INTRODUCTION

Background

Traumatic abdominal wall hernia (TAWH) is defined as disruption of the underlying musculature and fascia without skin penetration or preexisting hernia [1]. First reported in 1906, TAWH remains rare, with an incidence of 0.17% to 0.9% among trauma patients [2–5]. With the widespread use of abdominal computed tomography (CT) in trauma care, TAWH diagnoses have increased [6]. Nevertheless, whether all TAWHs require surgical repair—and, if so, the optimal method and timing—remains unclear [7].

Because treatment decisions rely on patient condition and clinician judgment, consensus on TAWH management is still lacking. Earlier algorithms recommended repair for all TAWHs, with the timing and approach determined by patient condition and the extent of intra-abdominal injury or contamination [8,9]. However, not all traumatic abdominal wall injuries (AWIs) without herniation require surgery [10].

Hernia repair is generally performed in a tension-free manner to reduce recurrence. Technical difficulty varies by AWI location [8,11,12]. When AWI involves the rectus or lateral abdominal wall muscles, access is straightforward and mesh fixation is feasible. By contrast, posterolateral injuries near the iliac crest are technically demanding because tension-free repair requires reattaching disrupted muscles to the iliac bone, which is associated with higher TAWH recurrence rates [4,10].

In acute traumatic AWI, substantial soft-tissue contusions or hematomas commonly accompany underlying muscle disruption [6,13]. On imaging and physical examination, these can mimic intact abdominal wall layers, obscuring the extent of fascial defects. Consequently, herniation may be missed on initial imaging. Furthermore, prolonged immobilization after high-energy trauma can delay hernia detection. These factors complicate the selection of optimal acute-phase management for traumatic AWI.

Objectives

We hypothesized that in traumatic AWI with hematoma, nonoperative management (NOM)—close observation with follow-up imaging after the acute phase—would facilitate detection of evolving hernias. These hernias could then be selectively repaired. If abdominal wall integrity is preserved after hematoma resorption, surgery may be unnecessary.

METHODS

Ethics statement

This study was approved by the Institutional Review Board of Kyungpook National University Hospital (No. KNUH 2025-04-017). The requirement for informed consent was waived due to the use of deidentified data and the retrospective nature of the study.

Data collection

We conducted a retrospective analysis of patients treated at the level I trauma center of Kyungpook National University Hospital (Daegu, Korea) from January 2013 to December 2023, using medical records coded according to the Abbreviated Injury Scale (AIS). Collected variables included demographic characteristics, mechanism of injury, clinical and radiologic features of traumatic AWI, concomitant injuries, operative details, and in-hospital mortality.

Classification and definitions

TAWH was distinguished from AWI. AWI was defined as injury to the abdominal wall muscle and fascia with or without herniation. TAWH was designated as disruption of the underlying musculature and fascia without skin penetration or preexisting hernia [1].

Anatomical locations of AWI were categorized as follows: disruptions of the rectus muscle were defined as “anterior AWI,” while disruptions involving the internal, external, or transversus abdominis muscles of the flank, as well as the rectus aponeurosis, were considered “lateral AWI.” “Posterolateral AWI” was defined as injury to the posterolateral abdominal wall muscles along the iliac crest with disruption of the iliac attachment.

AWI grading followed the system proposed by Dennis et al. [6] (Table 1): grade I, subcutaneous tissue contusion; grade II, abdominal wall hematoma; grade III, single abdominal wall disruption; grade IV, complete abdominal wall muscle disruption; grade V, herniation of abdominal contents with complete disruption of the abdominal wall; and grade VI, complete disruption of the abdominal wall with evisceration. Injury mechanisms were classified as high- or low-energy. High-energy mechanisms included motor vehicle collision, pedestrian injury, crush, and fall, while low-energy mechanisms encompassed handlebar injury and slip/roll-down.

Emergency repair was defined as hernia repair within 1 week of trauma. Delayed management was defined as observation for AWI with or without hernia at least 1 week after trauma. NOM was a subset of the delayed management group, restricted to patients without herniation on index imaging, who were closely observed and regular follow-up imaging was done. Delayed hernia referred to herniation that was absent on index imaging but evident on follow-up imaging.

Inclusion and exclusion criteria

We included patients aged ≥18 years with blunt trauma and grades III–VI blunt AWIs. We excluded hernias due to penetrating mechanisms and cases with incomplete medical records. To ensure reproducible outcome ascertainment, for the NOM subset, patients with unstable vital signs, severe traumatic brain injury, poor general condition, or loss to follow-up were excluded.

Statistical analysis

Normality was assessed using the Kolmogorov-Smirnov test. Continuous variables were reported as medians with interquartile ranges or means±standard deviations, as appropriate. Categorical variables were summarized as frequencies and percentages. Group comparisons used the Student t-test or Mann–Whitney U-test for continuous variables and the Pearson chi-square test or Fisher exact test for categorical variables, as appropriate. Odds ratios (ORs) with 95% confidence intervals were calculated for significant associations. P-values of <0.05 were considered to indicate statistical significance. All analyses were conducted using IBM SPSS ver. 29.0 (IBM Corp).

RESULTS

Clinical characteristics

Of 83,532 adult patients with blunt trauma, 44 had AWI (incidence rate, 0.05%). The overall treatment flow is shown in Fig. 1A. Based on initial evaluation, 26 patients were assigned to the emergency surgery group and 18 patients (40.9%) to the delayed management group. After applying the exclusion criteria within the delayed management group, 10 patients ultimately underwent NOM.

The mean patient age was 53.1±19.4 years; 30 patients (68.2%) were male and 14 (31.8%) were female. The mean Injury Severity Score (ISS) was 20.3±11.1, and the mean abdominal AIS score was 2.64±1.00. The mean body mass index (BMI) was 24.8±3.9 kg/m², and the mean length of stay (LOS) was 45.7±38.6 days. The mean follow-up was 23.7±25.6 months. Overall mortality was 6.8% (n=3).

Mechanisms of injury

Thirty-six patients sustained high-energy injuries, whereas eight had experienced low-energy injuries. The most common high-energy mechanism was motor vehicle collision (n=10, 22.7%), followed by crush injury (n=9, 20.5%), motorcycle collision (n=6, 13.6%), pedestrian strike (n=4, 9.0%), fall (n=4, 9.0%), and tractor collision (n=3, 6.8%). Low-energy mechanisms comprised handlebar injuries (n=5, 11.4%) and slip/roll-down injuries (n=3, 6.8%).

Concomitant intra-abdominal organ injuries

Intra-abdominal organ injuries occurred in 27 patients (61.4%). The mesentery was most frequently involved (n=13, 48.1% of patients with intra-abdominal injury), followed by the liver and spleen (n=12, 44.4%), small bowel and colon (n=9, 33.3%), and kidney (n=2, 7.4%).

Surgical repairs

Thirty-two patients (72.7%) underwent surgery; 26 (81.3%) received emergency repair, and 6 (18.7%) underwent delayed repair. Among those undergoing emergency repair, 22 (84.6%) had definitive hernia repair during the immediate operation. Because primary abdominal wall closure was not feasible at the index operation, the remaining four patients (15.4%) required a staged approach; hernia repair was completed within 1 week (Fig. 1B). Among the 26 emergency repair, 20 were TAWH (grades V–VI) and 6 were grade III–IV AWI (anterior, n=1; lateral, n=3; posterolateral n=2). The posterolateral repairs were indicated by extended diaphragm injury or herniation detected at second-look laparotomy.

In the delayed management group, 18 patients (41.0% of AWI) did not receive emergency repairs. Among them, delayed repair was planned for eight patients (44.4%); six ultimately underwent the procedure, whereas two with confirmed herniation declined surgery and were subsequently lost to follow-up at our institution.

Types and grades of AWI

Based on anatomical classification, 4 patients (9.1%) had anterior AWI, 17 (38.6%) had lateral AWI, and 23 (52.3%) had posterolateral AWI. Regarding AWI grades [6], 3 cases (6.8%) were grade III, 16 (36.4%) were grade IV, 24 (54.6%) were grade V, and 1 (2.3%) was grade VI.

Comparison of emergency repair and delayed management

As detailed in Table 2, 26 patients (59.1%) underwent emergency repair, and the remaining 18 (40.9%) received delayed management. Age, sex, BMI, LOS, follow-up duration, and mortality did not differ significantly between groups. No significant difference in ISS was found between groups (19.4±9.7 vs. 21.6±13.0, P=0.529). High-energy mechanisms were more frequent in the delayed group (73.1% vs. 94.4%, P=0.115). Pelvic fractures (26.9% vs. 61.1%, P=0.032) and lumbar spine fractures (11.5% vs. 44.4%, P=0.031) were also significantly more common in the delayed group. The incidence of hollow viscus injuries (46.2% vs. 38.9%, P=0.760) and solid organ injuries (30.8% vs. 16.7%, P=0.480) did not differ significantly between the two groups. The delayed group also had a higher proportion of posterolateral AWI (34.6% vs. 77.8%, P=0.007) and grade IV injuries (15.4% vs. 66.7%), whereas grade V injuries were more common in the emergency group (73.1% vs. 29.4%).

Comparison of posterolateral AWI with other AWI groups

As shown in Table 3, posterolateral AWI comprised of 23 patients (52.3%), versus 21 (47.7%) for anterior/lateral AWI. The posterolateral group included fewer men (52.2% vs. 85.7%, P=0.024), was younger (47.4 years vs. 59.3 years, P=0.041), and had a higher BMI (26.3 kg/m² vs. 23.2 kg/m², P=0.009). Mortality and LOS (53.0 days vs. 37.7 days, P=0.192) did not differ significantly between groups. The posterolateral group had higher rates of pelvic fractures (60.9% vs. 19.0%, P=0.004) and lumbar spine fractures (39.1% vs. 9.5%, P=0.019). The proportion of high-energy injuries (91.3% vs. 71.4%, P=0.126) and ISS (22.6 vs. 17.8, P=0.153) did not differ significantly between the groups. Intra-abdominal injury also exhibited no significant difference (56.5% vs. 66.7%, P=0.548). In the posterolateral group, surgical repair was less common (56.5% vs. 90.5%; P=0.009; OR, 0.14), whereas mesh use among cases involving repair was more frequent (92.3% vs. 47.4%; P=0.011; OR, 13.33). Differences in emergency repair (69.2% vs. 89.5%, P=0.152), delayed repair (30.8% vs. 10.5%, P=0.194), and in recurrence (23.1% vs. 10.5%; P=0.341) were not statistically significant. Grade IV injuries were more common in the posterolateral group (56.5% vs. 14.3%), whereas grade V injuries were less common (39.1% vs. 71.4%).

Intra-abdominal injury distribution by AWI location

Fig. 2 shows the distribution of intra-abdominal injuries by AWI location. All patients with anterior AWI had concomitant intra-abdominal organ injuries. Anterior AWI was mainly accompanied by hollow viscus injury: small bowel (n=4), colon (n=1), and mesentery (n=3), with one liver injury.

Of 17 patients with lateral AWI, 10 (58.8%) had intra-abdominal injuries. Five had hollow viscus injuries, four had solid organ injuries, and one had both. Injuries most frequently involved the colon (n=4), liver (n=3), and spleen (n=2). Kidney injuries occurred only with lateral AWI.

Among 23 patients with posterolateral AWI, 13 (56.5%) had intra-abdominal organ injuries. Hollow viscus injuries were common (9 of 13), predominantly mesenteric injury (6 of 9). One case included a concomitant solid organ injury. Four patients had isolated solid organ injuries. Notably, 10 of 23 patients (43.5%) with posterolateral AWI had no intra-abdominal injury.

NOM of posterolateral AWI

Eighteen patients did not undergo emergency repair. Eight patients were excluded because of unstable vital signs (n=3), severe traumatic brain injury (n=2), or loss to follow-up (n=3). Accordingly, 10 patients (22.7% of all traumatic AWI) were monitored for hematoma resolution at the AWI site.

Table 4 summarizes the characteristics of patients undergoing NOM. Nine of 10 patients (90%) had posterolateral AWI caused by high-energy mechanisms. At the acute stage, one patient was grade III and nine were grade IV. Among 10 patients, three developed delayed hernias during follow-up. Delayed hernias were diagnosed at 1, 2, and 10 months after injury. In these cases, the final grade assigned after hematoma resolution differed from the initial grade at diagnosis. The remaining seven patients had no delayed herniation. Follow-up imaging confirmed preserved abdominal wall integrity after hematoma resolution. The mean follow-up among these patients was 24 months (Fig. 3).

DISCUSSION

TAWH is a rare consequence of blunt trauma, occurring in less than 1% of blunt injuries [2,3]. Standardized management guidelines have not been established, given this rarity [4,7,14]. This study analyzes acute traumatic AWI, with particular focus on posterolateral AWI—an injury subtype that presents distinct management challenges.

Our findings indicate that immediate surgical repair is not required for all traumatic AWI. In selected high-energy posterolateral injuries, particularly those with substantial hematomas on initial imaging, NOM was effective [3,13,14]. Deferring surgery and monitoring with serial examinations and follow-up imaging allowed hematoma resorption and reassessment of abdominal wall integrity. This approach helped identify patients for whom NOM may be appropriate, particularly when acute-phase imaging showed hematoma without clear herniation. This selective strategy challenges the doctrine of mandatory early repair for all TAWH and reflects a shift toward conservative management in hemodynamically stable patients without overt intra-abdominal injury.

In our cohort, the delayed management group had significantly more pelvic and lumbar spine fractures. Although not statistically significant, a trend was also noted toward more high-energy trauma (OR, 6.26), suggesting that injury severity and associated skeletal trauma likely influenced the decision to defer repair. All anterior AWIs underwent surgery, likely reflecting the high prevalence of concomitant intra-abdominal organ injury in this subgroup.

AWIs are traditionally classified by anatomical location—anterior, lateral (flank), and posterior (lumbar)—as described previously. We use the term “posterolateral AWI” for injuries of the posterior-lateral abdominal wall that disrupt the musculature from its iliac-crest attachments. This definition distinguishes traumatic injuries of the iliac crest region from spontaneous lumbar hernias arising at known weak points, such as the Grynfeltt or Petit triangles [15,16]. In our study, posterolateral AWIs predominantly arose due to high-energy mechanisms and displayed management patterns distinct from anterior or lateral injuries; therefore, recognizing this subtype is clinically relevant.

Because the iliac wing is rigid, posterolateral AWIs are usually caused by high-energy trauma and commonly accompany skeletal injuries. In our cohort, 91% of posterolateral injuries followed high-energy mechanisms, and pelvic or lumbar spine fractures occurred significantly more often than in anterior or lateral injuries [17].

Posterolateral TAWHs pose substantial technical challenges. Achieving tension-free closure often requires reattaching torn musculature to bone or bridging the defect with mesh anchored to the iliac crest [18,19]. Without meticulous technique, recurrence has historically been higher in this location [4,12]. A tension-free repair with adequate reinforcement, typically mesh, is essential because it reduces recurrence [20]. A recent multicenter study reported that nearly one-quarter of TAWH repairs used bone-anchor fixation to secure tissue or mesh to the iliac crest; however, recurrence and surgical-site infection rates did not differ significantly between repairs with and without bone anchors [21]. By contrast, anterior and lateral TAWHs are comparatively straightforward to repair with primary suture and mesh because bony insertions are unnecessary. Accordingly, when the patient’s condition permits, early repair is often preferred for anterior or lateral TAWHs at diagnosis, as tension-free closure is usually attainable in those locations. Although anterior and lateral AWIs were generally assumed to undergo emergency repair regardless of herniation, delayed management was adopted in four lateral cases. Among them, two patients without herniation died with unstable vital signs. The remaining two lateral TAWHs underwent delayed repair owing to poor general condition in one case and missed diagnosis in the other. In contrast, among patients with posterolateral injury without herniation at baseline, 5 of 14 (35.7%) developed a delayed hernia; two patients without protocolized follow-up re-presented 1 year later with bulging. One of them declined surgery and was lost to follow-up, whereas the other underwent repair but required reoperation for recurrence and remains under follow-up.

In acute trauma, an abdominal wall defect has traditionally prompted urgent exploration to address the defect and exclude concomitant intra-abdominal injury [8]. Coleman et al. [10] reported that 44% of patients underwent immediate laparotomy or laparoscopy; however, nearly 29% of these procedures were nontherapeutic, with no repairable intra-abdominal injury identified. In our cohort, intra-abdominal organ injury occurred in 61.4% of patients with AWI: all anterior AWIs had such injuries, whereas the rates were 58.8% for lateral and 56.5% for posterolateral injuries, respectively.

With advances in imaging and trauma care, a selective approach is now feasible. Hemodynamically stable patients without significant intra-abdominal injury on CT can be observed expectantly [3,4]. In our cohort, nearly half of posterolateral AWIs had no intra-abdominal organ injury on the initial CT and were managed nonoperatively when feasible. Large multicenter studies mirror this practice; approximately 37% of patients with TAWH were managed without immediate repair in one analysis [14]. In particular, posterolateral hernias have a substantially lower incidence of concomitant bowel injury than anterior abdominal wall hernias [10].

One notable observation was delayed hernia development in conservatively managed patients. Almost all patients selected for NOM had posterolateral injuries classified as AWI grade IV, typically accompanied by a large hematoma that obscured the fascial defect [6]. With careful observation and interval imaging, seven cases (70%) maintained muscle continuity after hematoma resolution, and no hernia developed during long-term follow-up. In the remaining three cases (30%), an abdominal wall defect became apparent on follow-up imaging at 1, 2, and 10 months after injury, thereby “declaring” a hernia well after the initial trauma. Therefore, vigilant clinical surveillance with scheduled imaging follow-up is essential for all patients managed initially with NOM, given the possibility of delayed herniation.

Determining the optimal timing and technique for TAWH repair remains crucial. Recent evidence suggests that acute repair yields outcomes comparable to delayed repair [14]. A large multicenter study found no significant difference in long-term recurrence between hernias repaired during the index hospitalization and those repaired electively [7]. Conversely, several reports caution that expedited repairs under suboptimal conditions may increase failure. Honaker and Green [4] reported that all recurrences occurred after immediate repair, whereas Brenneman et al. [9] observed that primary repairs without mesh performed during initial emergency laparotomies failed in most cases.

Limitations

Our study has several limitations. First, it is a single-center retrospective analysis with a small sample, which limits generalizability and may introduce selection bias. In addition, reliance on charts and imaging reports may have led to under-ascertainment or misclassification; if nondifferential, this would likely bias the estimates toward the null. Second, the follow-up schedule was not standardized, and several patients were lost to long-term follow-up, potentially causing delayed hernia formation or postoperative recurrence to be missed. Third, detailed anatomical data on defects (e.g., defect size and muscle quality) were unavailable, precluding analysis of their influence on management and outcomes. Finally, we did not assess long-term functional outcomes or quality of life, which are important considerations for patients managed nonoperatively.

Conclusions

In hemodynamically stable patients without intra-abdominal injuries requiring urgent surgery, an initial trial of NOM is reasonable for grade IV or lower posterolateral AWI, even in the setting of high-energy trauma. This strategy may avert unnecessary emergency laparotomy and its complications when paired with vigilant follow-up to detect delayed herniation. Any hernia that develops can then be repaired electively under optimal conditions, enabling tension-free repair, typically with mesh augmentation. Management of TAWH should be individualized according to concomitant injury burden and the patient’s condition. Our experience adds to the evidence that, in carefully selected posterolateral AWI without herniation, initial NOM may be safe and effective. Multicenter research is needed to develop consensus guidelines on the timing and technique of repair for these rare but challenging injuries.

ARTICLE INFORMATION

Author contributions

Conceptualization: GWK; Data curation: GWK, SH; Formal analysis: GWK, CYJ, SH; Methodology: CYJ, SHC, KHL; Project administration: CYJ, SHC, KHL; Visualization: SHC, SH; Writing–original draft: GWK, SH; Writing–review & editing: CYJ, SHC, KHL. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors did not receive any financial support for this study.

Data availability

Data analyzed in this study are not available due to privacy policy restrictions.

Fig. 1.

Treatment flow of patients. (A) Treatment flow of patients with abdominal wall injury (AWI). (B) Details of surgical repair methods. TAWH, traumatic abdominal wall hernia; TBI, traumatic brain injury; NOM, nonoperative management. ^a)AWI repair performed at the initial operation.

Fig. 2.

Distribution of intra-abdominal injuries by abdominal wall injury (AWI) location.

Fig. 3.

Computed tomography (CT) images illustrating two outcomes of abdominal wall injury: (A, B) preserved abdominal wall integrity after hematoma resolution and (C, D) delayed hernia. (A) Initial CT shows indeterminate herniation of the left posterolateral abdominal wall (arrow). (B) Follow-up CT at 2 months shows hematoma resolution with preserved abdominal wall integrity (arrow). (C) Initial CT shows indeterminate herniation of the right posterolateral abdominal wall (arrow). (D) Follow-up CT at 1 month reveals a delayed hernia (arrow).

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References

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