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 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.