Post-bullhorn Injury Abdominal Wall Hernia: Role of Laparoscopic Tissue Repair

1. Traumatic abdominal wall hernias (TAWHs) are relatively uncommon entities that
have been reported to occur due to motor vehicle accidents, seat-belt injuries,
handle-bar injuries and bullfighting. Bullhorn-injury associated traumatic hernia
(BATH) due to blunt injury leading to TAWH is a rather uncommon mechanism. We
report here a case of a middle-aged male who presented on seventh day following
bullhorn injury with a swelling above right groin.
.
Introduction
A43 years male came to us with five-day history of painful swelling above right groin
which appeared on coughing and straining only. He further told that he was hit by a
bull using its horn at the same site 1-week back. Patients all vitals were within normal
limit and abdomen was soft, non-distended and non-tender. Clinical features (Figure
1) and radiological features (Figure 2) of the patient are summarized. Since the
patient was hemodynamically stable, patient was planned for laparoscopic repair of
defect after few weeks. Patient underwent laparoscopic transperitoneal anatomical
repair of hernial defect. Per-operative findings and procedure performed are
demonstrated in Figure 3. Patients post-operative period was uneventful and patient
was discharged on day-3. Patient has been in follow-up for last six months without
any reported complication.
Case Report
Bullhorn-injury associated traumatic hernia (BATH) occurs as a result of direct blow by
the horn of a bull, which compromises the integrity of muscles and fascia at weaker points
(1-6)
of abdominal wall. Only six such cases have been previously reported. BATH needs to
be recognized as a separate sub-category among TAWHs due to the great force
generated at the small area of impact. Bullhorn blunt injuries can be high-impact or low-
impact (as was our case). High-impact injuries, suspected major intra-abdominal injuries
and patients with unstable vitals must undergo immediate exploration. USG is the first
investigation in all such cases but CT scan is the investigation of choice over MRI as it can
be used in emergency settings as well. Laparoscopic repair of TAWH have been
described with reliable repair of defects and optimal outcome but in almost all cases
mesh repair has been the preferred option even if the patient has presented
(7) (8)
immediately. Honaker et al. reported a recurrence rate of 8.3% in 38 cases of TAWH,
with all the recurrences occurring in patients undergoing immediate repair. Coleman et
(9)
al. reported a recurrence rate of 26% for TAWH in 80 cases with acute repair being
(10)
associated with majority of the recurrences. Even, Damschen et al. recognized that
immediate surgery does not prevent late sequelae. This again reinforces our concept of
relatively delayed repair. Laparoscopic facilities are now available even in emergency
settings at many centres and owing to its obvious advantages, needs to be used in these
patients judiciously. This is the first case of BATH managed laparoscopically and first
case of TAWH in adults managed by laparoscopic anatomic tissue only repair.
Discussion
Images
Figure 1: A - Bullhorn-associated traumatic hernia above right inguinal
region with healing bruise at lower part of swelling with a suprapubic scar
of previous cystolithotomy; B – Site of laparoscopic ports
Figure 2: CECTAbdomen showing the hernial defect of about 2 cm just
above the right inguinal region
Figure 3: A- Split defect in the fascial and muscle layer;
B - Laparoscopic anatomic repair of hernial defect with polypropylene 1-0
sutures
Flowchart 1: Management algorithm of a patient of BATH
Presentation
Immediate Delayed
Evaluate the
hernial defect
size, location,
contents by
CECT
Unstable Stable
Emergency
Exploration with
anatomical/mesh
repair of hernial
defect depending
upon size of defect
and local tissue
strength, hematoma,
laceration
CECT
Abdomen
No intra-
abdominal
injury or injury
that can be
managed
conservatively
Major/operable
abdominal
injury
Managepatient
conservatively
for 3-4 weeks Delayed
anatomical
(=2cm
defect)/mesh
repair (>2 cm
defect);
laparoscopic
> open
Usually no
major or
associated
injury
and/or
stable
patient
Proposed Management Algorithm
Bullhorn injury is an uncommon mechanism of development of traumatic hernia
and may present as isolated muscle and fascial splitting. Patients presenting late but
with stable vitals can be managed by delayed elective repair of hernial defect.
Laparoscopic anatomical tissue repair using a non-absorbable suture is a valid and
feasible option in such small defects which are not associated with formation of a
definitive hernial sac.
Conclusion
1. Comin Novella L, del Val Gil JM, Moreno Muzas C, Oset Garcia M. The bull: the great danger of
summer festivals. Cirugia espanola. 2008;83(4):215.
2. Singal R, Dalal U, Dalal AK, Attri AK, Gupta R, Gupta A, et al. Traumatic anterior abdominal wall
hernia: A report of three rare cases. Journal of emergencies, trauma, and shock. 2011;4(1):142-
5.
3. Chate N, Deshmukh S, Dange A. Inguinal hernia resulting from bull horn injury. ANZ J Surg.
2011;81(12):943.
4. Singh B, Kumar A, Kaur A, Singla R. Bullhorn hernia: A rare traumatic abdominal wall hernia.
Nigerian Journal of Surgery. 2015;21(1):63-5.
5. Nirhale D, Athavale V, Bhatia M, Tomar V. Silent traumatic hernia. Sudan Medical Monitor.
2015;10(4):137-9.
6. Dharap SB, Noronha J, Kumar V. Laparotomy for blunt abdominal trauma-some uncommon
indications. Journal of emergencies, trauma, and shock. 2016;9(1):32-6.
7. Wilson KL, Davis MK, Rosser JC, Jr. A traumatic abdominal wall hernia repair: a laparoscopic
approach. JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of
Laparoendoscopic Surgeons. 2012;16(2):287-91.
8. Honaker D, Green J. Blunt traumatic abdominal wall hernias: Associated injuries and optimal
timing and method of repair.The journal of trauma and acute care surgery. 2014;77(5):701-4.
9. Coleman JJ, Fitz EK, Zarzaur BL, Steenburg SD, Brewer BL, Reed RL, et al. Traumatic
abdominal wall hernias: Location matters. The journal of trauma and acute care surgery.
2016;80(3):390-6; discussion 6-7.
10.Damschen DD, Landercasper J, Cogbill TH, Stolee RT. Acute traumatic abdominal hernia: case
reports.The Journal of trauma. 1994;36(2):273-6.
References
Thank You
Post-bullhorn Injury Abdominal Wall Hernia:
Role of Laparoscopic Tissue Repair
Dr Kaushal Deep Singh, Dr Vikas Singh
Uttar Pradesh University of Medical Sciences, Saifai, Etawah