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 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.