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 60-year-old female presented with obstipation and vomiting following blunt trauma abdomen in the emergency department 2 days back. Patient had fallen from a bullock cart and had sustained blunt trauma abdomen. There was history of obstipation and vomiting. Vitals were stable. She was obese, and abdomen was moderately distended. There was bruising over the skin in right iliac fossa. Abdominal examination revealed a tender reducible mass of 15 × 20 cm2 size in the right iliac fossa. Routine blood investigations were within normal limits. CECT abdomen showed a defect in the anterior abdominal wall above the right iliac crest with herniation of ascending colon and small gut along with avulsed muscle seen in right lumbar region and stranding of subcutaneous fat [Figure and ] There was minimal fluid in the pelvis.\nExploratory laparotomy was performed through an incision over the swelling and findings were a 15-cm wide gap in the aponeurotic part of the external oblique muscle, with small bowel loops along with caecum and ascending colon herniating into the defect. After reduction of herniated contents, abdominal wall defect was repaired primarily with reinforcement by onlay prolene mesh. Patient was discharged in satisfactory condition. On follow-up after 8 months, patient is doing well and asymptomatic.