[Necrosis of the rectus abdominis muscle. Complication after ilioinguinal approach]

After a car accident, a 19-year-old man had to undergo laparotomy in a local hospital due to intra-abdominal bleeding. A right-sided transrectal incision was chosen, and to improve exposure the rectus muscle was cut horizontally at the cranial end of the incision. Ten days after the accident the patient was transferred to our hospital for stabilization of the pelvic and acetabular fracture on the right side. An ilioinguinal approach was chosen. Two days later the abdominal cavity was opened due to necrosis of the cranial part of the rectus abdominis muscle. Following a 10-day period without pathological symptoms, suddenly sepsis developed. Ultrasound showed a lot of fluid in the rectus sheath; no muscle structure could be identified. The operation showed total necrosis of the rectus muscle due to thrombotic occlusion of the inferior epigastric artery. The standardized tourniquets around the vessels used during the ilioinguinal approach seemed to be responsible for the rectus muscle necrosis. Therefore, if a combined intraabdominal and pelvic approach has to be used, median laparotomy is the better choice, because no risk is posed to the blood supply of the rectus muscle, in contrast to the ilioinguinal approach. The problem is discussed in detail.