liver with minor active haemorrhage. The right abdominal wall was ruptured—the right rectus abdominis muscle had been torn from its costal attachments to the midpoint. The hepatic flexure of the colon had herniated through the intercostal muscles of the eighth and ninth ribs and was lying adjacent to the fractured ribs (Fig. c). Both small and large bowel had herniated through the abdominal wall lateral to rectus abdominis, but remained covered by external oblique (Fig. d). Herniation of small and large bowel immediately adjacent to the fractured ribs raised the suspicion of occult bowel injury not detected on CT.\nThe operative management was undertaken by both thoracic and abdominal surgeons. The ribs were re-opposed with absorbable polyglycolic acid sutures and a chest drain inserted. At laparotomy, it was noted that the hernia sac contained omentum, the bowel having reduced spontaneously under general anaesthesia. A small rent in the mesentery of the proximal small bowel was noted. The abdominal defect was repaired with a 20 × 30 cm sheet of cross-linked acellular porcine dermal collagen (Permacol™, Covidien, Gosport, Hants, UK) which was sutured to the margins of the fascial defect with interrupted nylon sutures, using a ‘bridge’ technique, with a 5-cm underlay on the left.\nPost-operatively, the patient was managed in the intensive care unit for 24 h. A seroma that developed at the hernia site after 1 week was treated conservatively. Impaired abdominal wall function, particularly reduced mobility, was noted post-operatively. Sitting up from lying down position and hip flexion caused difficulty, but improved with intensive physiotherapy. He was discharged home 9 days after admission.\nSix weeks after discharge, he was well with good mobility. He had a persistent seroma at the hernia site. A repeat CT of the thorax and abdomen at 10 weeks demonstrated no residual defect in the anterior abdominal wall and resolution of the seroma (Fig. ).
A 70-year-old male was presented to the emergency department after being hit by a bull. He presented with a complaint of pain in the abdomen and swelling in the left lumbar region []. On presentation, his vital parameters (blood pressure: 120/80, pulse rate: 72/min, respiratory rate: 18/min, temperature: afebrile) were stable. On physical examination, his left abdomen was found to have a bulging mass, not reducible, without definite ecchymosis. There was mild tenderness and rebound tenderness over the protrusion, but there was no muscle guarding or generalized tenderness over the whole abdomen. We suspected the abdominal protrusion to be caused by a fascial disruption, although the demarcation could not be clearly delineated by physical examination. The bowel sounds were normal. The findings from the initial laboratory studies were normal. Chest and abdomen X-rays were normal. Abdominal ultrasound showed a small amount of free fluid in perihepatic space, pelvis, and in between gut loops and protrusion of omentum from lateral abdominal wall.\nAfter preoperative work-up, decision was made to operate. An incision was made over the herniation site, and omentum was found to be herniated out of the defect that was reduced into the peritoneal cavity []. After looking out for any bleeding from the omental vessels, blood collected in the peritoneal cavity was aspirated, and clots were removed, still looking out for the cause of hemoperitoneum. The surgery was converted into a midline laparotomy, and a thorough evaluation of solid organs and gut was carried out. Spleen, liver and small bowel were found to be normal.\nIntraoperatively, there was gangrene of a part of the transverse colon in its distal 1/3rd part near splenic flexure with a tear in the mesocolon []. The gangrenous portion of the transverse colon was resected and converted into colostomy. The tear in the mesocolon was repaired. Both abdominal wounds were closed in layers. Patient felt well after the surgery and was discharged on the 7th postoperative day. Closure of colostomy and primary repair of the hernia were done 3 months after the initial injury.