Re: ‘Traumatic inguinal hernia: An uncommonly reported entity’

Dear editor

We read with interest the article by Jadav et al. entitled ‘Traumatic inguinal hernia: An uncommonly reported entity’, which describes a fatal case of traumatic inguinal herniation of the terminal ileum into the scrotal sac in a 20-year-old male motorcyclist after a side-on collision and subsequent run over by a speeding lorry. ¹ There was complete disruption of all of the boundaries of the inguinal canal, including deep and superficial rings, causing traumatic herniation of 90 cm of the terminal ileum into the scrotal sac. ¹ According to the authors, a sudden increase in intra-abdominal pressure, along with the shearing effect on the abdominal muscle and fascia in this high-velocity trauma to the thoraco-abdominal region, should be considered as the primary aetiological mechanism in the development of traumatic hernia in this case. ¹

Most traumatic inguinal hernias follow vehicle accidents or seatbelt or handlebar injuries. This involves the application of blunt force to the abdomen over a large enough area to prevent skin penetration. These tangential forces cause pressure-induced disruption of the abdominal wall muscles and fasciae ² – that is, deep soft-tissue lacerations. As the skin is more elastic than other layers, it remains intact. The skin is then torn off from the underlying muscular fascia, resulting in a ‘pocket’ formation due to avulsion: a décollement traumatique is formed. ³ After skin avulsion, deep soft-tissue lacerations and the formation of a décollement, an acute herniation of abdominal organs occurs due to the increase in intra-abdominal pressure: the skin avulsion and décollement had to be formed prior to displacement of the abdominal organs. ³

One of the main responsibilities of the forensic pathologist, besides determining the cause of death, is to document injuries and deduce how they occurred. ⁴ We believe that the injury mechanism in the case presented by Jadav et al. was different from the one suggested by the authors. The course of action most probably first included side-on collision of the motorcyclist’s body with an obstacle – part of the lorry – with tangential force action on the abdominal region. This ‘first blow’ probably caused laceration of the soft tissues, muscles and fasciae of the abdominal wall, as well as disruption of all boundaries of the inguinal canal, including deep and superficial rings, seen during the autopsy. In the right lower part of the anterior abdominal wall of the deceased (as can be seen in the first figure in the article by Jadav et al.), there are several horizontal and oblique linear skin excoriations, probably originating from the side-on collision with the lorry while the victim was still sitting on the motorcycle. After this collision, the injured motorcyclist most probably fell and was run over by a lorry. It is likely that only then, due to the increase in intra-abdominal pressure, did an acute herniation of 90 cm of the terminal ileum into the scrotal sac occur (as can be seen in the first and third figures in the article by Jadav et al.). Simultaneously with this herniation, it is probable that other injuries of internal organs and multiple fractures also occurred.

It is very probable that traumatic herniation through the inguinal canal, such as in the case presented by Jadav et al., ¹ is a two-phase injury. The first phase causes avulsion and laceration of the soft tissues and opening of the ‘passage’ – the inguinal canal – while the second phase includes a rise in abdominal pressure, which leads to organ displacement and herniation. Thus, we believe that it is not high-velocity trauma induced by a speeding lorry that caused the traumatic herniation in the case presented by Jadav et al., ¹ but rather the two-phase mechanism: first, side-on collision, and second, running over.