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.
A 6-year-old boy was admitted to the emergency department 3 days after a bicycle accident. The handlebar of his bicycle traumatized his abdominal wall above the left iliac crest. Twelve hours before the admission he noticed a palpable mass and a minor bruising to this specific point (Fig. ).\nThe physical examination revealed the presence of a painless swelling measuring 8 × 3 cm2 and did not reveal any pathological sign from the abdomen. The swelling was reducible, disappeared in supine position and increased by coughing. The diagnosis of a HH was suspected and confirmed by ultrasound that showed the disruption of internal and external oblique and transverse muscle (6 × 1.5 cm2) and the projection of omentum through the hernia without other associated internal organ injuries (Fig. ). The hematological and biochemical tests were normal. We suggested the admission of the child in our clinic for further clinical monitoring but the parents denied.\nThe reassessment after 2 weeks of rest at home showed an obvious size reduction of the hernia. Because of the significant size difference a MRI evaluation was decided, that confirmed that the disruption size was 3 × 0.7 cm2. In the follow up a month later, the hernia was no longer palpable and the ultrasonography identified a defect <2 mm without herniation.