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 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.