Traumatic abdominal wall hernia classification.

To the Editor: Recently, Liasis et al. published a review article entitled ‘‘Traumatic abdominal wall hernia: is the treatment strategy a real problem? ’’ The article was written superbly, and it was the first and the largest review on this subject matter. However, it would be unfair and incomplete if we do not inform the Journal and the readers that the study was not fully inclusive of all the literature simply because of overlooked terminology. We also would like to suggest a different classification of traumatic abdominal wall hernia (TAWH), based on our own institution’s experience using the principle of biomechanism. Finally, we also want to bring the attention of our reader to the existence of the most severe form of TAWH, which we previously coined as ‘‘a seat belt lethal triad. ’’ Supplemental Digital Content (SDC) 1, http://links.lww. com/TA/A292 lists several other case reports and a case series of TAWH that came under a terminology other than TAWH, traumatic handle bar hernia, and traumatic ventral herniaVthe search terms that were used in the study of Liasis et al. Our own institution had previously published our experiences of specific type of TAWH. Our series was actually the second largest series (n = 30 patients); only Netto et al. have reported a similar but a larger series (n = 34) of TAWH. However, in ours and several others, instead of using the term TAWH, we have used the term traumatic flank hernia, abdominal wall injuries, and/or disruption because of the typical location of this injury and the ability to detect this injury early during its acute presentation. Furthermore, Liasis et al. excluded the ‘‘lumbar hernia’’ studies from their review, but this would leave out several relevant articles (SDC 1, http://links.lww.com/TA/A292). Liasis et al. may have been misled by the term lumbar hernia. In the study by Esposito et al. the authors first defined the anatomy of the traumatic ‘‘lumbar hernia’’ but actually divided it into a ‘‘superior’’ and ‘‘inferior’’ triangle. Many TAWHs, at least those similar to the one presented in the case report by Esposito et al., always located in the ‘‘inferior’’ lumbar triangle, often related to a motor vehicle collision (MVC) and a seat belt use. This type of injury is actually located more toward the flank and the anterior of the abdomen, as in our own experiences and by other series that however used the term traumatic ‘‘lumbar hernia’’ (SDC 1, http://links.lww.com/TA/A292). The TAWH in the superior lumbar triangle alone is very uncommon; in our own experience, it usually represents a severe form of injury that extends from the inferior triangle. Altogether, because of this difference in terminology, there are additional 50 cases of TAWH that were not included in the study of Liasis et al., bringing the total existing cases of TAWH reported in the literature to at least 298 cases. Moreover, in the review article of Liasis et al., the authors have hinted of previous TAWH classification based on a historical form, using location, force, hernia size, mechanism, or type of accident (Table 1 in their article). However, the authors did not provide a succinct classification that would be practical and useful for clinicians. We believe that all TAWHs usually fall under three classifications or headings based on the biomechanism and the principle of imparted energy: 1. A blunt direct forceVthis represents the typical handle bar injury, the animal gore, or any blunt direct force to the abdominal wall. The injury or the hernia tends to be isolated, and the location of the hernia tends to be wherever the force is directed, that is, specific abdominal wall region, inguinal, and so on. Many of these types of TAWHs were listed in the study references of Liasis et al. 2. A sudden increase in intra-abdominal pressure forceVthis usually represents the high energy, high impact of blunt force as often seen in an MVC (but nonY seat beltYrelated), a high fall, a high-speed motorcycle collision, or an auto versus pedestrian. The nature of this hernia often occurs in the presence of multiorgan injury, and the hernia is usually located in the bilateral lower quadrant regions (SDC 1, http://links.lww.com/TA/A292). 3. An acceleration-deceleration shear and compressive force of the seat beltVthis probably represents the most common subtype of TAWH that we and others see, and it usually occurs in an MVC, and it is seat belt related. We do not see reports of this subtype of TAWH in a pediatric population, although most of the seat belt syndromeYrelated injuries are often reported in the pediatric population. It is either because children’s abdominal wall is very compliant that they do not get TAWH or because the incidence is just underdiagnosed. We believe that by grouping all TAWHs under this classification, it will allow clinician to better predict, diagnose, and prioritize the management of TAWH accordingly. Lastly, we just want to bring the attention of the journal readers to the existence of the most lethal form of TAWH. It is a constellation of TAWHs with other abdominal organ injuries in which we have previously coined the condition ‘‘seat belt lethal triad. ’’ The injuries include TAWH (abdominal wall disruption, Grade IV or V), hollow viscus injury, and abdominal vascular injury. We have previously reported a four-case series and reminded the clinician that the abdominal vascular injury can be easily missed. In conclusion, it is in our opinion that the review article by Liasis et al. was a thorough and extensive review of this subject. However, it would be misleading if we do not point out our own and other’s experiences of TAWH just because a different terminology was used. Our suggested classification of TAWH is all inclusive and has practicality for the clinician in terms of diagnosis and management. Finally, although rare, the existence of TAWH-related lethal triad is real, and all trauma surgeons need to be aware. *The authors declare no conflicts of interest.