A 65-year-old woman was the driver in a frontal collision with a truck at 50 km/h. She was alone in the car and wearing a seatbelt, and her car's airbags deployed. She was transported to our facility by ambulance. On arrival, tachypnea and tachycardia with a pulse generally over 100 beats per minute occurred during resuscitation. The systolic blood pressure was maintained at greater than 100 mmHg. During fluid resuscitation, a physical examination showed tenderness and distension in the right lower quadrant with a seat belt sign. Her left leg was deformed with perforation of the skin, suggesting an open fracture of the tibia. She remained hemodynamically stable during the resuscitation. An enhanced computed tomography scan of the abdomen showed a defect of the abdominal wall, herniation of the cecum and small bowel loops, free air in the abdomen, and acute traumatic dissection of the abdominal aorta and common iliac arteries (Fig. 1).
She was urgently brought to surgery and the abdomen was explored through a long midline incision. The exploration revealed a 12 x 30 cm defect of the abdominal wall in the right lower quadrant, laceration of the ileum mesenteric injury with bowel ischemia, a transected sigmoid colon with extensive spillage, and a transected inferior mesenteric artery. The abdominal aorta was exposed distal to the inferior mesenteric artery, but no aortic bleeding was seen. The inferior vena cava and right ureter were also completely exposed at the same level. The abdominal wall defect was present along the iliac crest, and bleeding was noted at that site.
After achieving hemostasis, approximately 160 cm of ileum and lacerated sigmoid colon was resected. Due to extensive spillage of stool and vascular injuries that would possibly require graft repair, we performed an end ileostomy as well as an end colostomy to minimize the chance of any subsequent anastomotic leakage. The distal ends of the bowel were closed and placed in the abdomen.
The abdominal wall could not be closed at the initial operation due to the large defect size. Negative pressure wound therapy was thought to be useful for temporary coverage. We could not perform a tension-free repair because of the risk of infection with extensive intra-abdominal contamination. The fascial defect was closed as much as possible and negative pressure wound therapy instituted for the part of the defect that could not be definitively closed. At the end of the operation, the patency of both stomas was verified digitally.
The following day, we removed the negative pressure wound therapy devices and found that the abdominal wall could be approximated; sutures were placed at the bedside. After repeating this technique, the abdominal wall was completely closed by postoperative day 10. A series of these procedures is shown in Fig. 2. During this gradual closure, there was no evidence of abdominal compartment syndrome (as measured by bladder pressure and clinical status) or respiratory complications.
Non-operative management to dissection of the abdominal aorta and common iliac arteries was selected because the patient had no symptoms of ischemia or bleeding. On postoperative day 16, the patient complained of nausea and vomiting. A computed tomography scan of the abdomen showed that dilation of the entire small bowel and angulation of the abdominal wall impinging on the ileostomy (Fig. 3). A digital exam of both stomas was impossible because of stenosis at the level of the fascia. On postoperative day 19, the fascia was incised in the operating room with the patient under general anesthesia and the tissue around the ileostomy was opened to release the stenosis at the site of the ileostomy, with clinical improvement.
There were no subsequent obstructions at that site. The colon proximal to the end colostomy was not dilated and the colostomy was observed. No symptoms developed at the colostomy site. Closure of the ileostomy and a colostomy were performed 14 months after the initial exploration; there was no evidence of hernia recurrence at 2 years follow-up, and the patient had no complaint about reconstructed abdominal wall.