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jo ur n al ho m epag e: ww w.elbites of fascia from the iliac crest. Elective mesh repair with sutureof mesh to recovered fascia has been proposed in these cases.57

We describe an acute-phase anatomical repair method fortraumatic abdominal muscle avulsion from the iliac crest usingsuture anchors. Suture anchors are widely used in orthopaedicsurgery to reattach tendons and ligaments to bone. These devicesconsist of a metal or absorbable screw, which can be inserted intobone. On the end of the screw (anchoring part) is a loop (eyelet)where suture is running through, which is used stitched onto thesubstance of the ligament or tendon, which is then approximatedto the anchor by tying the knots on the suture. Suture anchors(titanium anchor and non-absorbable braided sutures) have beenpreviously used in lumbar hernia repair to secure a mesh to theiliac crest.8

the handle. Insert the anchors into the iliac crest from the cranialdirection to the anatomic attachment area of abdominal muscles.After inserting the screw part fully into the iliac bone open theinserter, then take the sutures from the inserter and remove theinserter. Take one of the suture ends from the anchor and run itthrough the abdominal muscle fascia several (minimum of ve)times (starting from inside) and pull the suture out from the lateralside of the fascia. Run the other end of the suture through the fasciaonly (inside-out) once so that both ends come out from the outersurface of the muscle fascia (Fig. 3). Insert a second suture anchorand run the sutures as described. When all suture anchors andsutures are in place reduce the abdominal muscle to the iliac crestby pulling from the second suture end (run through only once) ofeach of the suture anchor. When the abdominal muscle is incontact with the iliac crest, secure the sutures of each sutureanchor by using normal surgical knots (Figs. 4 and 5). Suture themuscle attachment further by suturing the muscle fascia to iliacperiosteum or gluteal fascia by interrupted or running sutures.Close the subcutaneous tissue and skin by routine techniques if the

* Corresponding author at: Trauma Service, Division of Surgery, John Hunter

Hospital, Locked Bag No. 1, Hunter Region Mail Centre, NSW 2310, Australia.

Tel.: +61 2 49214259; fax: +61 2 49214274.

E-mail address: Zsolt.balogh@hnehealth.nsw.gov.au (Z.J. Balogh).

00201383/$ see front matter 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.injury.2013.03.028Technical note

Acute repair of traumatic abdominal muA mesh-free technique using suture an

Tim Soderlund, Osamu Yoshino, Cino Bendinelli, N

Trauma Service, Division of Surgery, John Hunter Hospital, Newcastle, NSW, Australia

Traumatic lumbar hernia is described as extrusion of intra-peritoneal or extra-peritoneal contents through a defect in thelateral abdominal wall. The injury is most commonly located in thetriangle formed by the posterior margin of external obliquemuscle, lateral border of latissimus dorsi muscle and aponeurosesof transversus muscle and internal oblique muscle, which arecontinuous with lumbodorsal fascia.1 In blunt trauma, abdominalmuscle rupture with or without herniation is found in 0.9% of thepatients having abdominal computed tomography (CT) on admis-sion2 and in 0.2% of all blunt-trauma patients.3 Associated intra-abdominal injuries are extremely common (up to 80%) but not arule.24 Emergent laparotomy is required in up to 50% of patientswith traumatic hernia.14 Diagnosis of these injuries can be madeon CT, but often due to other injuries and haemodynamicinstability the diagnosis is intra-operative during laparotomy.When abdominal muscle avulsion from iliac crest occurs, primaryrepair is usually difcult because of either muscle retraction (dueto delayed presentation or staged procedure) or lack of proper

A R T I C L E I N F O

Article history:

Accepted 23 March 2013Please cite this article in press as: Soderlund T, et al. Acute repair of trtechnique using suture anchors. Injury (2013), http://dx.doi.org/10.1cle avulsion from iliac crest:ors

alie Enninghorst, Zsolt J. Balogh *

Surgical technique

The Ethics Committee waiver was obtained from the HunterNew England Research Ethics committee. Written consent wasobtained from the patients for the use of radiologic andphotographic images.

The patient is positioned supine on the operating table. A wedgecan be placed under the ipsilateral pelvis to facilitate access to theiliac crest. General anaesthesia with complete muscle paralysis andprophylactic dose of intravenous antibiotics are recommended.Make a skin incision along the iliac crest from anterior superioriliac spine to the lateral border of latissimus dorsi muscle on theinjured side. Incise the subcutaneous tissue is along the skinincision. Subcutaneous tissue can be detached from muscle fasciadue to injury, leading to creation of a large subcutaneous cavity(Figs. 1 and 2). Reduce any herniated abdominal contents into theperitoneal cavity. Typically, all muscle and fascia attached to theiliac crest have been avulsed and retracted. Use two to three sutureanchors to reattach the avulsed muscles. The suture anchors arepre-packaged to an inserter having a screwdriver-type handle. Thesutures are inside the inserter and handle. The suture anchors areinserted into the bone by hand similar to a wood screw put into thewood, that is, applying slight pressure and at the same time turning

ry

s evier . c om / lo cat e/ in ju r yaumatic abdominal muscle avulsion from iliac crest: A mesh-free016/j.injury.2013.03.028

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JINJ-5343; No. of Pages 3tissue viability allows or by using negative pressure woundtherapy, as these injuries are usually associated with largesubcutaneous cavity formation (Morel-Lavallee lesion). Patientsare allowed to start mobilising immediately after surgery, butrecommended to avoid stretching and strenuous exercises of therepaired muscle for 3 weeks.

Discussion

We have described an easy and quick mesh-free technique foracute repair of traumatic abdominal muscle avulsion from the iliaccrest. The technique is based on suture anchors commonly used inorthopaedic surgery to reattach tendons and ligaments to the bone.We have used this technique in closure of ilioinguinal approach inacetabular surgery as well. Because this technique is used early,

Fig. 1. Preoperative CT of a patient with complete avulsion of abdominal musclesfrom iliac crest with associated Morel-Lavallee lesion. The avulsion of abdominal

wall muscles from iliac crest is evident in left side (white asterisk).

Fig. 2. Intraoperative ndings of the patient in Fig. 1 showing the completeabdominal muscle avulsion from iliac crest. Iliac crest is marked with dotted line.

Patient is in supine position and her feet are to the left in the picture and head to the

right.

Please cite this article in press as: Soderlund T, et al. Acute repair of trtechnique using suture anchors. Injury (2013), http://dx.doi.org/10.1before permanent shortening of the muscles, the repair is tension-free. In addition, the approach causes minimal additional tissuetrauma.

We assume muscle function to be improved by anatomicalrepair compared to delayed mesh repair. However, to the bestof our knowledge there are no studies addressing functional

Fig. 3. Schematic drawing of the repair technique.

Fig. 4. Intraoperative picture of the same patient as in Figs. 1 and 2 after sutureanchor repair. Patients feet are towards the top of the picture and head towards the

bottom of the picture. The one of the suture anchors is shown by black arrow.

aumatic abdominal muscle avulsion from iliac crest: A mesh-free016/j.injury.2013.03.028

outcomes among different repair methods. These mesh-freerepairs are theoretically more prone to recurrent hernia, which,however, can be xed with mesh when the patient has recoveredfrom other injuries.

In conclusion, acute mesh-free anatomical repair of abdominalwall muscle avulsions from the iliac crest is feasible and an easyoption with the use of suture anchors.

Conict of interest

The authors declare that there is no conict of interest.

References

1. Burt BM, A HY, Wantz GE, Barie PS. Traumatic lumbar hernia: reportof cases and comprehensive review of the literature. J Trauma 2004;57:136170.

2. Dennis RW, Marshall A, Deshmukh H, Bender JS, Kulvatunyou N, Lees JS, et al.Abdominal wall injuries occurring after blunt trauma: incidence and gradingsystem. Am J Surg 2009;197:4137.

3. Bender JS, Dennis RW, Albrecht RM. Traumatic ank hernias: acute and chronicmanagement. Am J Surg 2008;195:4147.

4. Netto FACS, Hamilton P, Rizoli SB, Nascimento B, Brenneman FD, Tien H, et al.Traumatic abdominal wall hernia: epidemiology and clinical implications. JTrauma 2006;61:105861.

5. Lichtenstein IL. Repair of large diffuse lumbar hernias by an extraperitonealbinder technique. Am J Surg 1986;151:5014.

6. Burick AJ, Parascandola SA. Laparoscopic repair of a traumatic lumbar hernia: acase report. J Laparoendosc Surg 1996;6:25962.

7. Bathla L, Davies E, Fitzgibbons Jr RJ, Cemaj S. Timing of traumatic lumbar herniarepair: is delayed repair safe? Report of two cases and review of the literature.Hernia 2011;15:2059.

8. Patten LC, Awad SS, Berger DH, Fagan SP. A novel technique for the repair oflumbar hernias after iliac crest bone harvest. Am J Surg 2004;188:858.

Fig. 5. Postoperative pelvic X-ray of the patient from Figs. 1, 2 and 4 after sutureanchor repair. The site of the suture anchors is shown by white arrows.

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JINJ-5343; No. of Pages 3Please cite this article in press as: Soderlund T, et al. Acute repair of trtechnique using suture anchors. Injury (2013), http://dx.doi.org/10.1aumatic abdominal muscle avulsion from iliac crest: A mesh-free016/j.injury.2013.03.028

Acute repair of traumatic abdominal muscle avulsion from iliac crest: A mesh-free technique using suture anchorsSurgical techniqueDiscussionConflict of interestReferences