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 43-year-old middle-aged male of thin built and average nutrition came to us with 5-day history of a swelling, about 2 cm in size, above the right groin. The swelling appeared on coughing and straining only. He had history of being hit by a bull using its horn at the same site 1 week back. At presentation, patient's vitals were within normal limit for his age. On examination, a resolving yellowish-brown 2 cm × 1 cm bruise was present at the alleged site of injury that was 4 cm medial to anterior superior iliac spine and 2 cm above the deep inguinal ring []. On coughing, a small bulge of about 3 cm appeared at the site of injury []. Ultrasonography (USG) revealed a small defect in the anterior abdominal wall with no free fluid in peritoneal cavity or any solid organ injury. No free intraperitoneal gas was visualized on the erect chest X-ray. Since the patient was hemodynamically stable with no apparent sign of internal abdominal injury, the patient was planned for laparoscopic repair of defect. The patient was admitted after 6 weeks. A contrast-enhanced computed tomography (CECT) of the abdomen was done to define the defect. It revealed a small defect of approximately 2 cm size in the anterior abdominal wall []. The patient was planned for a laparoscopic mesh repair of the hernial defect. However, intraoperatively, we found a small clean split defect in the muscle and fascial layers of anterior abdominal wall of <2 cm size []. Thus, an anatomic tissue repair of the defect in single layer was done transperitoneally using continuous nonabsorbable 1-0 polypropylene sutures []. Patient's postoperative course was uneventful and the patient was discharged on day 3. The patient has been in follow-up for the past 6 months without any reported complication.