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The diagnosis and evaluation of traumatic abdominal wall hernia can be challenging because of its low incidence and nonspecific clinical presentation. Without a high index of clinical suspicion, the detection of traumatic abdominal wall hernia may be delayed. A 71-year-old female patient was struck in the lower abdomen by a cow horn and initially received only conservative management at a local clinic. However, her pain worsened despite conservative measures, and she developed a reducible bulging mass. Computed tomography revealed an abdominal wall defect with small bowel herniation. She was transferred to our hospital's emergency department, where urgent surgery was performed. A laparotomy was conducted to repair the abdominal wall defect and explore potential intra-abdominal injuries. The defect was successfully repaired, and the patient was discharged without complications on postoperative day 10.
Traumatic abdominal wall hernia (TAWH) is a rare entity that can present with delayed symptoms or minimal early clinical signs. Symptoms such as pain, bruising, and abdominal distension are common after blunt trauma and can contribute to missed or delayed diagnoses of TAWH. Therefore, diagnosing and evaluating TAWH requires a high level of clinical suspicion and often relies on imaging modalities. Herein, we report a case involving delayed diagnosis of TAWH associated with a cow horn injury, a particularly unusual mechanism in Korea.
CASE REPORT
Ethics statement
Informed consent for publication of the research details and clinical images was obtained from the patient.
Patient information
A 71-year-old female patient was struck in the lower abdomen by a cow horn, resulting in bruising and pain (Fig. 1). Initially, she received conservative management at a local clinic. Two days later, her pain intensified, and a bulging mass was palpable, prompting computed tomography (CT) evaluation at the same clinic. The abdominal CT scan revealed a 5.5×3.4-cm abdominal wall defect in the lower abdomen (Fig. 2), indicative of TAWH. The patient was transferred to our hospital’s emergency department for definitive management.
Clinical findings
On arrival, she complained of severe pain and discomfort. Physical examination identified tenderness in the left lower quadrant, along with a reducible bulging mass corresponding to the site of the abdominal wall defect. Her medical history included hypertension and angina pectoris. Upon presentation, vital signs were stable: blood pressure 150 mmHg, heart rate 75 beats per minute, respiratory rate 16 breaths per minute, and temperature 36.3 °C. Laboratory results were as follows: white blood cell count, 7.56×103/μL; hemoglobin, 12.8 g/dL; platelet count, 262×103/μL; and C-reactive protein, 3.57 mg/dL (reference range, 0–0.3 mg/dL).
Therapeutic intervention
Open repair of the anterior abdominal wall hernia was performed via a low midline incision, revealing a transverse rupture approximately 12 cm in length in the left rectus muscle below the umbilicus, as well as extensive injury to subcutaneous fat. Exploration of the small bowel, extending from the ligament of Treitz to the ileocecal valve, showed multifocal mesenteric hematomas without impairment of bowel perfusion or other intra-abdominal injuries (Fig. 3).
In this case, fascial reconstruction was feasible without prosthetic reinforcement (e.g., mesh) since no significant fascial tissue loss was noted. Subsequently, negative pressure wound therapy was employed due to severe edema, exudation in the subcutaneous fat, and extremely thin skin at the site of direct trauma. Skin closure was completed 2 days later (Fig. 4).
Follow-up and outcomes
The patient was discharged without complications on postoperative day 10 (Fig. 5). At the 1-week follow-up visit, there were no abnormal postoperative findings.
DISCUSSION
TAWH is a rare injury, accounting for only about 1% of blunt trauma admissions [1]. TAWH was first described by Shelby [2] in 1906 and subsequently defined by Damschen et al. [3] as "herniation through disrupted musculature and fascia with adequate trauma, without skin penetration, and no evidence of a prior hernia defect at the site of injury." Although handlebar hernias are more frequently reported, TAWH resulting from cow horn injuries is exceedingly rare [4,5]. In these cases, deeper tissue layers may sustain significant damage despite relatively minor superficial wounds [5]. Our case exemplifies how cow horn trauma can cause severe fascial disruption with minimal external signs, highlighting the importance of maintaining a high level of clinical suspicion and utilizing detailed imaging.
A reducible bulging mass or palpable abdominal wall defect may indicate a hernia, but nonspecific symptoms such as pain, bruising, or abdominal distension may obscure the injury's full extent [6–8]. In our patient, initial management was conservative due to the absence of overt skin lacerations or immediate hemodynamic instability. However, persistent and worsening pain necessitated further imaging studies. A CT scan confirmed the diagnosis of TAWH and ruled out significant injury to intra-abdominal organs [9,10].
Several classification schemes have been proposed to capture the complexity and variability of TAWH [11,12]. A CT-based grading system, ranging from subcutaneous tissue contusion (grade I) to complete abdominal wall disruption with evisceration (grade VI), was proposed by Dennis et al. [13]. While valuable for describing the extent of fascial disruption, such grading systems do not always provide definitive guidance regarding the necessity of urgent surgical intervention [11,14]. In this case, the patient’s injury was graded as grade V, and the defect's size, along with worsening symptoms, supported the decision for immediate operative repair.
The therapeutic strategy—early or delayed, open or laparoscopic, and with or without prosthetic materials—should primarily depend on the patient’s hemodynamic stability, the defect's size, timing of diagnosis, and associated injuries [11]. While delayed repair may be appropriate in certain stable patients with smaller defects, immediate surgical exploration is often warranted for large defects or significant clinical concerns. In this case, early operative management prevented complications related to potential muscle retraction and atrophy, which can complicate later closures.
Our findings suggest that a standardized protocol incorporating early imaging and clear surgical indications could optimize outcomes for TAWH, particularly in regions where cow horn injuries might occur more frequently. Future research elucidating the biomechanical forces involved in horn impacts may provide additional insights into these injuries, potentially improving diagnostic and intervention strategies.
In conclusion, diagnosing and managing TAWH remains challenging due to its rarity and nonspecific presentation. Patients with cow horn–induced TAWH and relatively minor superficial injuries may harbor significant deep fascial disruptions. Therefore, maintaining a high clinical suspicion, performing thorough imaging evaluations, and making management decisions based on precise assessments of the abdominal wall defect via CT are crucial.
ARTICLE INFORMATION
Author contributions
Conceptualization: CYP; Methodology: CYP; Investigation: all authors; Writing–original draft: HS; Writing–review & editing: CYP. All authors read and approved the final manuscript.
Conflicts of interest
The authors have no conflicts of interest to declare.
Funding
The authors received no financial support for this study.
Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
Fig. 1.
Bruising and distension observed in the left lower abdomen.
Fig. 2.
Abdominal computed tomography scan demonstrating a 5.5×3.4-cm defect in the left lower abdominal wall (white arrow) and herniation of the small bowel segment (red arrow).
Fig. 3.
Intraoperative findings. (A) A 12-cm transverse rupture in the left rectus muscle below the umbilicus with significant subcutaneous fat injury. (B) Multifocal hematomas in the mesentery of the small bowel.
Fig. 4.
Wound closures. (A) Negative pressure wound therapy after repair of the left rectus muscle. (B) Skin closure performed 2 days after the hernia repair.
Fig. 5.
Follow-up abdominal computed tomography scan on postoperative day 9 showing no abnormal findings.
REFERENCES
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Traumatic abdominal wall hernia associated with a cow horn in Korea: a case report
Fig. 1. Bruising and distension observed in the left lower abdomen.
Fig. 2. Abdominal computed tomography scan demonstrating a 5.5×3.4-cm defect in the left lower abdominal wall (white arrow) and herniation of the small bowel segment (red arrow).
Fig. 3. Intraoperative findings. (A) A 12-cm transverse rupture in the left rectus muscle below the umbilicus with significant subcutaneous fat injury. (B) Multifocal hematomas in the mesentery of the small bowel.
Fig. 4. Wound closures. (A) Negative pressure wound therapy after repair of the left rectus muscle. (B) Skin closure performed 2 days after the hernia repair.
Fig. 5. Follow-up abdominal computed tomography scan on postoperative day 9 showing no abnormal findings.
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Fig. 4.
Fig. 5.
Traumatic abdominal wall hernia associated with a cow horn in Korea: a case report
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