Traumatic abdominal wall hernia caused by a low fall

BACKGROUND: Traumatic abdominal wall hernias (TAWH) are uncommon injuries classically associated with high-energy blunt traumatic mechanisms. Motor vehicle collisions cause the highest proportion of all TAWH. Literature is currently limited, with some debate existing over surgical management strategies. CASE PRESENTATION: A 67-year-old man presented after falling from a short step stool while landscaping his yard. On exam, an exquisitely tender lateral flank mass was present with peristaltic movement. CT imaging revealed a TAWH with incarcerated large and small bowel. He was taken to the OR for exploratory laparotomy and mesh hernia repair. The patient was discharged on the third postoperative day with no untoward complications. DISCUSSION: This patient’s mechanism and injury pattern are together a rare combination. Exam findings and radiologic technologies are used to hone the clinical index of suspicion for TAWH. Traumatic abdominal wall defects can have unusual anatomic borders, not always obeying well-known hernia patterns. In this case, the potential space for visceral herniation was created by an 11th rib fracture with associated avulsion of the oblique musculature. Operative approach can be open or laparoscopic, however concomitant injuries directly influence surgical management. Evidence for mesh versus primary repair for TAWH is conflicted by the current literature. CONCLUSIONS: Nearly any amount of blunt abdominal force can cause TAWH. For wall defects with bowel herniation caused directly by trauma, the safest approach may involve exploratory laparotomy. Future multi-center studies may be able to distinguish TAWH repair strategies based on herniation through old defects versus newly-created abdominal wall injuries.