Immediate Laparoscopic Repair of a Traumatic Abdominal Wall Hernia in a 2-Year-Old Child

Introduction

Traumatic abdominal wall hernias are quite rare and have only been described around 50 times in the literature. ³ These hernias are caused by blunt trauma that does not penetrate the skin, but has enough force to disrupt the underlying fascia and allow for subcutaneous herniation of bowel contents. Traditionally, these hernias have been repaired with open surgery. We describe the first laparoscopic repair of a traumatic abdominal wall hernia in an acute setting in a child.

Case History

A 2-year-old boy with no previous medical history presented to the emergency room of our hospital after having been accidentally hit by his grandmother's car. He arrived hemodynamically stable with a Glasgow coma scale (GCS) of 12. On physical examination, the patient was found to have a right humeral fracture as well as abrasions that covered about 60%–70% of his abdomen. On the left side, there was palpable bowel just underneath the skin. Computed tomography (CT) imaging revealed a traumatic left anterior abdominal wall hernia that appeared to contain both small bowel and transverse colon (Fig. 1a, b). In addition, there was dilatation of proximal small bowel, suggestive of mechanical obstruction by the hernia. No gross intra-abdominal free air was noted. CT scan showed free fluid in the pelvis with no solid organ injury and some bowel wall enhancement that was suspicious for bowel injury; hence, the patient was taken for immediate exploratory laparoscopy. During surgery, a 7–10 cm defect in the abdominal wall was found extending from near the midline to the left flank. Laparoscopic exploration did not reveal any significant bowel injury or any other injury. We laparoscopically repaired the abdominal wall hernia by the technique described next.

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FIG. 1.

(a,b) Computed tomography scan abdomen showing the left abdominal wall hernia.

Procedure

The patient was taken to the operating room, intubated, and anesthetized. A 5 mm incision was made in the scar of the umbilicus, and a 5 mm Step expandable port was introduced into the peritoneal cavity by using a modified Hasson's technique. Pneumoperitoneum was then achieved with CO₂ of 5 L/minute with a pressure of 12 mm Hg. Once adequate pneumoperitoneum had been achieved, a 5 mm 30-degree laparoscope was introduced into the peritoneal cavity. A 2 mm stab incision was then made on the right flank, and a grasper/needle holder was directly introduced without ports. On inspection, there was a traumatic left-sided abdominal wall defect with a hernia (Fig. 2). The omentum and bowel were seen to have herniated through the defect. Once the herniated bowel had been gently reduced and pulled down, the full extent of the defect was revealed. No other abnormalities were seen.

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FIG. 2.

Hernia after contents reduced.

After exploratory laparoscopy had been completed, repair of the defect was started. A GraNee needle (R-Med, Inc., Oregon, OH) was used to place several sutures through the abdominal wall hernia defect (Fig. 3a–c). Using the GraNee needle technique, the two ends of the defect were brought together with subcutaneous sutures. Approximately 10–12, 2-0 Vicryl sutures were placed in total, which took about an hour (Fig. 3d).

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FIG. 3.

(a–c) Using the GraNee needle technique, the two ends of the defect were brought together with subcutaneous sutures. (d) Approximately 10–12 2-0 Vicryl sutures were placed.

Once the repair had been completed, the instruments were withdrawn under vision. The umbilical port was withdrawn after desufflation of the peritoneal cavity. The umbilical fascia was closed with 2-0 Vicryl on a UR6. A single suture was used. The wounds were irrigated with saline, and the port sites were closed with Dermabond glue. The abdominal wall was then covered with Vaseline gauze as a dressing. The patient tolerated the procedure well and was extubated.

Results

After the procedure, the patient did well and was discharged on postoperative day 5. At 1 and 6 months follow-up, he was in good condition, with the scars well healed and no evidence of recurrence (Fig. 4).

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FIG. 4.

Excellent cosmetic results at follow-up.

Discussion

We report the first case of successful laparoscopic repair of a traumatic abdominal wall hernia in a pediatric patient. Additionally, this repair was done in an acute setting (in conjunction with an exploratory laparoscopy), which has not previously been described in a child. Subcutaneous herniation of intestinal contents after non-penetrating blunt abdominal wall trauma is most commonly reported after bicycle handlebar injuries or another severe blunt-force injury.^1,4 Our patient developed a subcutaneous intestinal hernia after blunt abdominal trauma sustained after being struck by a car, but he did not suffer any visceral injury. Due to the nature of the trauma, impressive physical exam, and suspicion of bowel trauma on imaging, we were compelled to perform an exploratory surgery to visualize the suspected internal bowel injury. We decided that it would be best to perform herniorraphy at the same time as the exploration. Given the age of our patient, mesh was not considered appropriate. This approach allowed us to perform a one-step operation on the day of admission, at which point all significant internal injury was ruled out, and the traumatic abdominal wall hernia was repaired. This gave our patient the best chance for quick and complete recovery, unlike delayed approaches used in the past. The laparoscopic approach also conferred significant benefit to the patient by both decreasing hospital stay and delivering cosmetic benefit, as was noted in previous case reports in adults.^2,3 We believe that this method of immediate laparoscopic repair is one that can be considered with confidence in patients with a similar type of abdominal wall injury.