A rare case of bullhorn-injury associated traumatic hernia of anterior abdominal wall managed by laparoscopic sutured tissue-only repair.

Traumatic abdominal wall hernias (TAWHs) are relatively uncommon entities. Common mechanisms that predispose to such hernias include motor vehicle accidents, seat belt injuries, fall from height, handlebar injuries, and bullfighting. Bullhorn injury leading to TAWHs is an uncommon mechanism. We report here one such patient who was managed by laparoscopic transperitoneal anatomical repair of the defect using polypropylene suture. The patient recovered well without any complication and is being followed up. Such small defects can be managed laparoscopically and tissue-only repair using a nonabsorbable suture is a feasible option. Our case is the first reported case of bullhorn-injury associated traumatic hernia managed laparoscopically and first reported case of TAWH in an adult which was managed by laparoscopic sutured tissue-only repair.

Introduction

Traumatic abdominal wall hernias (TAWHs) are relatively uncommon entities that are being reported with increasing frequency in current literature. Bullhorn injury leading to TAWH is a rather uncommon mechanism. Very few such cases have been reported in literature.[12345] We report here a case of a middle-aged male who presented on the 7th day following bullhorn injury with a swelling above the right groin.

Case Report

A 43-year-old middle-aged male of thin built and average nutrition came to us with 5-day history of a swelling, about 2 cm in size, above the right groin. The swelling appeared on coughing and straining only. He had history of being hit by a bull using its horn at the same site 1 week back. At presentation, patient's vitals were within normal limit for his age. On examination, a resolving yellowish-brown 2 cm × 1 cm bruise was present at the alleged site of injury that was 4 cm medial to anterior superior iliac spine and 2 cm above the deep inguinal ring [Figure 1]. On coughing, a small bulge of about 3 cm appeared at the site of injury [Figure 1]. Ultrasonography (USG) revealed a small defect in the anterior abdominal wall with no free fluid in peritoneal cavity or any solid organ injury. No free intraperitoneal gas was visualized on the erect chest X-ray. Since the patient was hemodynamically stable with no apparent sign of internal abdominal injury, the patient was planned for laparoscopic repair of defect. The patient was admitted after 6 weeks. A contrast-enhanced computed tomography (CECT) of the abdomen was done to define the defect. It revealed a small defect of approximately 2 cm size in the anterior abdominal wall [Figure 2]. The patient was planned for a laparoscopic mesh repair of the hernial defect. However, intraoperatively, we found a small clean split defect in the muscle and fascial layers of anterior abdominal wall of <2 cm size [Figure 3]. Thus, an anatomic tissue repair of the defect in single layer was done transperitoneally using continuous nonabsorbable 1-0 polypropylene sutures [Figure 3]. Patient's postoperative course was uneventful and the patient was discharged on day 3. The patient has been in follow-up for the past 6 months without any reported complication.

Figure 1

(a) Bullhorn-injury associated traumatic hernia above the right inguinal region with healing bruise at lower part of swelling with a suprapubic incision of previous cystolithotomy; (b) Site of laparoscopic ports utilized for repair of defect

Figure 2

Contrast-enhanced computed tomography abdomen showing the hernial defect of about 2 cm just above the right inguinal region

Figure 3

(a) Split defect in the fascial and muscle layer; (b) Laparoscopic anatomic repair of hernial defect with polypropylene 1-0 suture

Discussion

Bullhorn injuries are described as “sheathed goring” in which deep layers may be injured with no or minimal skin wounds due to its elastic quality, carrying a high risk of missed and severe injuries. Bullhorn-injury associated traumatic hernia (BATH) should be considered a distinct entity among TAWH as a large force acts over a very small area. Bullhorn injury may lead to high impact injuries that will present early[234] and may be associated with other injuries as well. It may also present as lower impact injuries which will usually be isolated injuries presenting late as reported by Nirhale et al.[1] and as was with our case. In case of injury to intra-abdominal viscera, the patient presenting immediately may present without features of peritonitis as in the case reported by Singal et al.[5] Location of hernial defect is usually in the iliac fossa, inguinal region, and lumbar region which are anatomically weak points.

USG is the initial investigation most commonly employed specially in emergency settings. However, CECT abdomen is the recommended investigation in all such patients’. On CT scan, hernial defect and associated injuries are identified, defined, and described with reliable sensitivity and specificity.

In unstable patients or patients with associated injuries requiring operative intervention like the case reported by Singh et al.,[2] emergent life-saving open surgery in the form of laparotomy with possible anatomic repair of the defect (as in case of Singal et al.)[5] is the only option. The use of mesh should be avoided for the possibility of infection, if the wound is contaminated or if abdominal compartment syndrome is present, and in patients undergoing damage control surgery. In stable patients presenting early, associated injury has to be rule out by appropriate imaging such as CECT. Here, laparoscopy may be considered to evaluate the peritoneal cavity; however, CECT would still be necessary to assess the retroperitoneum. In stable patients presenting late, delayed repair after few weeks (4–8 weeks) seems a valid option because it gives time for resolution of local edema, hematoma, and inflammation. Dharap et al.,[3] who have done repair in elective setting, used mesh for repair. Nirhale et al.[1] have also operated the patient in elective setting, but they had chosen anatomic repair. Other authors[45] have operated the patient in emergency setting and have gone for the more common notion of avoiding mesh and doing anatomic repair. Once associated internal injury is ruled out by clinical and radiological evaluation in any such patient whether presenting early or late, the surgeon can choose regarding the appropriate timing of surgery, approach (open or laparoscopic), and type of repair (suture repair or mesh). In our case as the patient was hemodynamically stable at initial presentation, we waited for 6 weeks and then did laparoscopic sutured tissue-only repair of defect. Advantage of delayed repair was evident in the form of the clean split of muscles which was seen intraoperatively due to resolution of local edema and inflammation [Figure 2] that made sutured tissue repair feasible. Sutured repair was chosen over mesh repair intraoperatively due to the very small size (<2 cm) of hernial defect and the clean splitting seen in muscle layers which was easily amenable to repair using polypropylene. Moreover, the muscles surrounding the split defect had normal tone without any apparent weakness, and centrifugal forces due to movement of intra-abdominal viscera and the intra-abdominal pressure are more on central part of the abdomen as compared to the peripheral part so sutured repair appeared a safe option in this patient. The use of mesh is not without complications (seroma formation, infection, shrinkage, autoimmune reactions, mesh migration, and rejection),[6] so it appeared to us not to be using mesh in this case because of lack of proper indications. This decreased the operative time and prevented the potential complications this middle-aged patient might have sustained due to the use of prolene meshes, especially the mesh-related foreign body sensation and discomfort such patients often complain.

Early repair has been the most commonly reported entity in literature and its proponents say that with delayed repair defects may enlarge, muscle may undergo disuse atrophy, primary approximation may become difficult, and other injuries may be missed. However, more recently, delayed repairs of TAWHs have been reported with optimal outcomes.[7] Coleman et al.[8] have reported a recurrence rate of 26% for TAWH in their case series with acute repair being associated with majority of the recurrences. This again reinforces our concept of delayed repair. Laparoscopic repair of TAWH has been described with reliable repair of defects and optimal outcome, but in all other reported cases, mesh repair was the preferred option.[9] Hence, our case is unique in the sense that we used laparoscopic anatomic tissue repair with nonabsorbable suture. Our case is the first case of BATH employing principle of laparoscopy and first reported case of TAWH in an adult which was managed by laparoscopic sutured tissue-only repair.

Conclusion

Patients of BATH presenting late but with stable vitals can be managed by delayed elective hernial defect repair. Delayed laparoscopic anatomical repair using a nonabsorbable suture is a valid and feasible option in such small defects which are not associated with formation of a definitive hernial sac.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.