Giant Post -Traumatic Umbilical Hernia

Introduction: Traumatic Abdominal Wall Hernia (TAWH) is a rare kind of hernia. The diagnosis of TAWHs can be challenging and TAWHs may go undiagnosed for long periods of time. Case presentation: A sixty-year-old male who had been involved in a car crash 10 years earlier was referred to us for a giant post-traumatic umbilical hernia. The clinical assessment revealed an irreducible huge hernia of the anterior abdominal wall with a port size of 7x13 cm containing intestinal loops with no radiological signs of ischemia or venous stasis. The patient underwent elective surgery consisting of an open approach with mesh. Discussion: A study on 3,947 blunt trauma patients reported a 0.9% rate of TAWHs. The mechanisms hypothesized to lead to TAWHs are a sudden and marked increase in intra-abdominal pressure and/or acceleration-deceleration sheer forces impacting with a compressive seatbelt. The incidence of umbilical hernia reported in the literature is 2%. The diagnosis of TAWHs remains challenging owing to the patients’ conditions at the time of trauma, and the TAWH may escape diagnosis for a long period of time. The timing for surgical repair is driven by the severity of the injury and the size of the TAWH. The use of mesh in TAWH repair is debated, it being necessary to weigh up the advantages and the disadvantages of using mesh. In conclusion, TAWH is a rare entity that is, however, likely to be underestimated as a result of other, often severe, traumatic injuries the patient may have sustained. ABBREVIATIONS TAWH: Traumatic Abdominal Wall Hernia; CT: Computed Tomography INTRODUCTION We describe the case of a 60-year-old man affected by a giant abdominal wall hernia that had occurred following a car crash. Traumatic Abdominal Wall Hernia (TAWH) is a rare kind of hernia. The first case was described in 1906 [1]; since then, approximately 250 cases have been reported in the literature (in both adults and children) [2]. Damschen et al. [3], defined TAWH as the herniation through disrupted musculature and fascia associated with adequate trauma, without skin penetration or any evidence of a prior hernia defect at the site of injury. A TAWH may be difficult to detect and consequently go undiagnosed for a long period of time after trauma. The most common causes of TAWHs are handlebar injuries in infants and motor vehicle collisions in adults [4]. The correct timing of surgical repair depends on the type, and severity, of any other clinical injuries caused by the trauma, the patients’ general clinical conditions, the size of the hernia, and the risk of incarceration as well as of the protrusion of vital organs through the hernia sac [5]. CASE PRESENTATION A sixty-year-old man of Caucasian Italian origin, who was obese (BMI 35.5), an alcoholic and who had been involved in a car crash 10 years earlier, was referred to us on account of a giant umbilical hernia. The trauma had also determined a sternal fracture and the fracture of the L1 lumbar vertebra. The patient reported that the hernia had appeared shortly after the accident and that it had grown significantly in size in the last two years. An abdominal examination revealed an irreducible huge hernia of the anterior abdominal wall. The overlying skin was thicker than normal and inflamed, though without any signs of fistulization (Figure 1). An abdominal CT scan revealed a massive umbilical hernia (with a 7x13 cm port) containing intestinal loops with no radiological signs of ischemia or venous stasis (Figure 2). Owing to his history of alcoholism, the patient underestimated the hernia, allowing it to become giant. The hernia had become painful, highly unsightly and carried a significant risk of incarceration in the year before it came to our attention. The patient underwent elective surgery consisting of a direct approach using two separate incisions between the iliac spines, above and below the voluminous hernia. The sac contained the Central Bringing Excellence in Open Access   Luffarelli et al. (2016) Email: JSM Med Case Rep 1(1): 1003 (2016) 2/4 jejunum, the ileum and the right colon. Since the appendix was found to be stretched, an appendectomy was also performed (the histological examination revealed chronic appendicitis). The sac was removed with the skin and the subcutaneous fat (weighing 3 kg) (Figure 3). Exploration of the abdomen confirmed that the port size diameter was approximately 10 cm. The layers of the abdominal wall were sutured. This anatomical reconstruction was reinforced with an intra-abdominal polyester composite mesh (Parietex®) that had an overlap of at least 4 cm and was fixed with sutures (Figure 4). The post-operative results were satisfactory, and the patient was discharged after two days. In the early follow-up period, the patient developed superficial skin necrosis in the area of the abdominal wall associated with deglovement, which required secondary intention healing assisted by a vacuum-assisted closure system (Figure 5). The 1-year follow-up revealed very good functional and aesthetic results, without any recurrence (Figure 6).