A 38-year-old north Indian man was brought to the emergency department of our hospital after suffering a head-on collision while driving his car. On examination, he was conscious, oriented, and, in severe pain. His vital signs were normal, except for tachycardia. There were no signs of head, chest, pelvic, or limb injury. A visible swelling was present in the umbilical and epigastric regions with overlying bruising of the skin (Figure ). On palpation, it was tender, firm, non-pulsatile, and non-reducible, but there was a slight increase in size over the next hour. The patient was triaged as a blunt trauma abdomen - a probable steering wheel injury, hemodynamically stable, with probable rectus hematoma. Expectant treatment was started and a computed tomography (CT) scan was performed. The CT scan (Figure ) revealed a supra-umbilical defect in the midline anterior abdominal wall (maximum diameter 5 cm), with herniation of bowel loops and mesentery through it, with extensive interstitial edema. There was also associated free fluid in the peritoneal cavity, and a minor splenic laceration. Anticipating strangulation of the bowel, the abdomen was explored through a midline incision. There were 2-3 loops of edematous jejunum and mesentery in the subcutaneous space, herniating from a full-thickness defect in the abdominal wall. There was also a mesenteric hematoma with loss of vitality of the corresponding jejunal segment (one foot). A resection-anastomosis was performed. No other solid organ injuries were seen. The defect was repaired with an interrupted monofilament polypropylene suture without tension. The patient's wound healed without complications and was discharged on the 6th day. He was asymptomatic, 1 month after the operation.
A 45-year-old male laborer was admitted in emergency department with complaints of pain abdomen and constipation. There was history of fall from a height on to a blunt object. Two days back, the patient was febrile and had tachypnoea and tachycardia. His blood pressure was in normal range. There was abrasion and bruise over the skin, along with surgical emphysema on right lumbar region. On abdominal examination, tenderness and guarding were elicitable in the right lumbar region. Blood tests were normal. USG of the abdomen revealed free fluid in the perihepatic region. Chest X-ray revealed gas under both domes of diaphragm.\nCECT of the abdomen showed a defect in the abdominal wall with herniation of small bowel loops []. Rest of the abdominal organs were normal. The abdomen was explored through a midline incision. There was a rent in the right rectus muscle with peritoneal disruption of approximately 8 cm in length. The ileal loops were herniating through the peritoneal defect. A solitary perforation of 2 cm in size was identified approximately 50 cm proximal to ileocaecal junction. Minimal peritoneal contamination was present. Loop illeostomy was done in left iliac fossa with repair of right lumbar defect in layers over a drain. Postoperative period was uneventful. Restoration of bowel continuity was done after 3 months. Patient is doing well in follow-up.