Traumatic Abdominal Wall Hernia

Discussion on potential indicators and complications of lower abdominal injuries, with a focus on handlebar injuries and their treatment. The team analyzed the patient's CT scan, identifying a traumatic small bowel hernia and associated hemoperitoneum, and discussed the best approach to treating the injury. The team emphasized the importance of thorough repair and closure of all layers to prevent future hernias, and cautioned about potential complications that could arise.

Next Steps

• Surgical team to ensure thorough closure of all anatomical layers when repairing traumatic abdominal wall hernias to minimize risk of recurrence.

• Emergency department to maintain high index of suspicion for delayed bowel injury in patients with handlebar injuries, even if initially asymptomatic.

• Radiology team to carefully assess for subtle signs of bowel perforation or mesenteric injury on CT scans of blunt abdominal trauma patients.

Summary

Lower Abdominal Injuries and CT Scan Review

Discussion continued on potential indicators of lower abdominal injuries, with a focus on handlebar injuries and their complications. Stressed was the importance of not dismissing patients with asymptomatic injuries. Highlighted was the significance of the abdominal wall anatomy. Results were shared of patient's lab work, indicating elevated white blood cells and a slightly elevated ASP, while other values were within normal range. A CT scan of the pelvis with contrast was conducted, and the team requested the radiology fellow to review the images due to his inability to access them.

Detailed Analysis of Patient's CT Scan

This case presented a detailed analysis of a patient's CT scan, focusing on a traumatic small bowel hernia and associated hemoperitoneum. There was presence of a moderate amount of blood in the pelvis, the right paracolic gutter, and around the external iliac artery and vein. They identified a small bubble of air anterior to the right psoas muscle, which was considered concerning for bowel perforation. While the small bowel perfusion appeared fine, the cecum and the ascending colon showed thickening and hypoenhancement, which could indicate either a perfusion defect or a hematoma.

Laparoscopic Exploration for Bowel Assessment

Discussion about the best approach to treating a patient's injury. The team was considering either a midline laparotomy or a laparoscopic procedure. Dr. Emil explained the benefits of the Endo Chameleon ratcheting head laparoscope, which allows for a greater degree of freedom and a better assessment of the bowel. The team ultimately decided to proceed with a laparoscopic exploration to assess the bowel and determine if a bowel resection was necessary. Dr. Lemerge shared his perspective that, in the absence of laparoscopy, he would have opened over the defect in a transverse manner.

Hepatic Flexure Injury and Complications

The team discussed a case involving a hepatic flexure injury and a bruised cecum and colon. They emphasized the importance of thorough repair and closure of all layers to prevent future hernias. Significance of peritoneal closure was also highlighted, although it was noted it's not necessary for wound integrity. The discussions cautioned that patients could develop complications, such as mesenteric hematoma, even if they initially appear to be recovering well. The team stressed the need to counsel families about potential sequelae.