The methodology of this study was approved by the institutional review board for the protection of human subjects at the University of Oklahoma (IRB# 13620).
Patient A:
Patient A was a 7-year-old boy who presented to our Level 1 Trauma facility after being a restrained backseat passenger in a Motor Vehicle Collision (MVC). Prior to arrival, pre-hospital personnel noted a leftward spine deformity and lower extremity motor and sensory deficits. Upon arrival, the patient had a Glasgow Coma Scale (GCS) of 15 and was hemodynamically stable, but was noted to have a seat-belt sign across the abdomen. The patient had no sensation or motor capacity in bilateral lower extremities. CT scans were performed and the patient was noted to have bilateral pneumothoraces, hemo- and pneumoperitoneum, mesenteric contrast extravasation, and multiple cervical, thoracic and lumbar spine fractures. Due to a worsening abdominal exam as well as concerning CT findings, the patient was taken to the operating room (OR) for an exploratory laparotomy. Operative findings included a large bucket-handle deformity in the mid-small bowel with devitalized segments of large and small intestine, a periduodenal hematoma, and a right traumatic lumbar hernia. Bowel resection of devascularized intestine was performed along with abdominal packing and partial re-approximation of the lumbar hernia before the patient became hypothermic. Temporary abdominal closure was performed and he was transferred to the pediatric intensive care unit (PICU) for rewarming and resuscitation. The following day, he returned to the OR with Neurosurgery for fusion of his multiple cervical, thoracic, and lumbar fractures. One day later the patient returned to the operating room for repeat exploratory laparotomy with bowel re-anastomosis, and definitive repair of the lumbar hernia using a tension free primary closure technique with interrupted permanent suture. At this time, the abdomen was noted to have inadequate domain due to intraabdominal swelling and could not be closed. Consequently, a temporary abdominal closure was replaced at this time, and he returned 2 days later for definitive closure and ostomy creation. The patient remained in the hospital until his ostomy was productive, pain was well controlled, and he was able to tolerate a peroral (PO) diet. He remained paraplegic despite the spinal fusions. He was discharged on hospital day 22 to a rehabilitation center.
Patient B:
Patient B is a 9-year-old boy who presented as the restrained backseat passenger in an MVC. He was noted to be hypotensive at the scene of the event and received 1-unit of packed red blood cells (pRBC) prior to arrival. His GCS was recorded as 12 en route and he was noted to have a palpable step-off deformity of the lumbar spine. Upon arrival, the patient remained hypotensive and his FAST (Focused Assessment with Sonography in Trauma) exam was positive in the right upper quadrant. He was noted to have an abdominal seat-belt sign on secondary exam. After further blood product administration, his blood pressure normalized and his GCS improved. He underwent CT scan of his head, chest, abdomen/pelvis, and spine. Imaging revealed a small subdural hemorrhage, bilateral pneumothoraces with pulmonary contusions, rib fractures, moderate volume hemoperitoneum, grade II renal laceration, traumatic herniation of the right lateral abdominal wall with herniation of fat and bowel, an acute Chance fracture of L3, nondisplaced fracture of L2, and a left humerus fracture (Figure 1).
Due to these findings, he was taken to the OR for an exploratory laparotomy. Operative findings included moderate hemoperitoneum, a large mesenteric hematoma, bucket-handle small bowel injury, bleeding from the right colic artery, active retroperitoneal bleeding, and a right sided lumbar hernia. Resection of the devitalized portion of small bowel was performed along with repair of the right colic artery. The bowel was left in discontinuity. Due to hemodynamic instability as well as continued bleeding from the right retroperitoneum, the right lower quadrant was packed and a temporary abdominal closure was performed. The patient was then transported to the PICU for further resuscitation. Twenty-four hours later, the patient returned to the OR and side-to-side anastomosis of small bowel was performed. At that time, a devitalized section of the right colon was noted and resection and re-anastomosis was performed. The right lumbar hernia was also repaired primarily with several interrupted slowly dissolvable sutures. The bleeding from the right retroperitoneum was well controlled after packs were removed, but small bowel remained dusky and the decision was made to continue with temporary abdominal closure and repeat examination in 24-48 hours. Upon repeat laparotomy, one portion of the small bowel remained ischemic and a resection with anastomosis was performed. The abdominal wall was then closed at this time. A Morel-Lavallee degloving lesion was also noted and a negative pressure wound therapy (NPWT) system was placed. He returned to the OR several days later for NPWT dressing change as well as open reduction and internal fixation of his left humerus and operative repair of his L3 Chance fracture. The patient progressed well, but remained paraplegic in his lower extremities. He was discharged to a rehabilitation facility on hospital day 29.
Patient C:
Patient C is a 5-year-old boy who presented as an unrestrained passenger involved in an MVC. He initially complained of back pain and abdominal pain, but otherwise had a GCS of 15 and was neurologically intact. Upon arrival to the emergency department, he was hemodynamically stable and the only remarkable finding was spinal tenderness. He denied lower extremity paresthesia and was able to move all extremities. Initial FAST exam was negative. He underwent CT imaging and was found to have facial fractures, moderate volume intraperitoneal free fluid, traumatic herniation of the left lateral abdominal wall, acute Chance fracture of L2 with retropulsion, L1 spinous process fracture, and left rib fractures (Figure 2).
Due to the patient developing hypotension, a repeat FAST exam was performed revealing fluid in Morison’s pouch. The patient was taken to the OR for an exploratory laparotomy and was found to have a mesenteric hematoma, a bucket-handle small bowel injury, and bilateral lumbar hernias. Necrotic small bowel was noted and a resection with primary anastomosis was performed as well as repair of bilateral lumbar hernias using a primary tissue repair with interrupted slowly absorbable suture. The abdomen was closed and the patient was transported to the PICU for further resuscitation. Two days later he returned to the OR for thoracolumbar fusion with Neurosurgery. He progressed accordingly and was able to tolerate a diet and ambulate with physical therapy. He was discharged to a rehabilitation facility on hospital day 9 with ongoing left lower leg weakness.
Review of Literature:
One of the first incidences of a TLH in the literature was described in 1973[6]. This involved the case of a 5-year-old male after being run over by a truck. He suffered a devastating rectal injury, pelvic fractures, and denervation of sacral nervous plexus. A laparotomy was performed visualizing these injuries along with a tear of the left psoas muscle with complete division at the pelvic brim. This was not repaired during the initial laparotomy, but after the development of obstructive symptoms and a large flank bulge, a second operation revealed a left lateral/flank abdominal wall hernia at the site of the torn psoas muscle. Multiple dilated loops of bowel were found between skin and musculature.
A second case also described a posterolateral herniation after a high-speed MVC in an 11-year-old boy[7]. The initial physical exam revealed an obese abdomen with an obvious seat-belt sign, but no tenderness or masses were noted. He presented with a distracting left arm deformity and severe pain in that extremity. Ultimately, a CT of the abdomen was obtained showing a hernia in the right lateral abdominal wall containing ascending colon and terminal ileum. He was then taken to the operating room for exploratory laparotomy and an ileomesenteric and sigmoid mesenteric devascularization was discovered in addition to the large right sided lumbar hernia. A bowel resection was performed as well and primary closure of the hernia defect with interrupted suture. The patient progressed well after the operation and was discharged home on post-operative day 9.
The third case described a 7-year-old boy who presented to a trauma center after high impact MVC [8]. He was a restrained passenger and presented with a seat-belt sign and abdominal tenderness. CT scan showed intraabdominal free fluid and a left posterolateral lumbar herniation. The patient developed peritonitis and was taken to the OR where a laparotomy was performed and three bowel injuries were repaired along with a left hemicolectomy and primary anastomosis due to devitalized colon. The left lumbar hernia was reapproximated via a primary tissue repair. No additional injuries were reported. His post-operative course was unremarkable and he was discharged on the 9th postoperative day.