Traumatic lumbar abdominal wall hernias: 2 cases

Ben Carrick, on behalf ofMr Gallagher, Mr GriffithsRVI17-05-15

Case 1 MH

• 36 yr old male• No relevant PMH• Admitted 18/4/13• Restrained driver of a car involved in a head

on collision. Car rolled over, he was ejected, trapped for 60 mins

• Driver +1 of other car dead on scene

• HR110 after 500mls N/S BP 130/95 CR 2s• pH 7.23 BE -20 Lactate 0.2• R humeral head #, right acetabular #• CT traumatic rupture of right abdominal wall,

herniation of bowel, small volume haemoperitoneum, normal small bowel and mesentery

• Admitted to HDU• Went to theatre later 18/4 for an ORIF of

open # R olecranon, ORIF of Lis Franc R foot + 1st metatarsal, application of distal femoral traction pin

• Theatre 22/4 ORIF # R acetabulum, + L ankle

• Theatre 26/4 (Gallagher)• Laparotomy, distal ileal resection and abdominal wall

repair with Biodesign– 10cm ischaemic/incarcerated distal small bowel resected, LIF

end ileostomy– Small abscess drained– Cattell-Braasch maneuvre to mobilise around kidney around to

near aorta– Biodesign mesh anchored from 11+12th rib down to psoas and

pelvic brim, protacks round onto anterior abdominal wall– Unable to repair musculature due to trauma

• Theatre 23/4 R shoulder prox humeral Philos plate

• Readmitted to HDU 24/4 with ileus and a small R PE, bibasal atelectasis + R basal consolidation

• IVC filter inserted• Theatre 2/5 ORIF R 1st metatarsal• Subsequently transferred to Dartford for

ongoing care

Case 2 MC• 62 yr old female• Admitted 28/8/14 – transferred from UHND• Restrained driver in a head on collision @ 60mph• No relevant PMH• Bilateral pneumothoraces -> drains inserted• High O2 requirements but acid/base normal• Became hypotensive at UHND -> transferred here• T2#, R 1-3 L 2-4 rib #s , bilat sacroiliac #,

manubrium/sternum. Liver laceration.

• Theatre 28/8 R foot Ex-Fix• Perc Trache 2/9• Theatre 4/9 ORIF R Pilon #

• Theatre 5/9• Laparotomy, repair of R traumatic lumbar

hernia– Cattell-Braasch maneuvre to access posterior

abdominal wall– Permacol inserted, tacked (Securestrap) to

muscle, round into ‘Rives-Stoppa’ space and down on to bladder

– Nerves preserved where identified and possible

• Prolonged ileus and respiratory wean• Discharged to Hexham for rehab 15/10/14

Literature review

• Summary– There’s not a lot published on it– Different mechanisms and areas mixed in– Early repair advised, but late can be safe– ALWAYS LOOK FOR ASSOCIATED INJURIES

“Traumatic abdominal wall hernias”

• Not a helpful term – combines ‘handlebar’-type injuries with compression/impact type injuries and acceleration/deceleration-type injuries

• First described in 1906 by Shelby• Increasingly described via CT• Longest case series is 197 ‘mixed’ cases• Next is 46• Longest of this kind is 6 over 11 years• Most are single case (x3), One of 3 cases

• McWhorter in 1939– ‘1. Early appearance following trauma,– 2. Persistence of severe pain in the injured area,– 3. Degree of prostration,– 4. Symptoms severe enough for the patient to seek

medical help within the first 24 hours following trauma– 5. Absence of hernia before the injury, and– 6. Evidence of adequate trauma to cause the hernia.”

– Now largely supplanted by routine CT!

• Multiple other attempts at classification but broadly;

– Low energy, focused, injuries – such as handlebar

– High energy, diffuse, injuries with tissue destruction, shear and associated abdominal injuries – such as RTC

If you read one paper…

• “Traumatic abdominal wall hernia:Is the treatment strategy a real problem?”By Liasis et al, J Trauma Acute Care Surg 2012,

74 (4) 1156-62

- Notes that >75% of these injuries occur in the lower abdomen

- 53% had other intra-abdominal injuries

If you read 2 papers…• “Abdominal wall injuries occurring after blunt

trauma: incidence and grading system”• By Dennis et al, Am J Surg 2009, 197, 413-7• Grades Abdominal Wall Injuries 1-6• 1 – subcutaneous tissue contusion• 2 – abdominal wall muscle haematoma• 3 – single abdominal wall muscle disruption• 4 – complete abdominal wall muscle disruption• 5 as 4 but with herniation of contents

• 6 as 4 but with evisceration

• In their series of 1549 traumas over 1 year;– 140 (9%) had abdominal wall injuries– 75 Grade 1– 39 Grade 2– 12 Grade 3– 11 Grade 4– 3 Grade 5– 0 Grade 6

If you read 3 papers…

• “Traumatic lumbar hernias: do patient or hernia characteristics predict bowel or mesenteric injury?”

• By Mellnick et al, Emergency Radiology 2014, 21, 239-243

• 21 cases – 1 “superior” (Grynfelt), 20 “inferior” (Petit)

• 11/20 inferior injuries had ‘Bowel Or Mesenteric” injuries, more on L>R

Treatment

• All should be treated• Timing dependent upon presence/absence of

other injuries – esp bowel/vascular– ‘Lethal triad’ of hernia, bowel and vascular injury

• Repair with mesh – biological or prosthetic• Little data on this– 1 series had a 10% recurrence rate at 10 years with

prosthetic mesh

• No up to date data

Summary

• 2 cases – RTC, high impact but with similar abdominal wall injuries

• Similar, early abdominal wall reconstruction with satisfactory outcome

• An uncommon injury