A 9-year-old boy was brought in by ambulance to the Children's Hospital at Westmead following a motor vehicle accident. He was an improperly restrained, back seat passenger. He presented complaining of abdominal pain. On arrival, he was hemodynamically stable, with a Glasgow Coma Scale of 15. A seatbelt sign was identified across his lower abdomen. There was a tender fullness in the left flank, but it was difficult to decipher a clear mass or defect due to his high body mass index (>30). There was a laceration over his forehead extending to the hairline. The remainder of the examination was unremarkable.\nThe plain abdominal radiograph showed an unusual gas shadow in the left lower quadrant. A focused abdominal sonography for trauma was positive with free fluid in Morrison's pouch and the rectovesical pouch. The diagnosis of TAWH was made by abdominal computed tomography (CT), which revealed a large left lower lateral abdominal wall muscle defect, spanning 120 mm anteroposteriorly and 70 mm craniocaudally []. Small bowel, mesentery, and a small portion of the distal transverse colon were herniating through the defect, with associated fat stranding in the mesenteric root. Free fluid in the left subphrenic and hepatorenal space was identified.\nAn emergency trauma laparotomy was performed. He required resection of a segment of ischemic sigmoid bowel with primary anastomosis and repair of jejunal serosal tear and a large jejunal mesenteric defect. The large abdominal wall defect was closed in layers with PDS and a permacol patch secured to reinforce the defect.\nHis postoperative course was complicated by persistent fevers. An abdominal ultrasound revealed a 48 mL cutaneous collection in the left flank. Incision and drainage of the collection occurred on postoperative day 12. Intraoperatively, fecal material was identified in the left flank collection, and we proceeded to laparotomy. It was identified on laparotomy that necrosis of the psoas muscle had led to a posterior abdominal wall breakdown and herniation of the sigmoid colon anastomosis which subsequently leaked. The anastomosis was revised and the hernia repaired. He subsequently required incision, drainage, and washout of anterior and posterior wall collections 4 days later. His postoperative course was slow, and he was discharged home 33 days after the trauma. At a 4-month follow-up appointment, he was recovering well with no evidence of recurrence.
A 56-year-old male presented to the emergency room 4h after a motor car accident during which his right lower quadrant sustained a direct hit by the gear-poke of a car. There was no history of previous abdominal wall hernias. The vital signs were stable. Abdominal examination revealed tender irreducible soft tissue swelling in the right iliac fossa with superficial ecchymosis and positive cough impulse. Muscular guarding, tenderness and rebound tenderness was observed all over the abdomen. Bowel sounds were absent. There were no associated injuries and the rest of the physical examination did not reveal any abnormality. The laboratory investigations were within the normal limits. The radiological examination of the cervical spine, chest and abdomen were normal. Computed tomography (CT) of the abdomen showed a defect in the anterior abdominal wall muscles in the right iliac fossa with bowel loops herniating through the defect [].\nExploratory laparotomy was performed. There was about 200 ml of free blood in the peritoneal cavity and transverse tear of the mid-ileal mesentery causing a gangrene of approximately 20 cm of the bowel. There was also a defect of approximately 8 × 5 cm involving all the layers of the anterior abdominal wall muscles in the right iliac fossa with intact skin. Lacerated muscles were present at the edges of the defect. Active mesenteric bleeding vessels were ligated. The devascularized segment of ileum was resected and end-to-end anastomosis was performed. The mesenteric defect was closed. No other intraabdominal injuries were found. The abdominal wall defect was repaired in layers. The muscular and fascial defects were closed in the anatomic layers. The abdominal incision was closed in a standard manner. Postoperative course was uneventful. Follow up after 2 years showed no evidence of recurrence.