Contemporary management of traumatic abdominal wall hernias: What you need to know

Traumatic abdominal wall hernia (TAWH) is an uncommon but clinically important consequence of both blunt and penetrating abdominal trauma. It is defined by disruption of the abdominal wall musculature and fascia with herniation of intra-abdominal or retroperitoneal contents through the defect. Although penetrating abdominal wall defects are usually apparent and can often be primarily closed during operative exploration, blunt TAWH is significantly more heterogeneous and challenging. The skin may remain intact while the muscle, fascia, neurovascular supply, and bony attachments are disrupted. The reported incidence of TAWH varies according to imaging strategy and trauma population, but frank herniation remains rare, occurring in <1% of blunt trauma patients in most contemporary series. The major management challenge is deciding whether the patient requires immediate trauma laparotomy or laparoscopy, acute abdominal wall repair, staged management with same-admission repair, or delayed hernia repair/abdominal wall reconstruction. Evidence remains primarily dominated by retrospective single-center series, multicenter registry studies, and systematic reviews with heterogeneous definitions and follow-up. Although traditional dogma had taught that these repairs should always be performed in a delayed fashion, recent multicenter data, systematic reviews, and surgeon experience suggest that timing of repair, type of repair, and mesh use must be individualized; bowel injury, contamination, defect location, and patient physiology are more important than a universal early-versus-delayed algorithm. This article summarizes the practical issues the trauma and acute care surgeon needs to know: diagnosis, classification, associated injuries, indications for exploration, repair timing, operative strategy, management of lateral and posterior defects, mesh use in contaminated fields, and associated outcomes.