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Abdominal wall fascial disruption after blunt trauma: A case report and review of the literature
FESTSCHRIFT
Abdominal Wall Fascial Disruption After Blunt Trauma: A Case Report and Review of the Literature Ched Singleton, MD, John Groves, MD, and Roy Gandy, MD Department of Surgical Education, Baptist Health System, Inc., Birmingham, Alabama KEY WORDS: traumatic hernia, abdominal wall hernia
INTRODUCTION Traumatic abdominal wall fascial disruption is not a common injury, despite the high prevalence of blunt abdominal trauma. It has been described sporadically in the literature since 1906 when Selby reported a case of a traumatic abdominal wall hernia in a patient who fell 6 feet onto a wheelbarrow handle.1 We present our experience with a 61-year-old man who sustained a traumatic abdominal wall hernia after a fall of approximately 10 feet.
CASE REPORT A 61-year-old man fell approximately 10 feet from a ladder after losing his footing. He landed directly across a 2 ⫻ 8 board, striking the left side of his abdominal wall. Upon arrival to the emergency room, he was hemodynamically stable with a Glasgow Coma Scale of 15. Appropriate resuscitative efforts were performed, including primary and secondary surveys. Complete physical examination revealed a contusion to the left abdominal wall with the imprint of a 2 ⫻ 8 board. An obvious fascial defect in this area existed, but the skin was intact. Other than localized tenderness, no signs of diffuse peritoneal irritation were found. Computed tomography (CT) scan of the abdomen and pelvis was performed and showed disruption of the abdominal wall fascial layers with herniation of bowel contents, but no apparent injury to the underlying solid organs (Fig. 1). The patient was taken to the operating room for exploratory laparotomy through an upper midline incision to exclude concurrent injury and to repair the defect. The entire abdominal cavity was explored. The only abnormality was a 10 cm ⫻ 4 cm full-thickness transversely oriented tear in the abdominal wall. This included all layers of the abdominal wall. The spleen, Correspondence: Inquiries to Ched Singleton, MD, Department of Surgical Education, Baptist Health System, Inc., 701 Princeton Ave., SW, 4 East, Birmingham, AL 352111399; fax: (205) 783-3164; e-mail: [email protected].
pancreas, liver, kidneys, mesentery, and small and large bowel were free from injury. The defect was closed primarily in layers with nonabsorbable suture. He was discharged on hospital day 5 after an uneventful postoperative course.
DISCUSSION Traumatic abdominal wall hernia (TAWH) resulting from blunt trauma is a relatively rare entity. However, although it is still not a common occurrence, a review of the literature over the past 20 to 30 years reveals an increasing number of reports, probably because of improved data collection from trauma centers. Reports of TAWH variably describe mechanism and extent of injury, anatomic location, and associated injuries. A fall across bicycle or motorcycle handlebars is a commonly reported mechanism of injury.2,3 In 1980, Dimyan et al coined the term “handlebar hernia” in describing a backseat motorcycle passenger who sustained a 3-cm tear in the inguinal floor.4 Other reports have documented more unusual wounding agents, including the barrel of a tank gun and disruption of all three layers of the abdominal wall in a 6-year-old boy gored by the horn of a cow.5 Those secondary to blunt abdominal trauma after motor vehicle accidents may be caused by seat belts or sudden increase in intra-abdominal pressure from deceleration. Although most garden-variety abdominal wall hernias occur at defined points of potential or iatrogenic weakness, TAWH are varied in their location and extent of injury. Damschen et al concluded from a review of the literature and 5 cases of their own that the location of the herniation was variable and showed no correlation with the mechanism of injury.6 TAWH have been described in the upper and lower quadrants of the abdomen, presacral, lumbar, inguinal, periumbilical, and at or about the rectus sheath. The incidence of associated injuries, although usually small, has been reported to be as high as 30%.1–7 Associated injuries have been reported to be rare when the defect is below the umbilicus, frequent when located above or in the flank, and present in virtually all of those as a result of retroperitoneal
CURRENT SURGERY • © 2001 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/01/$20.00 PII S0149-7944(01)00446-9
467
FIGURE 1. CT scan of the abdomen and pelvis shows a large ventral defect in the abdominal wall, located somewhat asymmetrically to the left, with apparent herniation of fat and bowel contents. Solid organs appear intact. No definite free air or free fluid is seen within the abdomen.
herniation. If the peritoneum is torn, herniation of abdominal contents, especially bowel, may accompany a TAWH. Kaude in 1966 reported on a 16-year-old girl who suffered traumatic separation of the rectus muscles at the lower costal margin blunt after injury to the sternum and upper abdomen. She developed subsequent herniation of the transverse colon into the subcutaneous tissue of the anterior chest wall.8 Dajee and Nicholson in 1979 described a traumatic tear in the retroperitoneum with herniation of 2 feet of small bowel.9 Otero’s patient, a soldier who was struck across the lower abdomen by the barrel of a tank gun, suffered a complete disruption of the rectus fascia at the midline below the umbilicus with avulsion of the ileocecal mesentery and devascularization of a portion of the terminal ileum.5 Dreyfuss et al describe 2 cases of disruption of the rectus sheath and rectus abdominus muscle with herniation of the small bowel.10 Several authors have offered classifications of TAWH based on the above criteria. In 1964, Clain suggested that several criteria must be met to establish a diagnosis. First, the hernia must appear immediately after a nonpenetrating blow to the abdomen with a blunt object of moderate size, and second, medical attention must be sought soon enough after the traumatic event to verify that signs of acute trauma were present.2 Guly and Stewart divided traumatic hernia of the abdominal wall into 2 types: those caused by avulsion of abdominal wall musculature from bone and those caused by defects in the musculo-aponeurotic layers.11 Malangoni and Condon added to Clain’s criteria for a traumatic hernia by suggesting that no peritoneal sac be identified at the time of operation.12 Otero and Fallon characterized 3 types of TAWH based on severity and location: small defects located in the groin caused by a direct blow, moderate sized defects located laterally and associated with forces of significant energy or increases in intra-ab468
dominal pressure, and large defects associated with an extensive shearing force.5 Gill et al in a case report and review in 1983 proposed several criteria for a TAWH.13 First, the defect should have an immediate and temporal relationship to the traumatic event. Second, no pre-existing abdominal wall defect should exist. Third, no penetrating wound and no peritoneal sac should be present at the time of operative exploration.13 In addition, an associated tear may exist in the retroperitoneum or mesentery because of forward propulsion of tethered intra-abdominal contents. Finally, in a report of 5 cases of TAWH over 22 years, Damschen et al offers this definition: herniation of bowel contents through disrupted musculature and fascia, without disruption of the overlying skin and no evidence of a prior hernia defect at the site of injury.6 The most comprehensive classification was offered in 1988 by Wood et al. This group categorized 3 types of TAWH based on a comprehensive review of the literature up to that point.1 Type 1 consists of small abdominal wall defects caused by blunt trauma with small instruments, such as bicycle handlebars. The most common mechanism of injury is a direct blow to the abdomen from a small-to-moderate–sized object that does not penetrate the skin, such as handlebars from a bicycle or motorcycle. These occur mainly in the lower quadrants of the abdomen. They tend to occur in a tangential manner, whereas more direct blows would penetrate the abdominal cavity. Tangential injuries may create a shearing force that can avulse muscle from bone or disrupt the layers of the abdominal wall. The skin, being relatively elastic, remains intact. These injuries are not usually associated with other intra-abdominal injuries. Type 2 includes larger defects associated with motor vehicle accidents, seat belts and larger deceleration forces. A rare third type consists of intra-abdominal herniation through rents in the peritoneum. Sudden increases in intra-abdominal pressure
CURRENT SURGERY • Volume 58/Number 5 • September/October 2001
along with local forces, such as improper use of seat belts, may contribute to the mechanism in these types of injuries. Prompt diagnosis of TAWH must start with a high index of suspicion and be based on the nature, mechanism, and force of injury. Differential diagnosis should include pre-existing hernia, tumor, or rectus sheath hematoma. Physical examination may be normal. Abdominal wall hematoma, contusion, or ecchymoses may be evident. An obvious fascial defect may exist, with or without a reducible hernia present. Irregular appearance to the overlying skin may represent subcutaneous dissection of bowel contents. Plain radiographs may show loops of bowel outside of the domain of the peritoneal cavity or pneumoperitoneum. An associated diaphragmatic rupture may exist as well. Ultrasound examination may also be useful in this setting. A CT scan of the abdomen and pelvis, especially in the stable patient, should be performed and is a useful adjunct to evaluate both the extent of injury and the presence of associated injuries. Most authors advocate early exploration and primary repair with nonabsorbable suture through a midline incision. Also, TAWH has only been reported off the midline. Although TAWH has only been reported off the midline, a central incision facilitates a thorough inspection of the intra-abdominal contents.1–17 Early repair is technically easier, leads to a lower incidence of subsequent strangulation, and decreases the need for prosthetic material to repair the defect. Delayed repair may allow the underlying bowel to become adhered to the overlying skin. Prosthetic material has been used by some, but we recommend avoiding this whenever possible to prevent associated complications. Of paramount importance is adherence to the basic surgical principles of debridement of all nonviable tissue and tension-free repair. In some cases, such as those patients without evidence of concurrent injury and who are hemodynamically stable, limited exploration with an incision over the hernia may be feasible. Rarely, delayed repair of the fascial defect may be advisable, especially in those patients with multiple injuries or in those not requiring initial abdominal exploration. In summary, although TAWH is an uncommonly encountered injury, the surgeon must maintain a high index of suspicion. Because of the mechanism and extensive force needed to cause a TAWH, and the risk of associated intra-abdominal injuries, we advocate open surgical exploration through a midline incision, followed by primary repair when feasible.
REFERENCES
hernia: a case report and review of the literature. Am Surg. 1988;54:648-651. 2. Clain A. Traumatic hernia. Br J Surg. 1964;51:549-550. 3. Roberts GR. Traumatic abdominal wall rupture. Br J
Surg. 1964;51:153-154. 4. Dimyan MB, et al. Handlebar hernia. J Trauma. 1980;20:812-813. 5. Otero C, Fallon WF. Injury to the abdominal wall mus-
culature: the full spectrum of traumatic hernia. South Med J. 1988;81:517-520. 6. Damschen DD, Landercasper J, Cogbill TH, Stolee RT.
Acute traumatic abdominal hernia: case reports. J Trauma. 1994;36:273-276. 7. Atiemo EA, Goswami G. Traumatic ventral hernia.
J Trauma. 1974;14:181-182. 8. Kaude J. Traumatic rupture of the abdominal wall with
subcutaneous herniation of the transverse colon and perforation of the small bowel. Br J Radiol. 1966;39:950-951. 9. Dajee H, Nicholson DM. Traumatic abdominal hernia.
J Trauma. 1979;9:710-711. 10. Dreyfuss DC, Flancbaum L, Krasna IH, Tell B, Trooskin
SZ. Acute trans-rectus traumatic hernia. J Trauma. 1986; 26:1134-1136. 11. Guly HR, Stewart IP. Traumatic hernia. J Trauma. 1983;
23:250-252. 12. Malangoni M, Condon R. Traumatic abdominal wall her-
nia. J Trauma. 1983;23:356-357. 13. Gill IS, Toursarkissian B, Johnson SB, Kearney PA. Trau-
matic ventral abdominal hernia associated with small bowel gangrene: case report. J Trauma. 1983;35:145-147. 14. Dubois P, Freeman J. Traumatic adominal wall hernia.
J Trauma. 1981;21:72-73. 15. Kubalak G. Handlebar hernia: case report and review of
the literature. J Trauma. 1994;36:438-439. 16. Brenneman FD, Boulanger BR, Antonyshyn O. Surgical
management of abdominal wall disruption after blunt trauma. J Trauma. 1995;39:539-544. 17. Chanvitan A. Traumatic abdominal wall hernia: a case
1. Wood RJ, Ney AL, Bubrick MP. Traumatic abdominal
CURRENT SURGERY • Volume 58/Number 5 • September/October 2001
report. J Med Assoc Thai. 1986;69:341-345.
469
Abdominal Wall Fascial Disruption After Blunt Trauma: A Case Report and Review of the Literature Ched Singleton, MD, John Groves, MD, and Roy Gandy, MD Department of Surgical Education, Baptist Health System, Inc., Birmingham, Alabama KEY WORDS: traumatic hernia, abdominal wall hernia
INTRODUCTION Traumatic abdominal wall fascial disruption is not a common injury, despite the high prevalence of blunt abdominal trauma. It has been described sporadically in the literature since 1906 when Selby reported a case of a traumatic abdominal wall hernia in a patient who fell 6 feet onto a wheelbarrow handle.1 We present our experience with a 61-year-old man who sustained a traumatic abdominal wall hernia after a fall of approximately 10 feet.
CASE REPORT A 61-year-old man fell approximately 10 feet from a ladder after losing his footing. He landed directly across a 2 ⫻ 8 board, striking the left side of his abdominal wall. Upon arrival to the emergency room, he was hemodynamically stable with a Glasgow Coma Scale of 15. Appropriate resuscitative efforts were performed, including primary and secondary surveys. Complete physical examination revealed a contusion to the left abdominal wall with the imprint of a 2 ⫻ 8 board. An obvious fascial defect in this area existed, but the skin was intact. Other than localized tenderness, no signs of diffuse peritoneal irritation were found. Computed tomography (CT) scan of the abdomen and pelvis was performed and showed disruption of the abdominal wall fascial layers with herniation of bowel contents, but no apparent injury to the underlying solid organs (Fig. 1). The patient was taken to the operating room for exploratory laparotomy through an upper midline incision to exclude concurrent injury and to repair the defect. The entire abdominal cavity was explored. The only abnormality was a 10 cm ⫻ 4 cm full-thickness transversely oriented tear in the abdominal wall. This included all layers of the abdominal wall. The spleen, Correspondence: Inquiries to Ched Singleton, MD, Department of Surgical Education, Baptist Health System, Inc., 701 Princeton Ave., SW, 4 East, Birmingham, AL 352111399; fax: (205) 783-3164; e-mail: [email protected].
pancreas, liver, kidneys, mesentery, and small and large bowel were free from injury. The defect was closed primarily in layers with nonabsorbable suture. He was discharged on hospital day 5 after an uneventful postoperative course.
DISCUSSION Traumatic abdominal wall hernia (TAWH) resulting from blunt trauma is a relatively rare entity. However, although it is still not a common occurrence, a review of the literature over the past 20 to 30 years reveals an increasing number of reports, probably because of improved data collection from trauma centers. Reports of TAWH variably describe mechanism and extent of injury, anatomic location, and associated injuries. A fall across bicycle or motorcycle handlebars is a commonly reported mechanism of injury.2,3 In 1980, Dimyan et al coined the term “handlebar hernia” in describing a backseat motorcycle passenger who sustained a 3-cm tear in the inguinal floor.4 Other reports have documented more unusual wounding agents, including the barrel of a tank gun and disruption of all three layers of the abdominal wall in a 6-year-old boy gored by the horn of a cow.5 Those secondary to blunt abdominal trauma after motor vehicle accidents may be caused by seat belts or sudden increase in intra-abdominal pressure from deceleration. Although most garden-variety abdominal wall hernias occur at defined points of potential or iatrogenic weakness, TAWH are varied in their location and extent of injury. Damschen et al concluded from a review of the literature and 5 cases of their own that the location of the herniation was variable and showed no correlation with the mechanism of injury.6 TAWH have been described in the upper and lower quadrants of the abdomen, presacral, lumbar, inguinal, periumbilical, and at or about the rectus sheath. The incidence of associated injuries, although usually small, has been reported to be as high as 30%.1–7 Associated injuries have been reported to be rare when the defect is below the umbilicus, frequent when located above or in the flank, and present in virtually all of those as a result of retroperitoneal
CURRENT SURGERY • © 2001 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/01/$20.00 PII S0149-7944(01)00446-9
467
FIGURE 1. CT scan of the abdomen and pelvis shows a large ventral defect in the abdominal wall, located somewhat asymmetrically to the left, with apparent herniation of fat and bowel contents. Solid organs appear intact. No definite free air or free fluid is seen within the abdomen.
herniation. If the peritoneum is torn, herniation of abdominal contents, especially bowel, may accompany a TAWH. Kaude in 1966 reported on a 16-year-old girl who suffered traumatic separation of the rectus muscles at the lower costal margin blunt after injury to the sternum and upper abdomen. She developed subsequent herniation of the transverse colon into the subcutaneous tissue of the anterior chest wall.8 Dajee and Nicholson in 1979 described a traumatic tear in the retroperitoneum with herniation of 2 feet of small bowel.9 Otero’s patient, a soldier who was struck across the lower abdomen by the barrel of a tank gun, suffered a complete disruption of the rectus fascia at the midline below the umbilicus with avulsion of the ileocecal mesentery and devascularization of a portion of the terminal ileum.5 Dreyfuss et al describe 2 cases of disruption of the rectus sheath and rectus abdominus muscle with herniation of the small bowel.10 Several authors have offered classifications of TAWH based on the above criteria. In 1964, Clain suggested that several criteria must be met to establish a diagnosis. First, the hernia must appear immediately after a nonpenetrating blow to the abdomen with a blunt object of moderate size, and second, medical attention must be sought soon enough after the traumatic event to verify that signs of acute trauma were present.2 Guly and Stewart divided traumatic hernia of the abdominal wall into 2 types: those caused by avulsion of abdominal wall musculature from bone and those caused by defects in the musculo-aponeurotic layers.11 Malangoni and Condon added to Clain’s criteria for a traumatic hernia by suggesting that no peritoneal sac be identified at the time of operation.12 Otero and Fallon characterized 3 types of TAWH based on severity and location: small defects located in the groin caused by a direct blow, moderate sized defects located laterally and associated with forces of significant energy or increases in intra-ab468
dominal pressure, and large defects associated with an extensive shearing force.5 Gill et al in a case report and review in 1983 proposed several criteria for a TAWH.13 First, the defect should have an immediate and temporal relationship to the traumatic event. Second, no pre-existing abdominal wall defect should exist. Third, no penetrating wound and no peritoneal sac should be present at the time of operative exploration.13 In addition, an associated tear may exist in the retroperitoneum or mesentery because of forward propulsion of tethered intra-abdominal contents. Finally, in a report of 5 cases of TAWH over 22 years, Damschen et al offers this definition: herniation of bowel contents through disrupted musculature and fascia, without disruption of the overlying skin and no evidence of a prior hernia defect at the site of injury.6 The most comprehensive classification was offered in 1988 by Wood et al. This group categorized 3 types of TAWH based on a comprehensive review of the literature up to that point.1 Type 1 consists of small abdominal wall defects caused by blunt trauma with small instruments, such as bicycle handlebars. The most common mechanism of injury is a direct blow to the abdomen from a small-to-moderate–sized object that does not penetrate the skin, such as handlebars from a bicycle or motorcycle. These occur mainly in the lower quadrants of the abdomen. They tend to occur in a tangential manner, whereas more direct blows would penetrate the abdominal cavity. Tangential injuries may create a shearing force that can avulse muscle from bone or disrupt the layers of the abdominal wall. The skin, being relatively elastic, remains intact. These injuries are not usually associated with other intra-abdominal injuries. Type 2 includes larger defects associated with motor vehicle accidents, seat belts and larger deceleration forces. A rare third type consists of intra-abdominal herniation through rents in the peritoneum. Sudden increases in intra-abdominal pressure
CURRENT SURGERY • Volume 58/Number 5 • September/October 2001
along with local forces, such as improper use of seat belts, may contribute to the mechanism in these types of injuries. Prompt diagnosis of TAWH must start with a high index of suspicion and be based on the nature, mechanism, and force of injury. Differential diagnosis should include pre-existing hernia, tumor, or rectus sheath hematoma. Physical examination may be normal. Abdominal wall hematoma, contusion, or ecchymoses may be evident. An obvious fascial defect may exist, with or without a reducible hernia present. Irregular appearance to the overlying skin may represent subcutaneous dissection of bowel contents. Plain radiographs may show loops of bowel outside of the domain of the peritoneal cavity or pneumoperitoneum. An associated diaphragmatic rupture may exist as well. Ultrasound examination may also be useful in this setting. A CT scan of the abdomen and pelvis, especially in the stable patient, should be performed and is a useful adjunct to evaluate both the extent of injury and the presence of associated injuries. Most authors advocate early exploration and primary repair with nonabsorbable suture through a midline incision. Also, TAWH has only been reported off the midline. Although TAWH has only been reported off the midline, a central incision facilitates a thorough inspection of the intra-abdominal contents.1–17 Early repair is technically easier, leads to a lower incidence of subsequent strangulation, and decreases the need for prosthetic material to repair the defect. Delayed repair may allow the underlying bowel to become adhered to the overlying skin. Prosthetic material has been used by some, but we recommend avoiding this whenever possible to prevent associated complications. Of paramount importance is adherence to the basic surgical principles of debridement of all nonviable tissue and tension-free repair. In some cases, such as those patients without evidence of concurrent injury and who are hemodynamically stable, limited exploration with an incision over the hernia may be feasible. Rarely, delayed repair of the fascial defect may be advisable, especially in those patients with multiple injuries or in those not requiring initial abdominal exploration. In summary, although TAWH is an uncommonly encountered injury, the surgeon must maintain a high index of suspicion. Because of the mechanism and extensive force needed to cause a TAWH, and the risk of associated intra-abdominal injuries, we advocate open surgical exploration through a midline incision, followed by primary repair when feasible.
REFERENCES
hernia: a case report and review of the literature. Am Surg. 1988;54:648-651. 2. Clain A. Traumatic hernia. Br J Surg. 1964;51:549-550. 3. Roberts GR. Traumatic abdominal wall rupture. Br J
Surg. 1964;51:153-154. 4. Dimyan MB, et al. Handlebar hernia. J Trauma. 1980;20:812-813. 5. Otero C, Fallon WF. Injury to the abdominal wall mus-
culature: the full spectrum of traumatic hernia. South Med J. 1988;81:517-520. 6. Damschen DD, Landercasper J, Cogbill TH, Stolee RT.
Acute traumatic abdominal hernia: case reports. J Trauma. 1994;36:273-276. 7. Atiemo EA, Goswami G. Traumatic ventral hernia.
J Trauma. 1974;14:181-182. 8. Kaude J. Traumatic rupture of the abdominal wall with
subcutaneous herniation of the transverse colon and perforation of the small bowel. Br J Radiol. 1966;39:950-951. 9. Dajee H, Nicholson DM. Traumatic abdominal hernia.
J Trauma. 1979;9:710-711. 10. Dreyfuss DC, Flancbaum L, Krasna IH, Tell B, Trooskin
SZ. Acute trans-rectus traumatic hernia. J Trauma. 1986; 26:1134-1136. 11. Guly HR, Stewart IP. Traumatic hernia. J Trauma. 1983;
23:250-252. 12. Malangoni M, Condon R. Traumatic abdominal wall her-
nia. J Trauma. 1983;23:356-357. 13. Gill IS, Toursarkissian B, Johnson SB, Kearney PA. Trau-
matic ventral abdominal hernia associated with small bowel gangrene: case report. J Trauma. 1983;35:145-147. 14. Dubois P, Freeman J. Traumatic adominal wall hernia.
J Trauma. 1981;21:72-73. 15. Kubalak G. Handlebar hernia: case report and review of
the literature. J Trauma. 1994;36:438-439. 16. Brenneman FD, Boulanger BR, Antonyshyn O. Surgical
management of abdominal wall disruption after blunt trauma. J Trauma. 1995;39:539-544. 17. Chanvitan A. Traumatic abdominal wall hernia: a case
1. Wood RJ, Ney AL, Bubrick MP. Traumatic abdominal
CURRENT SURGERY • Volume 58/Number 5 • September/October 2001
report. J Med Assoc Thai. 1986;69:341-345.
469