Traumatic Anterior Abdominal Wall Hernia

Traumatic Anterior Abdominal Wall Hernia

1. Lump left Iliac Fossa CLINICAL CASE PRESENTATION UNIT A Presenter: Dr.Akshay Anand (JR 3) Department of Surgery Institute of Medical Sciences Banaras Hindu University Varanasi 221005

2. A 25 -year female , Hindu, student , Resident of Ramnaga r, UP presented to Surgery Outpatient Department Chief Complaints: Swelling in left lateral part of abdomen x 7 months

3. History of Present Illness As stated by patient she was apparently asymptomatic 7 months back when she noticed- Swelling in left lower abdomen x 7 months Insidious onset and g radually progressive Reducible H/O bowel evisceration following RTA Not associated with pain, or any other lump A ggravat ed on standing, coughing and straining, No history s/o any obstructive symptom

4. Negative history No H/o of burst abdomen or wound infection No f/s/o presence of foreign body at surgical site No H/o chronic bronchitis ,constipation No H/ o of urinary complaints No p ostprandial fullness and early satiety No H/o vomiting/ n on-passes of flatus and stool

5. Past history H/O Road traffic accident 8 months back(Evisceration of bowel in left illiac fossa with b/l 3 rd ,4 th ribs fracure with proximal Rt tibia and fibula# Managed with EL with PL with primary repair of two perforations adjacent to splenic flexure with diversion loop ileostomy 01/08/23 Ileostomy takedown done on on 31/10/23

6. Personal history Vegetarian diet Normal bowel and bladder habits No history of substance abuse There is no known food or drug allergy Sleep wake cycle is normal

7. Family history There is no history of similar illness in family member No H/o Tuberculosis, cancer or cancer related death in family

8. Summary A 25 year female presented with swelling in left lower abdomen since 7 month which was insidious in onset gradually progressive , a ppeared post trauma and gets a ggravat ed on standing, coughing and straining,disappears by itself on lying down not associated with any pain,fever or any other lump N o h/o intestinal obstruction

9. General Examination Patient is examined in well lit room with informed consent. Sh e was co-operative and well oriented to time, place and person, average built Vitals : Afebrile, Pulse:88/min, regular, normo- volumic Blood pressure:114/74 mmHg Respiratory rate: 16/min, thoracoabdominal ECOG - 1 BMI: 1 8 kg/m 2 No pallor, icterus, clubbing, cyanosis, pedal edema or any generalized lymphadenopathy

10. Inspection Abdomen: Flabby 6 x6 cm swelling in lef t hypochondrium and subcostal region region is visible on coughing and straining and reduces spontaneously with normal overlying skin without any scar mark Cough impulse present Umbilicus is centrally placed, inverted. All quadrants moving proportionally with respiration. Local Examination

11. Inspection A vertical midline scar mark of size 8 cm present with one 6 cm scar present in left lumbar region of previous trauma and 5 cm scar of stoma reversal present in right illiac fossa No visible pulsation/peristalsis/venous engorgement Hernial sites intact

12. Palpation Abdomen is soft, no tenderness present with normal temperature A well defined swelling (approx. 6 x 6 cm) palpable in left hypochondrium palpable on coughing and straining and reduces spontaneously A one finger defect palpable in left subcostal region Overlying skin was normal No other lump or organomegaly palpable Hernial orifices intact.

13. Percussion Splenic dullness not present No evidence of free fluid Auscultation Normal bowel sound audible

14. Renal angle: Non-Tender ,no fullness present Spine : Normal External genitalia : Normal Inguinal lymph nodes: Not palpable Left Supraclavicular nodes :Not palpable

15. Digital Rectal Examination(DRE) & Proctoscopy Normal anal tone No growth or deposits Faecal staining present No blood stain

16. Other systemic examination CNS – Higher mental function-WNL, Motor and sensory system intact CVS- S1 and S2 heard, No murmurs. Respiratory system- B/L equal air entry present - No added sounds

17. Summary A 25 year female presented with swelling in left lower abdomen since 7 month which was insidious in onset gradually progressive , appeared post trauma and gets a ggravat ed on standing, coughing and straining,disappears by itself on lying down not associated with any pain,fever or any other lump On examination: 6 x 6 cm swelling in lef t hypochondrium and subcostal region region is visible on coughing and straining and reduces spontaneously with normal overlying skin

18. Differential Diagnosis Incisional hernia Superior Lumbar hernia TAWH

19. Investigations CBC : RFT: Hb- 9.54 gm/dl Ur/Cr- 12.6 /1. 2 mg/dl TLC- 9090 /mm 3 Na- 1 37 mEq/L DLC- 6 2 / 28 / . 5 4 K- 3.4 mEq/L PLT- 15800 /microlitre LFT: PT/INR :16.9/1.36 SGPT/SGOT- 11 / 27 .0 IU/L TB/DB : 0. 5 /0. 3 mg/dl Viral markers : NR ALP- 200 IU/L TP/ALB- 6.7 / 3.7 g/dl

20. Ultrasonography Left lumbar region in subcostal area (L1)shows a defect in the intermuscular plane measuring 1.39 x 0.88 cm through which there is indentation of the omental fat only during valsalva maneuver which reduces back spontaneously at the end of maneuver F/S/O left lumbar hernia

21. Onlay mesh hernioplasty done on 24/04/24 Management

22. Thankyou