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JOURNAL READING

Large Bowel Perforation in an Acute Inguinal Hernia Resulting from Blunt

Abdominal Trauma

DISUSUN OLEH:

Hartas Zasika Ekos Ari 08700127

PEMBIMBING:

dr. M. Ali Yusni, Sp.B

BAGIAN BEDAH UMUM SMF ILMU BEDAH

RSUD dr. MOH. SALEH PROBOLINGGO

FAKULTAS KEDOKTERAN

UNIVERSITAS WIJAYA KUSUMA SURABAYA

TAHUN 2014

HALAMAN PENGESAHAN

JOURNAL READING : “Large Bowel Perforation in an Acute Inguinal Hernia Resulting from

Blunt Abdominal Trauma”

Telah disetujui dan disahkan pada :

Hari :

Tanggal :

Sebagai syarat kepaniteraan klinik SMF Ilmu Bedah RSUD dr. Moh Saleh Kota

Probolinggo Fakultas Kedokteran Universitas Wijaya Kusuma Surabaya.

MENGETAHUI :

Dokter Pembimbing

dr. M. Ali Yusni, Sp. B

IBIMA Publishing

International Journal of Case Reports in Medicine

http://www.ibimapublishing.com/journals/IJCRM/ijcrm.html

Vol. 2013 (2013), Article ID 439839, 4 pages

DOI: 10.5171/2013.439839

Laporan Kasus

Perforasi Usus Besar Pada Hernia Akut Inguinal

Akibat Trauma Tumpul Abdominal

Amit Kumar C Jain and S. Viswanath

Departemen Ilmu Bedah, Fakultas Kedokteran St. John’s , Jalan Sarjapur , Karnataka, India yang

ditujukan kepada: Amit Kumar C Jain; [email protected] 10 Juli 2013; Diterima 9

September 2013; Diterbitkan 30 November 2013 Academic Editor: Faruk Coskun.

Copyright © 2013 Amit Kumar C Jain and S. Viswanath. Didistribusikan dibawah kreatif common

CC-BY 3.0

Abstrak

Hernia Abdominal Traumatis adalah suatu keadaan yang jarang kurang dari 70 kasus yang dilaporkan, meskipun ada peningkatan insiden trauma. Sering kali, trauma ke perut mengakibatkan kerusakan organ padat atau berongga. Trauma menyebabkan Hernia pada Abdomen disebabkan oleh dampak tekanan tinggi atau rendah . pada jurnal ini melaporkan kondisi yang sangat jarang dimana ada cedera tumpul ke perut yang mengakibatkan hernia inguinalis akut dengan perforasi kolon sigmoid , usus kecil, dan bagian dari kandung kemih beserta isinya. Untuk pengetahuan kita, ini adalah kasus pertama yang telah didokumentasikan oleh kami.

Kata kunci: Trauma, hernia inguinalis, perforasi.

Pendahuluan

Trauma Tumpul Abdominal (TTA) dapat menyebabkan sebuah kerusakan atau efek geser yang mengakibatkan kerusakan viscus berongga atau padat viscera (Biswas 2010, dari Eddie 2012). Sekitar jumlah 5% pasien dengan trauma tumpul memiliki luka pada mesentrium dan usus (Uppot2000).

Trauma Akut Hernia Abdominal dianggap sangat jarang dengan kurang dari 70 kasus yang dilaporkan dalam literatur hingga 2005 (Ogundiran 2012). Perforasi usus pada penderita hernia terjadi baik dari trauma tumpul ke perut atau dari trauma langsung ke hernia inguinalis (Uppot 2000).

Kami melaporkan untuk pertama kalinya terjadinya perforasi colon sigmoid dengan herniasi ke dalam kanalis inguinalis terjadi pada waktu yang sama.

Laporan kasus

Seorang pasien laki-laki 45 tahun yang telah dilaporkan Instalasi Gawat Darurat dengan riwayat trauma ke perut yang terjadi di pagi hari. Sebuah benda berbentuk tabung secara keras mengenai perutnya. Setelah kejadian tersebut , pasien mengeluh sangat nyeri perut dan terjadi pembengkakan inguinal-skrotum di sisi kiri. Tidak ada riwayat muntah, demam, atau pembengkakan inguinalis sebelumnya.

http://www.ibimapublishing.com/journals/IJCRM/ijcrm.html

Cite this Article as: Amit Kumar C Jain and S. Viswanath (2013), "Large Bowel Perforation in an Acute Inguinal Hernia Resulting from Blunt Abdominal Trauma," International Journal of Case Reports in Medicine, Vol. 2013 (2013), Article ID 439839, DOI: 10.5171/2013.439839

Jurnal internasional laporan kasus Kedokteran 2

Gambar 1: menunjukkan besar perforasi ( menunjuk sigmoid oleh forseps ) dan gangrenous

lateralis lipat dari kandung kemih ( panah )

Pada pemeriksaan, pasien ditemukan memiliki dyspnea dan tachypnea dengan jumlah pernafasan 44 x / menit. Nadinya adalah 130 x / menit dan tekanan darah adalah 130 / 70 mmhg.

Pada pemeriksaan Abdomen , pasien merasa nyeri ketika disentuh pada seluruh abdomen dengan mengawal dan kekakuan . Ada pembengkakan di inguino-scrotal yang nyeri dan tidak dapat direduksi.

Dari hasil laboratoriumnya menunjukkan hemoglobin - 16.7g%. Jumlah total count 3790mm3 ,platelets -1.97 lacs/mm3, INR - 1.3. Fungsi ginjal, elektrolit serum, dan fungsi hati nya ditemukan dalam batas normal. Analisa gas darah nya menunjukkan asidosis metabolik.

USG abdomen menunjukkan dalam jumlah sedang cairan bebas pada perut. USG skrotum menunjukkan hernia sisi kiri inguinoscrotal dengan lengkungan usus sebagai isinya dan heteroechoic area didalam skrotum yang menunjukkan terkumpulnya cairan

CT scan abdomen menunjukkan hernia inguinoscrotal sisi kiri dengan penurunan mukosa pada kolon sigmoid. Didalam kantong hernia tersebut ditemukan udara, cairan dan banyak lemak yang mengarah terjadinya ischemia usus. Ditemukan juga Pneumoperitoneum, cairan bebas dalam perut dan penebalan omental. Serta efusi pleura bilateral dan ateletaksis basal.

Selama Pasien menjalani operasi laparotomy ditemukan peritonitis dengan herniasi usus di sisi kiri cincin inguinal . Isi hernia itu tertarik kembali ke abdomen termasuk kolon sigmoid yang mengalami perforasi bersamaan feces didslsm kantung hernia, usus halus dan sisi luka gangren pada lipatan mukosa kandung kemih.

Pasien tersebut menjalani colostomy sigmoid, eksisi lipatan mukosa yang mengalami gangren dan peritoneal lavage. pasien juga menjalani laparotomy dan peritoneal lavage kembali 6 hari kemudian, setelah pasien mengalami demam sangat tinggi .

4 bulan kemudian setelah pemulihan pasca operasi , pasien menjalani Colostomy kembali

Diskusi

Trauma Abdomen dengan Hernia pertama kali dilaporkan oleh Selby pada tahun 1906 (Hardcastle 2005). Trauma Abdomen dengan Hernia didefinisikan sebagai hernia viscera melalui dinding perut yang disebabkan gangguan lapisan otot dan fasia tetapi dengan kulit yang utuh, dimana ada riwayat trauma berbeda sebelum terjadinya hernia (Hardcastle 2005). Cedera usus karena Trauma Tumpul Abdomen di hernia inguinalis sangat jarang ditemukan dalam literatur (Lyutskanov 2007). Trauma Abdomen dengan Hernia terjadi karena gaya tumpul yang menggeser arah otot dan fasia..

Amit Kumar C Jain and S. Viswanath (2013), International Journal of Case Reports in Medicine, DOI: 10.5171/2013.439839


Pergeseran ini diperkirakan terjadi pada titik-titik lemah anatomi seperti daerah inguinalis atau lateral abdomen bawah pada otot rektus (Bemmel 2011).

Pada saat sebelum terjadi hernia inguinalis, trauma secara langsung pada hernia menyebabkan usus tertekan masuk dan keluar , membentuk lingkaran terkunci. Apabila tekanan Intraluminal meningkat menyebabkan perforasi usus dalam kantung (Lyutskanov 2007). Tekanan 150-260mmHg diperlukan untuk rupture intestinal loop (Uppot 2000).

Hernia abdominal Traumatis dibagi menjadi 3 bagian (Wood 1988) yaitu,

1. Defek kecil kuadran bawah dan hernia inguinal , biasanya akibat trauma tumpul dengan setang sepeda. Ini adalah penyebab pertama paling banyak Hernia abdominalis traumatis hernia. Hal ini karena dampak energi rendah.

2. Defek dinding abdomen yang luas dalam kecelakaan kendaraan bermotor. Penyebab Kedua Hernia Abdominalis Traumatis terbanyak.

3. Hernia Intraabdominal melewati peritonium. Ini sangat jarang.

Pengobatan hernia abdominal traumatis terdiri dari operasi pembedahan dengan penutupan defek (Bemmel 2011). Perbaikan pada defek lebih baik dilakukan dengan jahitan bahan yang non absorben dan mesh harus dihindari untuk mencegah komplikasi sepsis (Hardcastle 2005). Terjadinya peritonitis membutuhkan intervensi pembedahan utama melalui laparatomi.

Kesimpulan

Hernia abdominal traumatis adalah sebuah kondisi yang sangat langka. Hernia Ini ada 3 jenis . Hal ini dapat terjadi dampak karena tekanan rendah atau tekanan tinggi. Pengenalan awal dan pengobatan adalah penting dalam mengurangi morbiditas dan mortalitas. Terkait cedera viseral perut selalu membutuhkan eksplorasi laparatomi/Laparoskopi untuk penanganan lebih lanjut. Penempatan mesh setelah Perbaikan hernia biasanya dihindari.

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References

Bemmel, A. J. M., Marle, A. G. J., Schlejen, P. M. & Schmitz, R. F. (2011). "Handle Bar Hernia: A Case Report and Literature Review of Traumatic Abdominal Wall Hernia in Children," Hernia, 15(4), 439-442.

Biswas, S., Vedanayagam, M., Hipkins, G. & Leather, A. (2010). "Acute Direct Inguinal Hernia Resulting from Blunt Abdominal Trauma: Case Report," World Journal of Emergency Surgery, 5, 16.

Hardcastle, T. C., Coetzee, G. N. & Wasserman, L. (2005). "Eviceration from Blunt Trauma in Adults: An Unusual Injury Pattern: 3 Cases and a Literature Review,"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 13, 234-235.

Hardcastle, T. C., Toit, D. F. D., Malherbe, C., Coetzee, G. N., Hoogerboord, M. & Warren, B. L. (2005). "Traumatic Abdominal Wall Hernia - Four Cases and a Review of the Literature," South African Journal of Surgery, 43(2), 41-43.

Lawal, K. & Adamu, A. (2012). "Handle Bar Hernia: A Case Report and Review of Literature," Archives of International Surgery, 2, 42-44.

Lyutskanov, V., Kondarev, M., Markov, G. & Kondarev, G. (2007). 'Small Bowel Perforation due to Blunt Abdominal Trauma Associated with Right Inguinal Hernia: Report of a Case,' The Internet Journal of Surgery, 13(2), 1-4.

Ogundiran, T. O., Obamuyide, H. A., Adesina, M. A. & Ademola, A. F. (2012). "Case Report of Traumatic Abdominal Wall Hernia Following Blunt Motorcycle Handlebar Injury and Review of Literature," Nigerian Journal of Clinical Practice, 15(2), 238-240.

Uppot, R. N., Gheyi, V. K., Gupta, R. & Gould, S. W. (2000). "Intestinal Perforation from Blunt Trauma to a Inguinal Hernia,"



American Journal of Roentgenology, 174(6), 1538.

Wood, R. J., Ney, A. L. & Bubrick, M. P.(1988). "Traumatic Abdominal Hernia: ACase Report and Review of the Literature,"The American Surgeon, 54(11), 648-651.

IBIMA PublishingInternational Journal of Case Reports in Medicinehttp://www.ibimapublishing.com/journals/IJCRM/ijcrm.htmlVol. 2013 (2013), Article ID 439839, 4 pagesDOI: 10.5171/2013.439839

Case Report

Large Bowel Perforation in an Acute Inguinal Hernia Resulting from Blunt

Abdominal TraumaAmit Kumar C Jain and S. Viswanath

Department of Surgery, St John’s Medical College, Sarjapur road, Karnataka, India

Correspondence should be addressed to: Amit Kumar C Jain; [email protected]

Received 10 July 2013; Accepted 9 September 2013; Published 30 November 2013

Academic Editor: Faruk Çoşkun

Copyright © 2013 Amit Kumar C Jain and S. Viswanath. Distributed under Creative Commons CC-BY 3.0

Abstract

Traumatic abdominal hernia is a very rare condition with less than 70 reported cases, in spite of an increase in the incidence of trauma. Often, the trauma to the abdomen results in damage to solid or to the hollow viscus. The trauma causing TAWH can be due to high energy or low energy impact. We report a very rare condition wherein there was a blunt injury to the abdomen that resulted in the acute inguinal hernia with perforated sigmoid colon, small bowel and part of urinary bladder being its contents. To our knowledge, this is the first such case being documented by us.

Keywords: Trauma, Inguinal hernia, Perforation.

Introduction

Blunt abdominal trauma (BTA) may cause either a crushing or a shearing effect resulting in damage to the hollow viscus or solid viscera (Biswas 2010, Lawal 2012). Around 5% of patients with blunt trauma have injury to mesentry and intestine (Uppot 2000).

Acute traumatic abdominal hernias are considered to be very rare with less than 70 cases reported in literature till 2005 (Ogundiran 2012). Bowel perforation in the patients with hernias occur either from blunt trauma to abdomen or from trauma directly to inguinal hernia (Uppot 2000).

We report for the first time the occurrence of a sigmoid perforation with its herniation into the inguinal canal occurring at the same time.

Case Report

A 45 year old male patient presented to our emergency department with history of trauma to the abdomen that occurred in the morning. A barrel had fallen on him. Immediately after the trauma, the patient developed severe abdominal pain and an inguino-scrotal swelling on the left side. There was no history of vomiting, fever or previous inguinal swelling.

_____________

Cite this Article as: Amit Kumar C Jain and S. Viswanath (2013), "Large Bowel Perforation in an Acute Inguinal Hernia Resulting from Blunt Abdominal Trauma," International Journal of Case Reports in Medicine, Vol. 2013 (2013), Article ID 439839, DOI: 10.5171/2013.439839

International Journal of Case Reports in Medicine 2

Figure 1: Showing the Large Sigmoid Perforation (Pointed by the Forceps) and Gangrenous Lateral Fold of the Bladder (Arrow)

On examination, patient was found to have dyspnoea and tachypnoea with a respiratory rate of 44 /min. His pulse was 130/min and blood pressure was 130/70mmHg.

On abdominal examination, patient had tenderness all over the abdomen with guarding and rigidity. There was a left inguinoscrotal swelling which was tender and irreducible.

His laboratory investigation showed a haemoglobin – 16.7g%. Total count – 3790mm3, Platelets – 1.97 lacs/mm3, INR-1.3. His renal functions, serum electrolytes and liver functions were found to be within normal limits. His ABG showed metabolic acidosis.

Ultrasound abdomen showed moderate free fluid in abdomen. Scrotal ultrasound revealed a left inguinoscrotal hernia with bowel loops as its content and a heteroechoic ares in scrotum suggestive of fluid collections.

CT scan abdomen was done which showed a left inguinoscrotal hernia with poor mucosal enhancement of sigmoid colon. There was air, fluid and extensive fat stranding within the hernia sac, to consider the possibility of bowel ischaemia. There was pneumoperitoneum, free fluid in abdomen and omental thickening. There

_______________

was also bilateral pleural effusion and basal atelectasis.

Patient underwent exploratory laparotomy which revealed a gross faecal peritonitis with herniation of bowels in left deep inguinal ring. The contents were pulled back in abdomen which included perforated sigmoid colon with faeces in the sac, small bowel and a gangrenous lateral fold of urinary bladder.

He underwent sigmoid colostomy, excision of gangrenous fold and peritoneal lavage. He underwent a relook laparotomy and peritoneal lavage 6 days later as he had high fever spikes.

Patient recovered postoperatively and he underwent colostomy reversal 4 months later.

Discussion

TAWH was first reported by Selby in 1906 (Hardcastle 2005). TAWH is defined as herniation of the viscera through the abdominal wall within the context of disrupted muscle and fascia layers but with intact skin, where there is distinct history of trauma preceding the occurrence of the hernia (Hardcastle 2005). Bowel injury due to BTA in an inguinal hernia is very rare in literature (Lyutskanov 2007). The TAWH occurs due to a blunt force that leads to shearing of muscle and fascia. This


3 International Journal of Case Reports in Medicine

shearing is thought to occur at anatomic weak points such as the inguinal region or the lower abdomen lateral to the rectus muscle (Bemmel 2011).

In a preexisting inguinal hernia, a direct trauma to the hernia causes compression of the incoming and outgoing loops of bowels, forming a sealed loop. Raised intraluminal pressure leads to perforation of the bowel within sac (Lyutskanov 2007). A pressure of 150-260mmHg is required to rupture the intestinal loops (Uppot 2000).

Traumatic abdominal hernia falls into 3 categories (Wood 1988) namely,

1. Small lower quadrant defects and inguinal hernias, typically the result of blunt trauma with bicycle handlebars. This is the most common traumatic abdominal hernia. It is due to low energy impact.

2. Large abdominal wall defects sustained in motor vehicle accidents. This is second most common

3. Intraabdominal herniation through rents in the peritoneum. This is very rare.

The treatment of traumatic abdominal hernia consist of surgical exploration with the closure of the defect (Bemmel 2011). The repair of the defect should be preferably done with non absorbable suture material and mesh should be avoided to prevent septic complications (Hardcastle 2005). Presence of peritonitis requires primary surgical intervention through laparotomy.

Conclusion

Traumatic abdominal hernia is an extremely rare condition. It is of 3 types. It can occur either due to low energy or high energy impact. Early recognition and treatment is essential in reducing morbidity and mortality. Associated abdominal visceral injury invariably requires an exploratory laparotomy/laparoscopy for further

_______________

management. Placement of mesh after repairing the hernia is usually avoided.

References

Bemmel, A. J. M., Marle, A. G. J., Schlejen, P. M. & Schmitz, R. F. (2011). "Handle Bar Hernia: A Case Report and Literature Review of Traumatic Abdominal Wall Hernia in Children," Hernia, 15(4), 439-442.

Biswas, S., Vedanayagam, M., Hipkins, G. & Leather, A. (2010). "Acute Direct Inguinal Hernia Resulting from Blunt Abdominal Trauma: Case Report," World Journal of Emergency Surgery, 5, 16.

Hardcastle, T. C., Coetzee, G. N. & Wasserman, L. (2005). "Eviceration from Blunt Trauma in Adults: An Unusual Injury Pattern: 3 Cases and a Literature Review,"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 13, 234-235.

Hardcastle, T. C., Toit, D. F. D., Malherbe, C., Coetzee, G. N., Hoogerboord, M. & Warren, B. L. (2005). "Traumatic Abdominal Wall Hernia - Four Cases and a Review of the Literature," South African Journal of Surgery, 43(2), 41-43.

Lawal, K. & Adamu, A. (2012). "Handle Bar Hernia: A Case Report and Review of Literature," Archives of International Surgery, 2, 42-44.

Lyutskanov, V., Kondarev, M., Markov, G. & Kondarev, G. (2007). 'Small Bowel Perforation due to Blunt Abdominal Trauma Associated with Right Inguinal Hernia: Report of a Case,' The Internet Journal of Surgery, 13(2), 1-4.

Ogundiran, T. O., Obamuyide, H. A., Adesina, M. A. & Ademola, A. F. (2012). "Case Report of Traumatic Abdominal Wall Hernia Following Blunt Motorcycle Handlebar Injury and Review of Literature," Nigerian Journal of Clinical Practice, 15(2), 238-240.

Uppot, R. N., Gheyi, V. K., Gupta, R. & Gould, S. W. (2000). "Intestinal Perforation from Blunt Trauma to a Inguinal Hernia,"


International Journal of Case Reports in Medicine 4

American Journal of Roentgenology, 174(6), 1538.

Wood, R. J., Ney, A. L. & Bubrick, M. P.(1988). "Traumatic Abdominal Hernia: ACase Report and Review of the Literature,"The American Surgeon, 54(11), 648-651.

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