Extremely rare hernia

It's been a pretty eventful week here in Cape Town.  Summer is coming into full swing and Christmas is around the corner.  It's a strange feeling.  I am planning to spend Christmas day on the beach.  It was about 95 degrees here today, and with the air conditioning being broken in the the operating theatre, it felt like we were operating in the tropics.  With a gown, mask, hat and gloves on, you can only imagine how hot 95 degrees feels.  Just putting on the gloves becomes a difficult task.

This series of pictures I'm showing you today is from a young man that was trapped in a car after it rolled into a tree.  As you can see in the first picture, he was pinned by the roof of the car, which left a rather large bruise on his stomach.  They had to use the jaws of life to extricate him from the car.  When he got to the hospital, his stomach was benign.  The next day however, he was complaining of right lower quadrant pain.  We got a CT scan and it appeared as if the trauma had given him a very large Spigelian hernia.  For those non-medical folks out there, a Spigelian hernia is a rare hernia that is caused by a defect just next to your six pack (or keg depending on your body habitus).  This guy was approaching keg status, so it was hard to really appreciate his hernia on physical exam.  It is extremely rare to have this type of hernia from trauma, and I only found 1 citation in the literature talking about "giant" Spigelian hernias caused by trauma.  That paper cited one case in which the hernia was 10cm in diameter.  That was the biggest Spigelian hernia the authors had ever seen or heard of.

Later that day we took this young man to the operating theatre.  When the anesthesiologist put him to sleep and placed the ET tube, he started coughing and we could finally appreciate how large the hernia actually was (second pic).  Once we opened him up, we discovered that his hernia was a 20cm!  There was no overlying peritoneum as you can see in the third picture which further proves it was the result of his recent trauma.  As you can see in the final picture, we placed a Parietex mesh (the biggest one they had at our hospital) and fixed the hernia.  He did very well post-op and walked out of the hospital 2 days after surgery.

This place is amazing.