Abdominal Wall Injuries Following

Blunt Trauma

Roxie M. Albrecht, MD, FACS, FCCM

Medical Director Trauma and Surgical Critical Care

Vice Chair and Professor of Surgery, OUHSC

Region Chief, Region VI ACS Committee on Trauma

Introduction First reported in 1906

Rare but increasingly recognized

66 patients prior to 2004

Netto J Trauma 2006, 34 patients

Bender Am J Surg 2008, 22 patients

Dennis Am J Surg 2009, 26 patients

Coleman J Trauma Acute Care Surgery 2016, 80

patients

Incidence:

0.2-0.9 % All Trauma Admission

9.2 % of blunt trauma patients with abd/pelvis CT

Location

Severity-based classification

Management Timing

Associated injuries

Location

Locations Anterior – Rectus

Flank – Involving Abdominal Obliques

Lumbar – Superior/Inferior lumbar Triangle

Inguinal

Spigelian

Grade I

Subcutaneous tissue

contusion

Dennis RW. Am J Surg 2009; 197:413-7

Grade II

AW muscle hematoma

Dennis RW. Am J Surg 2009; 197:413-7

Grade III

Single AW muscle

disruption

Dennis RW. Am J Surg 2009; 197:413-7

Grade IV

Complete abdominal

wall muscle disruption

Dennis RW. Am J Surg 2009; 197:413-7.

Grade V

Complete abdominal

wall disruption with

herniation of

abdominal contents

Grade VI

Complete abdominal

wall disruption with

open evisceration

AWI – Associated Injuries

AWI – Associated injuries

Bowel Ischemia with Mesentery Injury

AWI Associated Injuries

Vascular – Infra renal Aorta and Common Iliac Artery

AWI – Associated injuries

Bowel Injury with Free Air

AWI

Iliac

AWI – Associated Injuries

Urine extravasation – ureter injury

When to Operate

Immediate

Associated intra-abdominal injury requiring

operation

Type of Repair

Primary muscle repair

Biologic mesh/absorbable mesh bridge repair

Staged closure

Primary muscle with biologic/absorbable mesh

When to Operate

Delayed Repair

Acute – Within 2 weeks/index hospitalization

Early – 2 weeks to 6-12 months

Get them over their other injuries

Late - > 5 years

Type and Outcome of Repairs

Initial Repair N Reinforce Recur F/U Days F/U CT Days

Immediate 8 5 2 6/7 223 +/- 37 6/8 176 +/- 30

Delayed

In Hospital 5 2 1 3/5 130 +/- 44 1/5 180

Readmit 6 6 0 6/6 293 +/- 86 5/6 254 +/- 113

Late 3 3 0 3/3 113 +/- 83 1/3 280

Total 22 16 3 18/21 170+/- 32 13/22 212 +/- 41

Do They all Need Operations

Complications

Six wound infections

3 Immediate/Damage control group

2 Delayed In-hospital group

1 Expectant

Management Scheme

Delayed Repair Approach

Laparotomy

Flank Approach – Lateral Position – preference for lumbar

Laparoscopic – preference for anterior/lateral

Technique

Mesh Reinforcement – my preference

Intramuscular – open

Extra-peritoneal Laparoscopic

Challenge – Inferior attachment to iliac crest

Laparoscopic Tacks

Get out the orthopaedic toys

Drill

Suture anchors

Conclusions

Look for it – Radiologist may miss it

Staged repair for instability or contamination

Early repair if stable is acceptable

Delaying repair appears to be safe and

potentially beneficial

Reinforcement in majority of cases