Traumatic lumbar abdominal wall hernias: 2 cases Ben Carrick, on behalf of Mr Gallagher, Mr Griffiths RVI

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 + 1 st 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 th 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 1 st 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 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) 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, Grades Abdominal Wall Injuries – 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, 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