PMC6068073_01
a) Computed Tomography of patient during initial evaluation showing defect of oblique musculature. b) CT of patient during pre-operative planning phase showing same defect.
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Subsequent computerized tomography scans identified a small non-displaced sternal fracture, as well as an intraperitoneal bladder rupture and right lumbar hernia in the area of Petit's triangle, with complete avulsion of the abdominal wall musculature from the iliac crest. (Fig. 1) No other internal injuries were identified.
a) Patient pre-operatively showing significant bulging of right flank. b) Pre-operative marking of associated defect and landmarks (Head top of image, feet bottom of image).
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After re-evaluation by general and plastic surgery departments, decision was made for surgical repair (Fig. 2a and b).
Showing operative placement of the mesh in preperitoneal space and bone anchors approximating the oblique muscles to the iliac crest (Iliac Crest to right of image, oblique muscle to left of image).
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A preperitoneal plane was developed after the hernia sac was freed from all subcutaneous attachments, dissecting all layers of the abdominal wall away from the peritoneum in order to place a polypropelene mesh. (Fig. 3) A 6 x 6 cm defect was measured, and a 12 x 12 cm mesh was circumferentially sewn into place utilizing the abdominal wall musculature at the superior, medial and lateral aspects. Predrilled holes along the iliac crest were formed and Mitek QUICKANCHOR  suture anchors, preloaded with double arm braided polyethylene/polyester composite sutures were used to secure the oblique musculature to the iliac crest, allowing precise and accurate approximation of the muscle back into its anatomic location (Fig. 3).
Patient 6 months post-op. Note the lack of flank bulge and well healed scar.
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