Laparoscopic repair of traumatic flank hernias

Complex blunt traumatic abdominal wall hernias: Experience from a high-volume abdominal core health center

BACKGROUND

Traumatic abdominal wall hernias are rare and commonly involve the lateral abdominal wall due to shearing off the oblique and transversus abdominis muscles from the iliac crest. The vast majority of the current literature focuses on the index trauma admission, includes few patients, and provides little to no detail about the hernia repair itself. We aim to report our center's high-volume experience with a definitive repair of chronic traumatic lateral abdominal wall hernias.

METHODS

All patients who underwent lateral abdominal wall hernia repair performed at our institution from January 2015 through August 2023 were identified in the Abdominal Core Health Quality Collaborative. Only patients with blunt trauma etiology were included. Hernia characteristics, operative techniques, postoperative outcomes, and long-term patient-reported outcomes were extracted from the Abdominal Core Health Quality Collaborative database and supplemented with a manual chart review.

RESULTS

Forty-three patients with traumatic lateral abdominal wall hernias underwent repair within the study period. Elective repair occurred at a median of 3 years after a traumatic event. Nearly half of the patients had a recurrent hernia (41.9%) and most had a lumbar (L4) component (79.1%). The mean hernia width was 16.2 cm, and 30.2% had concomitant midline defects. Transversus abdominis release was performed in 88.4% of patients; 74.5% had heavy-weight polypropylene mesh placed and 76.7% had mesh fixation. Superficial surgical site infection occurred in 11.6% of patients, and 7% had a surgical site occurrence. At a mean follow-up of 1.9 years, 3 patients (7%) developed a hernia recurrence, which was noted on physical examination or imaging. One patient was reoperated on for recurrence, and 1 patient underwent partial mesh removal because of a chronic mesh infection.

CONCLUSION

In the largest series of definitive repairs of complex lateral abdominal wall post-traumatic hernias to date, elective open complex abdominal wall reconstruction is safe and associated with low morbidity and hernia recurrence rates.

Combined open-robotic 'sandwich' repair for flank hernias: a case series of 10 patients

BACKGROUND

Flank hernias represent a rare and technically challenging conundrum for abdominal wall surgeons. Various operative techniques have been attempted including open, laparoscopic, and robotic without an established gold standard. We present a novel technique utilizing a hybrid open-robotic "sandwich" technique for flank hernia repairs.

METHODS

Single center, retrospective case series of a single surgeon performing consecutive flank hernia patients via novel technique between 2017 and 2023. Demographic information, clinical hernia characteristics, operative technique, peri-operative complications, and long-term outcomes were collected.

FINDINGS

Ten patients underwent repair. Average age at repair was 67.6 (SD: 13.4), 70% males, mean BMI 29.6 (SD: 3.11), all ASA 3, and no current smokers. Average hernia defect measured 11.5 cm (SD: 8.3) vertically and 8.1 cm (SD: 3.7) horizontally. Mean operative time was 259.6 min (SD: 85.1), estimated blood loss 30.5 cc, and length of stay 1.6 days (SD 1.6). There were no intra-operative complications. 30-day morbidity included one (10%) patient developing an ileus and one (10%) patient had a hematoma. At a mean follow up of 34 months there was no chronic pain or hernia recurrences.

CONCLUSION

This study outlines a novel approach to complex flank hernia repairs utilizing a combination of an open and robotic approach. There were no long-term surgery related complications, chronic pain, or recurrences in our cohort with a minimum follow up of 6 months and mean of 34 months. Further studies need to be completed in prospective fashion to elucidate the goal standard repair for flank hernias.

Robotic extended total extraperitoneal transversus abdominus release for traumatic flank and abdominal intercostal hernias

PURPOSE

Traumatic abdominal intercostal/flank hernias present a perplexing challenge for surgeons seeking to repair them. There has been a paucity of studies describing robotic repairs of such hernias. We aim to evaluate the effectiveness of the Robotic-assisted Extended Total Extraperitoneal/Transversus Abdominus Release (rETEP/TAR) method in repairing traumatic abdominal intercostal and flank hernias.

METHODS

Patients with traumatic abdominal intercostal hernias at a high-volume hernia center between 2019 and 2022 were identified and retrospective data including patient demographics, perioperative parameters, postoperative complications and up to a three-year follow-up were collected for those undergoing rETEP/TAR. Robotic ETEP access was gained through the retro-rectus space ipsilateral to the hernia, using a transversus abdominis release performed laterally to the level of the posterior axillary line. Dissection was completed from the pelvis to the central tendon as necessary.

RESULTS

A total of 8 patients were analyzed. All patients suffered traumatic or Valsalvainduced hernias. The average age was 54 +/-15yrs. The mean defect size was 11x17cm. Heavyweight uncoated polypropylene mesh was placed in the retromuscular space and secured with transfascial suture. Mean mesh size was 34x30cm and mean operative time was 216 +/- 69 minutes. The median length of stay was 1 day. All patients reported improvement in pain without any evidence of recurrence at postoperative follow-up.

CONCLUSION

This study demonstrates that the Robotic-assisted ETEP/TAR technique is an effective way of repairing abdominal intercostal and flank hernias.

Open repair of flank and lumbar hernias: 142 consecutive repairs at a high-volume hernia center

BACKGROUND

Flank and lumbar hernias (FLH) are challenging to repair. This study aimed to establish a reproducible management strategy and analyze elective flank and lumbar repair (FLHR) outcomes from a single institution.

METHODS

A prospective analysis using a hernia-specific database was performed examining patients undergoing open FLHR between 2004 and 2021. Variables included patient demographics and operative characteristics.

RESULTS

Of 142 patients, 106 presented with flank hernias, and 36 with lumbar hernias. Patients, primarily ASA Class 2 or 3, exhibited a mean age of 57.0 ​± ​13.4 years and BMI of 30.2 ​± ​5.7 ​kg/m2. Repairs predominantly utilized synthetic mesh in the preperitoneal space (95.1 ​%). After 29.9 ​± ​13.1 months follow-up, wound infections occurred in 8.3 ​%; hernia recurrence was 3.5 ​%. At 6 months postoperatively, 21.2 ​% of patients reported chronic pain with two-thirds of these individuals having preoperative pain.

CONCLUSIONS

Open preperitoneal FLHR provides a durable repair with low complication and hernia recurrence rates over 2.5 years of follow-up.

Bone Anchor Fixation in the Repair of Blunt Traumatic Abdominal Wall Hernias: A Western Trauma Association Multicenter Study

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair.

METHODS

A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses.

RESULTS

176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts.

CONCLUSIONS

This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life.

Acute Traumatic Lumbar Hernia: Report of Two Cases

Acute traumatic lumbar hernia (ATLH) is rare in blunt trauma and can be overlooked due to the presence of multiple injuries following the trauma incidence. ATLH is usually found at the time of radiological examination or during surgical exploration. Awareness of the clinicians about the possibility of ATLH can enhance early diagnosis and reduce the occurrence of serious complications including bowel obstruction and strangulation. Herein, we present two cases of ATLH in which one of them was treated conservatively in the acute stage and the other patient was treated surgically. Conservative management can be adopted in the acute stage with the delayed repair of the hernia after resolving the muscles' contusion. However, early operative intervention is essential if conservative management failed or in the event of acute deterioration of the patient's condition.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study

BACKGROUND

Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH).

METHODS

Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence.

RESULTS

TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model.

CONCLUSION

Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Repair of traumatic flank hernia with mesh strip suture: a case report

Traumatic flank hernia is a relatively rare hernia. We report a case of a male patient with severe multiple trauma, including abdominal injury, who presented with flank hernia 3 years postinjury. The hernia was successfully repaired using mesh strips suture, and at the 12-month follow-up, no complications or recurrence was found. Our findings indicate that when it is difficult to secure a sufficient operative field for mesh anchoring in a traumatic flank hernia, a technique of sutured repair with mesh strips may be considered as a treatment option as it requires less dissection. Compared to the conventional planar mesh repair, this technique decreases the risk of injuries and ischemic necrosis of the surrounding tissues.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management.

METHODS

A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee.

RESULTS

Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869).

CONCLUSION

This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups.

LEVEL OF EVIDENCE

Therapeutic/care management, Level IV.

Transabdominal Partial Extraperitoneal Repair of Lateral Hernias of the Abdomen and Flank

Background: Lateral hernia (LH) repair is a challenging and debated topic in abdominal wall surgery because of the anatomical location and mesh placement and fixation. Large LHs should be managed with an open procedure; however, there is no consensus regarding the repair of small- to medium-sized LHs. We report our treatment of this type of LH using the transabdominal partial extraperitoneal (TAPE) technique. Methods: After retrospective review of the prospective hernia database at two hernia centers, patients with small- to medium-sized LHs who underwent the TAPE technique were identified and analyzed. The key components of our technique include wide dissection of peritoneum off the defect and use of that peritoneum to cover the lower and medial part of the mesh as much as possible. The parameters studied included patient demographics, intraoperative data, and postoperative outcome. Results: We studied 19 patients with small- to medium-sized LHs repaired using the TAPE procedure between 2017 and 2020. LH etiologies were primary hernia (n = 3), incisional hernia (n = 15), and traumatic hernia (n = 1). Mean defect size was 5.8 ± 2.1 cm (range 2.5-10 cm), mean operative time 118.1 ± 41.7 minutes (range 65-240 minutes), and mean postoperative stay 6.4 ± 2.0 days (range 6-9 days). There were no perioperative complications. At a mean follow-up of 20 months, no patient had recurrence of LH. Discussion: For small- to medium-sized LHs, the laparoscopic TAPE technique is minimally invasive and safe; the procedure is associated with minimal postoperative complications.

Totally endoscopic sublay (TES) repair for lateral abdominal wall hernias: technique and first results

BACKGROUND

The optimal surgical treatment for lateral hernias of the abdominal wall remains unclear. The presented prospective study assesses for the first time in detail the clinical value of a totally endoscopic sublay (TES) technique for the repair of these hernias.

METHODS

Twenty-four consecutive patients with a lateral abdominal wall hernia underwent TES repair. This technique is naturally combined with a transversus abdominis release maneuver to create a sufficient retromuscular/preperitoneal space that can accommodate, if necessary, a giant prosthetic mesh.

RESULTS

The operations were successful in all but one patient who required open conversion because of dense intestinal adhesion. The mean defect width was 6.7 ± 3.9 cm. The mean defect area was 78.0 ± 102.4 cm² (range 4-500 cm²). The mean mesh size used was 330.2 ± 165.4 cm² (range 108-900 cm²). The mean operative time was 170.2 ± 73.8 min (range, 60-360 min). The mean visual analog scale score for pain at rest on the first day was 2.5 (range 1-4). The average postoperative stay was 3.4 days (range 2-7 days). No serious complications (Dindo-Clavien Grade 2-4) were seen within a mean follow-up period of 13.3 months.

CONCLUSIONS

A totally endoscopic technique (TES) for the treatment of lateral hernias is described. The technique revealed to be reliable, safe and cost-effective. The first results are promising, but larger studies with longer follow-up periods are recommended to determine the real clinical value.

Traumatic abdominal wall hernias: a single-center case series of surgical management

Background

Traumatic abdominal wall hernias (TAWHs) are a rare clinical entity that can be difficult to diagnose and manage. There is no consensus on management of TAWH due to its low incidence and complex concomitant injury patterns. We hereby present the largest single-center case series in the USA to characterize associated injury patterns, identify optimal strategies for hernia management, and determine outcomes.

Methods

Patients who presented with a TAWH from blunt trauma requiring operative management were retrospectively identified over a 14-year period. Demographic data, Injury Severity Score (ISS), associated injuries, type of repair, durability of repair, and complications were collected, and descriptive statistics were calculated.

Results

Fifteen patients were identified. The average age was 31±11 years, ISS 15±9, and body mass index 33.4±7.1 kg/m². Mechanisms included falls (13%), motor vehicle collisions (60%), motorcycle accidents (20%), and pedestrian versus motor vehicle collisions (7%). The most commonly associated injuries included colonic injuries (53%), long bone fractures (47%), pelvic fractures (40%), and small bowel injuries (33%). Nineteen hernia repairs were performed: 6 underwent primary suture repair (32%) and 13 used mesh (68%). There were four recurrences. We could not find any significant relationship between contamination and mesh use or recurrence. There was one mortality related to sepsis.

Discussion

TAWHs have an associated injury pattern involving fractures and abdominopelvic visceral injuries where a tailored approach is advisable. Without hollow viscous injuries and gross contamination, these hernias can be repaired safely with mesh in the acute setting. However, in patients with gross contamination or hemodynamic instability, the risk of recurrence with primary repair must be weighed against the risk of infection and prolonged surgery with mesh repair. In those cases, a delayed reconstruction in the elective setting may be optimal.

Simplified Repair of Traumatic Iliac Crest Flank Hernias with Mesh Strips

Traumatic abdominal wall hernias are rare injuries resulting from blunt abdominal trauma. Traditional approaches have included both open and laparoscopic approaches, with placement of large meshes with giant overlaps. Perhaps the most technically difficult aspect of these repairs is fixating the abdominal wall to the iliac crest. The senior author has developed a method of repair using 2-cm strips of mesh. In this article, we present a description of 4 patients treated with this technique.

Robotic assisted treatment of flank hernias: case series

BACKGROUND

Flank hernias are uncommon, surgical treatment is challenging and the minimally-invasive approach not always feasible. The aim of this study was to report the safety and feasibility of the robotic-assisted repair.

METHODS

The study was approved by the local ethic committee (2019-01132 CE3495). A retrospective search on a prospectively collected dataset including demographic and clinical records on robotic surgery at our institution was performed to identify patients treated for a flank hernia. Patients were followed-up 6 months.

RESULTS

From January 2018 to December 2019, out of 190 patients who underwent robotic-assisted hernia surgery, seven with incisional flank hernia were included. Median age was 69.0 years (IQR 63.2-78.0), BMI was 27.3 kg/m2 (IQR 25.8-32.3) and two patients were male (29%). All patients were referred to surgery because of pain, whereas one of them described recurrent episodes of small bowel obstruction. The median hernia defect measured 25 mm ((IQR 21-40), median mesh diameter was 10 cm (IQR 10-12.5) and median operative time was 137 min (IQR 133-174). No intraoperative complication occurred. Postoperatively, one patient developed a pneumonia, which required antibiotics. Length of hospital stay was 4.0 days (IQR 3.0-7.7). Six months after surgery, neither recurrence nor chronic pain were recorded.

CONCLUSIONS

Robotics in abdominal wall hernia surgery remains a matter of debate, despite a growing interest from the surgical community. In our reported experience with flank hernias, we found the robotic-assisted approach to be safe and feasible for the treatment of this uncommon clinical entity.

An extraperitoneal approach for complex flank, iliac, and lumbar hernia

PURPOSE

The aim of this paper is to propose our four-step technique, an open extraperitoneal approach for complex flank, lumbar, and iliac hernias.

METHODS

A big polypropylene mesh is placed, covering and reinforcing all the lateral abdominal wall in an extraperitoneal space. Its borders are retroxiphoid fatty triangle and the costal arch cranially and the retropubic space caudally, psoas muscle, and paravertebral region posteriorly and contralateral rectus muscle medially. Mesh dimensions do not depend from the defect size, but prosthesis has to cover all the lateral abdominal wall.

RESULTS

No major complications have been reported. The mean length of stay is 4.8 days (range 3-11). Mean follow-up is 44.8 months (range 5-92). One recurrence (4.5%) has been reported at the 1-year clinical evaluation.

CONCLUSION

In conclusion, we believe that regardless size and location of the defect, every complex lateral hernia requires the same extensive repair because of the critical anatomy of the region with a big medium-heavyweight polypropylene mesh placed in an extraperitoneal plane, the only one that allows adequate covering of the visceral sac. Our technique is a safe, feasible, and reproducible treatment for this challenging surgical problem.

Combined open and laparoscopic approach for repair of flank hernias: technique description and medium-term outcomes of a single surgeon

PURPOSE

A residual bulge in the lateral abdominal wall is a reason for patient dissatisfaction after flank hernia repair (FHR). We hypothesized that combining a laparoscopically-placed intraperitoneal mesh (IPOM) with onlay hernia repair performed through a small open incision would increase repair durability and decrease such residual bulges. We aim to report our medium-term outcomes with this technique.

METHODS

Patients who have undergone FHR using the technique described above from March 2013 through June 2017 were identified in a prospectively maintained database. Outcomes of interest included surgical site infections (SSI), surgical site occurrences (SSO), surgical site occurrences requiring procedural intervention (SSOPI) and hernia recurrence.

RESULTS

Sixteen patients were identified (62% females; mean age 59 ± 8 years, mean body mass index 29.5 kg/m²). Mean hernia width was. 6.4 ± 3 cm and 31% were recurrent hernias previously repaired through an onlay approach. Mean operative time was 159 ± 40 min, fascial closure was achieved in all cases, and there were no intraoperative complications. Median length of stay was 3 days (IQR 3-4), and there were no unplanned readmissions or reoperations. At a median 37-month follow-up (IQR 21-55), wound morbidity rate was 12.5% (2 seromas). There were no SSI/SSOPI and one hernia recurrence (6%) was detected at 12 months postoperatively.

CONCLUSION

Combining laparoscopic IPOM with open onlay hernia repair resulted in low recurrence and acceptable wound morbidity rates, with no residual bulges noted at medium-term follow-up. Further studies with larger number of patients and other surgeon's experiences are necessary to determine the role of such technique in the surgical armamentarium for flank hernia repair.

Case report of traumatic abdominal wall hernia caused by seat belt

RATIONALE

Traumatic abdominal wall hernia (TAWH) is a rare form of hernia that is caused by disruption of the abdominal wall musculature and fascia. The diagnostic criteria and classification of TAWH are still unclear; furthermore, the ideal timing and method of surgical treatment are still unclear. Herein, we report a case of TAWH and describe the surgical approach used.

PATIENT CONCERNS

A 71-year-old Han Chinese female presented for swelling in the right lower abdominal quadrant. The patient underwent exploratory laparotomy because of a car collision before 1 year ago.

DIAGNOSIS

She was finally diagnosed with TAWH according to the abdominal computed tomography (CT) and surgery.

INTERVENTIONS

She was performed with an open surgery to repair the TAWH.

OUTCOMES

The patient was discharged without complications and showed no recurrence or complications during a follow-up period of 6 months.

LESSONS

TAWH is a rare form of hernia that presents a diagnostic and therapeutic challenge. The appropriate timing and approach of surgical treatment for TAWH depend on a case-by-case basis. This case highlights that delayed selective surgery may be more suitable for stable patients.

Mesh implants for hernia repair: an update

INTRODUCTION

Today the use of textile meshes has become a standard for the treatment of abdominal wall hernias and for the reinforcement of any tissue repair as the strength of the implant decreases the recurrence rates. With increasing use, side effects of the textile implants became apparent, as well.

AREAS COVERED

Based on publications in Medline over the past decade, general and specific benefits, as well as risks, are discussed with the challenge to define individual risk-benefit ratios. For meshes, certain high-risk or low-risk conditions can be defined. In an attempt to eliminate mesh-related risks, quality control for medical devices has meanwhile been revised. In both the USA and the EU post-market surveillance studies are required to keep medical devices approved.

EXPERT COMMENTARY

The impact of material on the complication rate will vary depending on the patient's co-morbidity or the risks of the procedure. Even the best material can end up with disappointing results in case of poor healing or poor surgery. On the other hand, when using high-risk devices, most of the complications after excellent surgery with excellent indication can be supposed to be mesh-related. Thus, the use of low-risk devices is recommended even though its advantage may not be demonstrable in clinical studies.

Delayed laparoscopic repair of a traumatic flank hernia: A case report and review of the literature

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Not all traumatic abdominal wall hernias require laparotomy at time of injury.

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Observation is considered to be safe when there is no other indication for surgery.

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Many patients managed non-operatively remain asymptomatic.

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Delayed laparoscopic repair with mesh reserved for hernias that become symptomatic.

Introduction

The traumatic abdominal wall hernia is a rare injury typically due to a high-energy blunt trauma mechanism. There is a lack of consensus on the appropriate management of these patients.

Presentation of the case

A 43-year-old male was evaluated for a left flank bulge eight months after a motorcycle collision. He was diagnosed with a traumatic abdominal wall hernia at time of injury that was managed non-operatively. He noticed a left flank bulge two months after his collision that progressively worsened in size and in discomfort. The patient underwent laparoscopic repair of the traumatic flank hernia. His postoperative course was uneventful and there was no recurrence at 3 years.

Discussion

Historically, exploratory laparotomy was considered necessary in patients diagnosed with a traumatic abdominal wall hernia at time of injury due to the high-percentage of concomitant intra-abdominal injuries. More recent studies suggest that some patients with a traumatic abdominal wall hernia may be safely managed non-operatively. A minority of these patients will require surgery for symptoms or complications related to the hernia and laparoscopic repair performed in a delayed fashion appears to have improved outcomes when compared to those that undergo repair at time of injury.

Conclusion

There is growing evidence supporting a non-operative management strategy in patients with a traumatic abdominal wall hernia who do not have a clear indication for abdominal surgery. These patients may be safely observed with delayed laparoscopic repair using synthetic mesh reserved for traumatic abdominal wall hernias that become symptomatic.

A Traumatic Direct Inguinal Hernia from Pelvic Ring Disruption

Introduction

Pelvic fractures usually involve a high-energy traumatic mechanism and account for approximately 3% of all blunt traumatic skeletal injuries. Additional musculoskeletal injuries are found in over 80% of unstable pelvic fractures. Traumatic abdominal wall hernias (TAWHs) are a rare entity, and traumatic inguinal hernias (TIHs) associated with open-book pelvic fractures have not been described previously.

Case Presentation

We present the case of a 45-year-old male motorcyclist involved in a collision resulting in a traumatic direct inguinal hernia due to abdominal wall disruption from an open-book pelvic fracture. He underwent a combined operation with an open reduction and internal fixation (ORIF) of his pelvic fracture and an abdominal wall reconstruction with a modified Stoppa technique utilizing mesh for his hernia.

Discussion

This is a unique presentation of a TIH due to an open-book pelvic fracture after blunt abdominal trauma. The formation of TAWH is typically from a combination of local tangential shearing forces and a sudden rise in intraabdominal pressures damaging the muscle, fascia, and peritoneum while the skin remains intact. In patients without hollow viscous injuries and gross contamination, these hernias can be repaired safely with mesh in the acute setting simultaneously with pelvic reduction.