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

Traumatic Abdominal Wall Hernia: Management Using a Standardized Approach

Traumatic abdominal wall hernias are a rare complication of high energy blunt trauma. There exist several studies evaluating and outlining potential management options but still no generalized consensus on management. This series was meant to evaluate the diagnosis and management of traumatic abdominal wall hernias. A prospectively maintained database was used to identify patients with TAWH from 2021 to 2022. The primary outcome was operative management. Secondary outcomes included: time to diagnosis and post-operative outcomes. Of the 19 patients in this case series, 100% (n = 19/19) were secondary to blunt trauma with a mean ISS of 21. Exploratory laparotomy was performed in 17 cases. 14 cases had concomitant traumatic injuries to visceral structures. Complications were found in nearly half of the patients with 3 experiencing wound dehiscence. Future studies should be aimed at standardizing management approach taking into account nature of the mechanism and concomitant injuries.

Pediatric Traumatic Lumbar Hernias and Associated Injuries: A Case Series

OBJECTIVE

Traumatic lumbar hernias are a rare entity mostly seen with high-impact, blunt abdominal trauma. This injury occurs when there is disruption of the posterior musculature along with bony structures, allowing for herniation of abdominal contents. There are minimal cases of this entity reported in adults, but even fewer in the pediatric population.

METHODS

We describe 3 cases of traumatic lumbar hernia at our institution as well as provide a review of the literature to elucidate the most common mechanisms, severity of injury, and associated injuries.

RESULTS

Traumatic lumbar hernia is most commonly seen in restrained passengers involved in motor vehicle collisions. A majority of cases are diagnosed using computed tomography imaging and less frequently during primary surgical exploration. The most common associated injuries were mesenteric and bowel injuries, followed by spinal and chest trauma. Traumatic lumbar hernia often leads to prolonged hospital stays and increased need for posthospital rehabilitation because of associated traumatic comorbidities.

CONCLUSIONS

Traumatic lumbar hernia is a rare entity in children, and early suspicion and identification of associated injuries is necessary in the management of these patients.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence.

MATERIALS AND METHODS

A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI.

RESULTS

157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model.

CONCLUSION

Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

Blunt Traumatic Abdominal Wall Hernias: An Indicator for Emergent Laparotomy?

BACKGROUND

Traumatic abdominal wall hernias (TAWH) are relatively uncommon; however, the shearing force that results in fascial disruption could indicate an increased risk of visceral injury. The aim of our study was to evaluate whether the presence of a TAWH was associated with intra-abdominal injury requiring emergent laparotomy.

METHODS

The trauma registry was queried over an 8-year period (7/2012-7/2020) for adult patients with blunt thoracoabdominal trauma diagnosed with a TAWH. Those patients who were identified with a TAWH and greater than 15 years of age were included in the study. Demographics, mechanism of injury, ISS, BMI, length of stay, TAWH size, type of TAWH repair, and outcomes were analyzed.

RESULTS

Overall, 38,749 trauma patients were admitted over the study period, of which 64 (.17%) had a TAWH. Patients were commonly male (n = 42, 65.6%); the median age was 39 years (range 16-79 years) and a mean ISS of 21. Twenty-eight percent had a clinical seatbelt sign. Twenty-seven (42.2%) went emergently to the operating room, the majority for perforated viscus requiring bowel resection (n = 16, 25.0%), and 6 patients (9.4%) who were initially managed nonoperatively underwent delayed laparotomy. Average ventilator days was 14 days, with a mean ICU LOS of 14 days and mean hospital LOS of 18 days. About half of the hernias were repaired at the index operation, 6 of which were repaired primarily and 10 with mesh.

CONCLUSION

The presence of a TAWH alone was an indication for immediate laparotomy to evaluate for intra-abdominal injury. In the absence of other indications for exploration, nonoperative management may be safe.

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.

An algorithm for the management of traumatic abdominal wall hernia based on a 9-year review

BACKGROUND

Traumatic abdominal wall hernia (TAWH) is a rare consequence of blunt abdominal trauma, usually in the setting of multitrauma, with little consensus or guidelines for management. We present a case series of patients with traumatic herniae over a 9-year period and a suggested management algorithm.

METHOD

Retrospective review of all patients with TAWH from 1st January 2011 to 31st December 2019 at a Level 1 adult Major Trauma Centre. Clinical presentation, surgical intervention and complications and recurrence were analysed.

RESULTS

Forty-seven patients were found to have TAWH, 0.5% of all major trauma admissions. Thirty (63.8%) were repaired, 12 acutely, 11 semi-acute and 7 delayed. All but 1 (fall>3 m) were transport associated, with a median Injury Severity Score (ISS) of 29. Follow-up data for operative cases were available for all but one (97%). Seven (23.3%) cases had a recurrence, more common in the acute repair group (33.3%) compared to semi-acute (18.2%), and elective group (14.3%).

CONCLUSION

TAWH is a rare but potentially serious consequence of blunt abdominal trauma. This series has favoured earlier repair for anterior TAWH, or all those undergoing a laparotomy for other reasons, and elective repair for lumbar or lateral TAWH that do not require a laparotomy for other conditions. We present our preferred algorithm for management, accepting that there are many available strategies in this heterogeneous group of injuries. Loss of follow up and recurrence are a concern, and clinicians are encouraged to develop processes to ensure that TAWH are not a 'forgotten hernia'.

Traumatic abdominal wall hernia and Morel-Lavallee lesion in a pediatric patient

Traumatic abdominal wall hernias and abdominal Morel-Lavallee lesions rarely occur in blunt abdominal trauma. There are only a few documented cases of these occurring simultaneously, especially in the pediatric population. We report a case of a 15-year-old boy with a concomitant traumatic abdominal wall hernia and Morel-Lavallee lesions. Abdominal wall reconstruction was performed successfully via the collaboration of trauma, minimally invasive surgery, and plastic surgery teams.

Management of Blunt Traumatic Abdominal Wall Hernias: An Analysis of the National Trauma Data Bank

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWH) are uncommon injuries with variable presentation and unstandardized management. Few national systematic descriptive studies have been conducted about TAWH. We present a retrospective descriptive study utilizing the National Trauma Data Bank (NTDB) to better characterize risk factors associated with TAWH and management practices.

METHODS

The NTDB (years 2016-2019) was examined for adult blunt trauma patients who had TAWH. Data included demographics, trauma-specific variables, management strategies, and outcome measures. Descriptive statistics were performed by univariate analysis.

RESULTS

2 871 367 adult blunt trauma patients were identified in the NTDB dataset. 206 had abdominal wall hernias (<.01%). Compared with the overall blunt trauma cohort, patients with TAWH had higher body mass index (BMI) and Injury Severity Scores (ISS), were more likely to be male, and had a higher mortality rate. 44 patients (21%) underwent operative management during their initial admission. Surgically managed patients were younger, had higher ISS and BMI, and were more likely to have concomitant intra-abdominal injuries. The few patients who had laparoscopic surgery had significantly higher BMI. Patients managed operatively had longer hospital and ICU lengths of stay and increased incidence of medical complications.

CONCLUSIONS

TAWH is an uncommon complication of blunt abdominal trauma, associated with higher BMI, ISS, and increased mortality. Initial operative management was pursued in 21% of cases, more often in younger, more severely injured patients with other intra-abdominal injuries. Evidence-based guidelines, based on multicenter prospective studies with longer follow-up, should be developed for management of these unique injuries.