Rupture of intestine in patients with herniae. A clinical study with a review of the literature

[Intestinal perforation following blunt abdominal trauma in patients with pre-existing inguinal hernia]

BACKGROUND

Intestinal perforation following blunt trauma to the abdomen is a rare but life-threatening complication in patients with pre-existing inguinal hernia.

MATERIAL AND METHODS

We examined retrospective case series of patients with intestinal perforation following blunt abdominal trauma.

RESULTS

Within 2 years, three patients with pre-existing inguinal hernia were referred to our clinic following simple falls while cross-country skiing. Upon signs of abdominal tenderness and radiographic evidence of free air, explorative laparotomy with revision of the affected bowel segments was performed. The postoperative course was uneventful in two patients. One developed adhesive ileus and incisional hernia within 1 year.

CONCLUSIONS

Intestinal perforation must be suspected in patients with inguinal hernia and signs of diffuse abdominal tenderness following blunt trauma. Urgent explorative laparotomy with revision of the affected bowel segments is mandatory in patients with free abdominal air. Secondary hernia repair may represent the safest and most reliable approach and should be delayed until full recovery from the initial surgery.

Rupture of herniated small intestine from blunt abdominal injury: a report of 2 cases

Two cases of perforation of the small bowel following blunt abdominal injury in patients with an abdominal hernia are presented. In one case the bowel was present in a large incisional hernia and the injuring force caused transection of the bowel at three different sites. The bowel was resected and the hernia was repaired at the same time. The patient died of associated chest injuries. In the second case, the bowel was caught in an inguinal hernia; although the injuring force was relatively mild it resulted in two perforations in the herniated terminal ileum. The patient survived following closure of the perforations and simultaneous repair of the hernia.

Isolated perforations of the ileum and jejunum in blunt abdominal trauma

A report of ten cases of perforations of the ileum and jejunum from blunt abdominal trauma is presented. The perforation was the only injury in eight patients, while in two there were other visceral injuries. The perforations were single in seven patients and double in three. Simple closure was used in seven cases and resection in three. Of the three patients who were operated upon late, one died.

Traumatic rupture of the ileum

Three cases of patients who sustained rupture of the ileum following blunt trauma to the abdomen are reported. The onset of symptoms was delayed for a period which varied between 5 and 12 hours after the injury.

As so many of these patients are either asymptomatic or have minimal symptoms for the first 6 hours after the injury it might be advisable to admit all cases of abdominal injury to hospital for observation.

Laboratory investigations of the haemoglobin, white-blood count, and serum amylase contributed nothing to the early diagnosis of the condition. Plain radiographs of the abdomen show gas under the diaphragm in only 34 per cent of cases of traumatic rupture of the ileum.

Needle aspiration of the abdomen for liberated intestinal contents was not carried out in this series. In other series this procedure was found to be accurate in 90 per cent of cases of traumatic rupture of the small bowel. This is the only investigation which can be regarded as making a useful contribution to the early diagnosis of the condition.

Laparotomy was carried out between 5 and 15 hours after the injury. There was gross contamination of the peritoneal cavity by intestinal contents. This was due in all 3 cases to a single laceration on the antimesenteric border of the bowel. The lacerations were situated at distances varying between 15 and 22.5 cm. from the ileocaecal valve and were between 1.3 and 2.5 cm. in diameter. These were closed using two layers of chromic catgut. The peritoneal cavity was washed out with saline and Noxyflex.

The death of 1 patient in the series occurred 13 hours after the injury and was due to a myocardial infarct. The mortality-rate of 33 per cent for the series is similar to that described in other reports.