A 47-year-old man presented as an activated trauma to a community based trauma center following a motor vehicle collision. He was the restrained passenger in a vehicle that struck a pole at an estimated 40-50 mph. Initially his complaint was abdominal pain with subsequent inability to urinate. The patient also noted some chest wall discomfort secondary to the seatbelt. Upon arrival he was hemodynamically stable, however physical exam revealed generalized tenderness to the sternum and suprapubic regions. Gross hematuria was noted upon insertion of a urinary catheter. Subsequent computerized tomography scans identified a small non-displaced sternal fracture, as well as an intraperitoneal bladder rupture and right lumbar hernia in the area of Petit's triangle, with complete avulsion of the abdominal wall musculature from the iliac crest. (Fig. 1) No other internal injuries were identified. The patient underwent same day laparotomy with cystorrhaphy by the urology team. The traumatic lumbar hernia repair was discussed by the general and plastic surgery teams, and immediate repair was deferred due to the bladder injury as well as the fact it was generally asymptomatic. The remainder of the trauma admission was uneventful. Over the following six months the patient began having increasing pain at the hernia site. After re-evaluation by general and plastic surgery departments, decision was made for surgical repair (Fig. 2a and b).
Operative technique began with dissection being carried out directly over the hernia. A preperitoneal plane was developed after the hernia sac was freed from all subcutaneous attachments, dissecting all layers of the abdominal wall away from the peritoneum in order to place a polypropelene mesh. (Fig. 3) A 6 x 6 cm defect was measured, and a 12 x 12 cm mesh was circumferentially sewn into place utilizing the abdominal wall musculature at the superior, medial and lateral aspects. The mesh was then anchored to the periosteum of the iliac crest in the caudal portion. Muscle flaps were created utilizing the external and internal oblique muscles to allow for coverage without undo tension. Predrilled holes along the iliac crest were formed and Mitek QUICKANCHOR  suture anchors, preloaded with double arm braided polyethylene/polyester composite sutures were used to secure the oblique musculature to the iliac crest, allowing precise and accurate approximation of the muscle back into its anatomic location (Fig. 3). A drain was placed within the dissected pocket and layered closure of the subcutaneous soft tissue layers and skin was performed.
Post operatively the patient has continued to progress well with no recurrence or gross limitations on follow up evaluations (Fig. 4).