blunt trauma of the abdominal wall can lead to a traumatic abdominal wall hernia ( tawh ) .
defined tawh as the  herniation through disrupted musculature and fascia associated with adequate trauma , without skin penetration , and no evidence of a prior hernia defect at the site of injury  .
although this type of hernia is unusual , it has been described in some reviews [ 27 ] .
two reviews studied tawh , especially in the lumbar position [ 8 , 9 ] . the increased abdominal pressure and shearing forces likely cause disruption of the abdominal wall muscles and fasciae .
we describe the history and imaging of a patient with a traumatic abdominal wall hernia and the operative treatment .
a 59-year - old male sustained a fall from a height of 9  m onto a pile of steel bars , landing on his right flank . upon arrival of helicopter emergency medical services , the patient was alert and complained of pain in the abdomen . an advanced trauma life support ( atls ) survey revealed a right - sided pneumothorax , which was treated with a chest tube .
after this intervention , the patient was respiratorily and haemodynamically stable and transported to the emergency department . upon arrival ,
the initial assessment according to the atls protocol was performed without any new findings according to the a , b , c and d approaches . during the secondary survey ,
inspection revealed a large swelling at the right side of the abdomen , with abrasions of the overlying skin ( fig .  1 ) .
focussed assessment with sonography for trauma identified the presence of free intraperitoneal fluid around the spleen .
1patient after blunt abdominal trauma with swelling of the right hemi - abdomen patient after blunt abdominal trauma with swelling of the right hemi - abdomen in addition , a computed tomography ( ct ) scan of the abdomen showed a traumatic hernia of the right lateral abdomen , with protrusion of bowel and laceration of the spleen ( fig .  2 ) .
the patient was transported to the operating theatre , and exploration of the abdomen through a median incision revealed a transverse rupture of the total abdominal wall , including rectus muscle and external , transverse and internal abdominal muscles , with a length of 30  cm from the midline to the vertebral column on the right side ( fig .  3 ) .
the small bowel , ascending colon and the right lobe of the liver were herniated due to this defect .
a non - vital part of the small bowel ( 10  cm ) was resected , and haemorrhages from the mesentery and spleen were treated .
this anatomical reconstruction was reinforced with an intra - abdominal polyester composite mesh ( parietex ) with at least 4  cm overlap and fixed with sutures and taggers .
after closure of the linea alba , the overstretched median fascia below the umbilicus was protected by an absorbable polyglactin mesh ( vicryl ) .
post - operatively , the patient developed superficial skin necrosis in the area of the abdominal wall with deglovement , which healed by secondary intention assisted by a vacuum assisted closure system . a ct scan of the abdomen 4  months after the operation showed the anatomical reconstruction of the right abdominal wall with the use of an intra - abdominal mesh fixed with taggers ( fig .  4 ) .
2preoperative abdominal computed tomography ( ct ) scan demonstrating three ruptured muscle layers on the right sidefig . 
3intra - operative picture of the right inner abdominal wall with rupture of all muscle layers .
.  1 parietal peritoneum , 2 rupture of abdominal muscle layers , 3 liverfig . 
4post - operative abdominal ct scan demonstrating anatomical restoration of the right abdominal wall with the use of an intra - abdominal mesh fixated with taggers preoperative abdominal computed tomography ( ct ) scan demonstrating three ruptured muscle layers on the right side intra - operative picture of the right inner abdominal wall with rupture of all muscle layers .
.  1 parietal peritoneum , 2 rupture of abdominal muscle layers , 3 liver post - operative abdominal ct scan demonstrating anatomical restoration of the right abdominal wall with the use of an intra - abdominal mesh fixated with taggers
our patient sustained a high - energy trauma caused by a fall from a large height .
this trauma gave rise to the tawh and associated devascularisation of the small bowel , necessitating bowel resection .
low energy trauma can lead to smaller tawhs , which can easily be missed on physical evaluation .
handlebar injury is an example of a low energy trauma that can lead to tawh [ 2 , 11 , 12 ] .
the diagnosis of a tawh on physical examination can be difficult ; because of its rare occurrence , a diagnosis of tawh is not often considered .
the tawh was not diagnosed by physical examination , and the very tender right hemi - abdomen was thought to be associated with intra - abdominal lesions . because life - threatening intra - abdominal injuries can occur after high - energy trauma , a ct scan should be used as a diagnostic method .
the ct scan in this case led to the diagnosis of tawh after careful examination of the abdominal wall and also to multiple haematomas in the mesentery and a spleen laceration .
the strong shear forces had split the three layers of the lateral abdominal wall and the peritoneum . with the routine use of ct scans after blunt trauma
tawh can be operated on by an incision overlying the defect , but in this case , a midline exploratory laparotomy was necessary for the associated intra - abdominal injuries .
in addition , because of the associated intra - abdominal injuries , delayed exploration of the tawh was not a treatment option in our case .
we combined the primary closure in the anatomical layers with an intraperitoneal mesh because the fascia was stretched out by the trauma and the hernia was very large .
we used a composite mesh because the inner side was in direct contact with the bowels . in a recent review of the open treatment of incisional hernia ,
also , in a recent retrospective study of 206 open sublay mesh repairs with intraperitoneal placement of a composite mesh , the infection rate was 10.2% in a 9.5-year period . in our case ,
resection of a small bowel section could have increased the risk of a mesh infection .
the high infection rate has to be weighed against the risk of recurrence . in a series of eight
acutely repaired tawhs without mesh , three developed a recurrent hernia after 8  months . in another series of seven acute repairs of tawhs ,
thus , the acute repair of a large tawh should not be underestimated because of the associated injuries and the risk of a recurrence .
 although blunt abdominal trauma is frequent , traumatic abdominal wall hernias ( tawh ) are rare . 
 we describe a large tawh with associated intra - abdominal lesions that were caused by high - energy trauma . 
 the diagnosis was missed by clinical examination but was subsequently revealed by a computed tomography ( ct ) scan . 
 repair consisted of an open anatomical reconstruction of the abdominal wall layers with reinforcement by an intraperitoneal composite mesh . 
 the patient recovered well and the results of a post - operative ct scan are presented . 
Introduction
Case report
Discussion