Traumatic inguinal hernia: Exploring the possible mechanism of its causation

Dear editor

We read with interest the comments of Živković et al. ¹ on our case report published in Medicine, Science and the Law entitled ‘Traumatic inguinal hernia: An uncommonly reported entity’. ² The authors have proposed an alternative mechanism of causation of traumatic inguinal hernia (TIH) in this case. We wish to thank them for showing interest in our work. However, we disagree with the mechanism reported by them.

Decollement injuries are mainly produced due to being run over by a turning wheel, causing tangential force over parts of the body, leading to separation of the skin from underlying muscular fascia and causing the formation of a ‘pocket’ filled with blood and fat tissue. ³ Apart from this mechanism, decollement can also be produced due to oblique or tangential force applied on a person in an erect position or by applying perpendicular force during free-fall impact. ³ In the reported case, there was neither a free fall and nor was the deceased in an erect position at the time of the incident, leaving being ‘run over’ as the only possibility for developing a decollement injury. Hence, we reiterate that the decollement injury, disruption of boundaries of the inguinal canal and subsequent herniation of the terminal ileum into the scrotal sac took place in a single event of being run over by a speeding lorry. This possibility is also supported in the literature cited by Živković et al. ¹ in which being run over was the cause for decollement injuries. ³

In run-over road traffic accidents, it is hard to predict the exact sequence of events due to the rapidity of the incident. The compression effect produced by the tyre is sufficient to produce both the shearing effect and consequent herniation of parts of the small intestine from the abdomen into the scrotal sac. In the reported case, the sudden increase in intra-abdominal pressure, along with the shearing effect on the abdominal muscle and fascia caused by the run-over, led to traumatic herniation of the small intestines. Thus, ‘high-energy’ impact should be considered as the cause for TIH in our case, rather than the possibility speculated by Živković et al. ¹