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 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.