A 27-year-old male with no past medical history was the driver and sole occupant of a car which crashed through a fence at 80 kph and hit a lamp post. He was wearing a seatbelt, the airbags did not deploy and despite the significant intrusion into the passenger space, he extricated himself unaided. He was resuscitated according to Advanced Trauma Life Support® principles. The primary survey identified decreased air entry at the base of the right lung and right-sided abdominal and lower chest tenderness. Abrasions were evident over the anterolateral abdominal wall and a large, right-sided abdominal swelling was noted.\nTrauma series computed tomography (CT) scans demonstrated a flail segment between the sixth and eight ribs with disruption of the intercostal muscles and a small right haemothorax (Fig. a). In the abdomen, there was hepatic contusion with an intrinsic liver injury (Fig. b). Blood was noted around the liver with minor active haemorrhage. The right abdominal wall was ruptured—the right rectus abdominis muscle had been torn from its costal attachments to the midpoint. The hepatic flexure of the colon had herniated through the intercostal muscles of the eighth and ninth ribs and was lying adjacent to the fractured ribs (Fig. c). Both small and large bowel had herniated through the abdominal wall lateral to rectus abdominis, but remained covered by external oblique (Fig. d). Herniation of small and large bowel immediately adjacent to the fractured ribs raised the suspicion of occult bowel injury not detected on CT.\nThe operative management was undertaken by both thoracic and abdominal surgeons. The ribs were re-opposed with absorbable polyglycolic acid sutures and a chest drain inserted. At laparotomy, it was noted that the hernia sac contained omentum, the bowel having reduced spontaneously under general anaesthesia. A small rent in the mesentery of the proximal small bowel was noted. The abdominal defect was repaired with a 20 × 30 cm sheet of cross-linked acellular porcine dermal collagen (Permacol™, Covidien, Gosport, Hants, UK) which was sutured to the margins of the fascial defect with interrupted nylon sutures, using a ‘bridge’ technique, with a 5-cm underlay on the left.\nPost-operatively, the patient was managed in the intensive care unit for 24 h. A seroma that developed at the hernia site after 1 week was treated conservatively. Impaired abdominal wall function, particularly reduced mobility, was noted post-operatively. Sitting up from lying down position and hip flexion caused difficulty, but improved with intensive physiotherapy. He was discharged home 9 days after admission.\nSix weeks after discharge, he was well with good mobility. He had a persistent seroma at the hernia site. A repeat CT of the thorax and abdomen at 10 weeks demonstrated no residual defect in the anterior abdominal wall and resolution of the seroma (Fig. ).
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.