traumatic abdominal wall hernia ( tawh ) has been defined as  herniation through disrupted musculature and fascia associated with adequate trauma , without skin penetration , and no evidence of a prior hernia defect at the site of injury . they are rare and over the past century 50 have been reported in the literature . some reports advocate a conservative approach with operative intervention at a later stage if indicated , whereas others have promoted immediate surgical intervention . we present a case of a 27-year - old male with significant disruption to his anterior abdominal wall with associated thoracoabdominal injuries who was managed operatively . a 27-year - old male with no past medical history was the driver and sole occupant of a car which crashed through a fence at 80 kph and hit a lamp post . he was wearing a seatbelt , the airbags did not deploy and despite the significant intrusion into the passenger space , he extricated himself unaided . the primary survey identified decreased air entry at the base of the right lung and right - sided abdominal and lower chest tenderness . abrasions were evident over the anterolateral abdominal wall and a large , right - sided abdominal swelling was noted . trauma series computed tomography ( ct ) scans demonstrated a flail segment between the sixth and eight ribs with disruption of the intercostal muscles and a small right haemothorax ( fig . the right abdominal wall was ruptured  the right rectus abdominis muscle had been torn from its costal attachments to the midpoint . the hepatic flexure of the colon had herniated through the intercostal muscles of the eighth and ninth ribs and was lying adjacent to the fractured ribs ( fig . 1c ) . both small and large bowel had herniated through the abdominal wall lateral to rectus abdominis , but remained covered by external oblique ( fig . herniation of small and large bowel immediately adjacent to the fractured ribs raised the suspicion of occult bowel injury not detected on ct . figure  1:(a  d ) initial ct imaging performed as part of the secondary survey . ( a  d ) initial ct imaging performed as part of the secondary survey . the ribs were re - opposed with absorbable polyglycolic acid sutures and a chest drain inserted . at laparotomy , it was noted that the hernia sac contained omentum , the bowel having reduced spontaneously under general anaesthesia . a small rent in the mesentery of the proximal small bowel was noted . the abdominal defect was repaired with a 20  30 cm sheet of cross - linked acellular porcine dermal collagen ( permacol , covidien , gosport , hants , uk ) which was sutured to the margins of the fascial defect with interrupted nylon sutures , using a  bridge technique , with a 5-cm underlay on the left . post - operatively , the patient was managed in the intensive care unit for 24 h. a seroma that developed at the hernia site after 1 week was treated conservatively . sitting up from lying down position and hip flexion caused difficulty , but improved with intensive physiotherapy . he had a persistent seroma at the hernia site . a repeat ct of the thorax and abdomen at 10 weeks demonstrated no residual defect in the anterior abdominal wall and resolution of the seroma ( fig .  2 ) . tawh remains a rare clinical entity and insufficient evidence exists to provide clear protocols for surgical management . there are three key issues in managing this condition : whether to operate or not , which reconstructive technique to use and which mesh to use , if any . there are case reports where a conservative approach has been adopted , although these are mainly in the paediatric group and are secondary to handlebar type injuries with minimal disruption to the abdominal cavity [ 3 , 4 ] . a conservative or delayed operative management strategy for low energy tawh may be feasible , but high - energy tawh are often associated with significant intra - abdominal injuries and an operative approach via midline laparotomy has been advocated . for incisional hernia repair , the use of mesh has become the gold standard because of a significant reduction in recurrence rates compared with primary suture repair . synthetic meshes are , however , associated with complications including erosion , fistulation and chronic infection . due to the potential for contamination in cases of high - energy tawh repair , a primary suture repair technique has been recommended by some authors because of the high ( 50% ) wound infection rate even when mesh was not used . primary suture repair may not be feasible if there is substantial domain loss . it would also be contraindicated if the lateral abdominal wall muscles have retracted and require component separation , as in our case . the potential for contamination , high rates of wound infection and the need to place mesh adjacent to recently herniated bowel raises a debate between the merits of synthetic and biologic meshes . abdominal wall repair with both absorbable and non - absorbable synthetic meshes in the presence of contamination has led to high rates of mesh infection , fistulation and even death . biologic meshes provide a collagen scaffold for native tissue to infiltrate and they are remodelled over time . a recent systematic review has demonstrated that cross - linked biologic meshes can be used with low rates of hernia recurrence and few complications . we utilized cross - linked acellular porcine dermis ( permacol , covidien , gosport , hants , uk ) , which has been reported to have a degree of resistance to bacterial collagenase activity and the optimum durability for effective hernia repair whilst still allowing native tissue ingrowth . management strategies should be tailored to the individual patient , but tend to favour operative intervention . in view of the high risk of wound infection there are case reports where a conservative approach has been adopted , although these are mainly in the paediatric group and are secondary to handlebar type injuries with minimal disruption to the abdominal cavity [ 3 , 4 ] . a conservative or delayed operative management strategy for low energy tawh may be feasible , but high - energy tawh are often associated with significant intra - abdominal injuries and an operative approach via midline laparotomy has been advocated . for incisional hernia repair , the use of mesh has become the gold standard because of a significant reduction in recurrence rates compared with primary suture repair . synthetic meshes are , however , associated with complications including erosion , fistulation and chronic infection . due to the potential for contamination in cases of high - energy tawh repair , a primary suture repair technique has been recommended by some authors because of the high ( 50% ) wound infection rate even when mesh was not used . it would also be contraindicated if the lateral abdominal wall muscles have retracted and require component separation , as in our case . the potential for contamination , high rates of wound infection and the need to place mesh adjacent to recently herniated bowel raises a debate between the merits of synthetic and biologic meshes . abdominal wall repair with both absorbable and non - absorbable synthetic meshes in the presence of contamination has led to high rates of mesh infection , fistulation and even death . biologic meshes provide a collagen scaffold for native tissue to infiltrate and they are remodelled over time . a recent systematic review has demonstrated that cross - linked biologic meshes can be used with low rates of hernia recurrence and few complications . we utilized cross - linked acellular porcine dermis ( permacol , covidien , gosport , hants , uk ) , which has been reported to have a degree of resistance to bacterial collagenase activity and the optimum durability for effective hernia repair whilst still allowing native tissue ingrowth . management strategies should be tailored to the individual patient , but tend to favour operative intervention . in view of the high risk of wound infection
traumatic abdominal wall hernias ( tawhs ) are rare 
 . they can arise from either high or low impact trauma and can be associated with significant associated injury . 
 we present the case of a 27-year - old male involved in a high - impact road traffic accident resulting in a tawh . 
 he sustained significant disruption to the abdominal wall and sustained injuries to the thoracic cage . 
 operative management was undertaken with a porcine dermal collagen mesh , using a bridge technique .