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 70-year-old male was presented to the emergency department after being hit by a bull. He presented with a complaint of pain in the abdomen and swelling in the left lumbar region []. On presentation, his vital parameters (blood pressure: 120/80, pulse rate: 72/min, respiratory rate: 18/min, temperature: afebrile) were stable. On physical examination, his left abdomen was found to have a bulging mass, not reducible, without definite ecchymosis. There was mild tenderness and rebound tenderness over the protrusion, but there was no muscle guarding or generalized tenderness over the whole abdomen. We suspected the abdominal protrusion to be caused by a fascial disruption, although the demarcation could not be clearly delineated by physical examination. The bowel sounds were normal. The findings from the initial laboratory studies were normal. Chest and abdomen X-rays were normal. Abdominal ultrasound showed a small amount of free fluid in perihepatic space, pelvis, and in between gut loops and protrusion of omentum from lateral abdominal wall.\nAfter preoperative work-up, decision was made to operate. An incision was made over the herniation site, and omentum was found to be herniated out of the defect that was reduced into the peritoneal cavity []. After looking out for any bleeding from the omental vessels, blood collected in the peritoneal cavity was aspirated, and clots were removed, still looking out for the cause of hemoperitoneum. The surgery was converted into a midline laparotomy, and a thorough evaluation of solid organs and gut was carried out. Spleen, liver and small bowel were found to be normal.\nIntraoperatively, there was gangrene of a part of the transverse colon in its distal 1/3rd part near splenic flexure with a tear in the mesocolon []. The gangrenous portion of the transverse colon was resected and converted into colostomy. The tear in the mesocolon was repaired. Both abdominal wounds were closed in layers. Patient felt well after the surgery and was discharged on the 7th postoperative day. Closure of colostomy and primary repair of the hernia were done 3 months after the initial injury.