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 25-year-old man was admitted to the emergency department after falling off his bicycle. He was hit by the bicycle's handle bar into the left side of the abdomen. The clinical examination revealed a fit young man who had only a scratch (abrasion) on the abdominal wall left of the umbilicus. Hemodynamically he was normal and alert and referred to intense pain at the abrasion site. The abdomen was soft, without signs of peritoneal irritation while sensitivity was only at the point of the abrasion. Laboratory tests, including white blood cells, liver enzymes, and amylase, were normal. The abdominal X-ray in upright (standing) position did not reveal the presence of free intraperitoneal air. Abdominal ultrasound did not reveal any solid abdominal organ injury nor the presence of free intraperitoneal fluid. The pain was attributed to hematoma of the rectus abdominis muscle pricey below the abrasion which was revealed by ultrasound.\nThe pain of the young man was gradually worsening and was mostly described diffusely throughout the whole abdomen. The abdomen remained soft and tender without signs of peritoneal irritation. We proceeded to the administration of per os contrast material and CT abdomen. The CT scan revealed the presence of sufficient amount of free intraperitoneal contrast but did not allow the clarification of the exact point of escape. The free contrast material was detected at the left side of the abdomen, at the area of the descending colon but mainly in the pelvis (). The intraluminal contrast had even reached up the level of the transverse colon.\nThe patient was taken to the operating room for exploratory laparotomy immediately after the CT scan (4 hours after the arrival at the emergency department and about 4.5 hours after the time of injury). Intraoperatively, fecal peritonitis due to isolated rupture of jejunum 30 cm from the ligament of Treitz was revealed. The rupture was at the center of an extensive jejunum serous layer fissure giving the picture of “blow out” perforation. At the jejunal mesentery there was minimal bruising. Multiple washings of the peritoneal cavity were performed with normal saline, and the restoration of jejunal injury was done with partial resection and end-to-end anastomosis ().\nThe postoperative course of the patient was uncomplicated, and he was discharged on the 6th postoperative day. 9 days later he returned with clinical and radiological signs of ileus that led us to the operating room 48 hours later due to deterioration of his clinical picture. The cause of the ileum was adhesions, so we proceeded to lysis of adhesions. The anastomosis was normal without leakage. Five days later the patient was discharged, and a year later he is still free of symptoms.