A 38-year-old north Indian man was brought to the emergency department of our hospital after suffering a head-on collision while driving his car. On examination, he was conscious, oriented, and, in severe pain. His vital signs were normal, except for tachycardia. There were no signs of head, chest, pelvic, or limb injury. A visible swelling was present in the umbilical and epigastric regions with overlying bruising of the skin (Figure ). On palpation, it was tender, firm, non-pulsatile, and non-reducible, but there was a slight increase in size over the next hour. The patient was triaged as a blunt trauma abdomen - a probable steering wheel injury, hemodynamically stable, with probable rectus hematoma. Expectant treatment was started and a computed tomography (CT) scan was performed. The CT scan (Figure ) revealed a supra-umbilical defect in the midline anterior abdominal wall (maximum diameter 5 cm), with herniation of bowel loops and mesentery through it, with extensive interstitial edema. There was also associated free fluid in the peritoneal cavity, and a minor splenic laceration. Anticipating strangulation of the bowel, the abdomen was explored through a midline incision. There were 2-3 loops of edematous jejunum and mesentery in the subcutaneous space, herniating from a full-thickness defect in the abdominal wall. There was also a mesenteric hematoma with loss of vitality of the corresponding jejunal segment (one foot). A resection-anastomosis was performed. No other solid organ injuries were seen. The defect was repaired with an interrupted monofilament polypropylene suture without tension. The patient's wound healed without complications and was discharged on the 6th day. He was asymptomatic, 1 month after the operation.
A 40-year-old woman of north Indian origin was brought to the surgical emergency room 2 hours after being attacked by a bull near her home. The animal had struck her with its horns over her right lower abdomen. The patient complained of pain and swelling over the involved area. On examination, her vital signs were normal. There was no associated head, chest, pelvic, or limb injury. A bruise and a visible, ill-defined swelling over the right lumbar and umbilical regions were seen. On palpation, the area was tender, and the swelling decreased on gentle pressure, with gurgling sounds. A defect of 8 cm in maximum diameter could be palpated with irregular, ill-defined margins. On asking the patient to cough, bowel loops could be palpated through the defect. Since the patient was hemodynamically stable and the diagnosis clinically apparent, a transverse laparotomy was performed incorporating the site of injury. An irregular defect was found involving all subcutaneous layers of the abdominal wall, and was repaired with a preperitoneal mesh. There was no associated intra-abdominal injury. The patient's recovery was uneventful and she was discharged on the 3rd postoperative day. She had no recurrence after 1 year of follow-up.