1 Introduction
Traumatic abdominal wall hernias represent a rare clinical entity, accounting for < 1% of all abdominal hernias.
[1] They are characterized by disruption of the myofascial layers and musculature of the abdomen without compromising the overlying skin due to high-energy blunt trauma.
[2] A subset of these injuries is "handlebar hernia, " caused by direct impact of a perpendicular blunt force, typically a bicycle or motorcycle handlebar, against the small surface area of the abdominal wall, which generates a sudden and intense increase in intra-abdominal pressure, thereby shearing the underlying fascia while the elasticity of the skin prevents its rupture.
[3-
5]A Spigelian hernia is characterized by the protrusion of preperitoneal fat or viscera through the Spigelian fascia, an area bounded medially by the lateral border of the rectus abdominis and laterally by the semilunar line.
[6] Primary Spigelian hernias account for 0.12%–2% of all hernia cases, whereas traumatic Spigelian hernias are even rarer entities.
[1,
6]The diagnostic process is often challenging because the "handlebar sign" may be absent or disproportionate to the injury.
[3] Furthermore, patients may be asymptomatic or present only with a vague bulge and dull pain.
[7] This report presents the rare case of a 39-year-old female with a traumatic Spigelian hernia following a bicycle handlebar injury.
2 Case Report
2.1 Patient information
A 39-year-old female presented with swelling in the right lower abdomen for 7 days following blunt trauma to the abdomen by a bicycle handlebar, associated with dull aching pain and nonpassage of stools for the last 48 h without clinical signs of bowel obstruction. She had no history of previous abdominal surgeries or significant comorbidities.
2.2 Clinical findings
Patient was conscious and oriented, with a pulse rate of 84 bpm, blood pressure of 110/70 mmHg, and a body mass index of 24 kg/m2. On examination, an 8 cm × 6 cm reducible swelling was present in the right iliac fossa with a positive cough impulse without overlying ecchymosis. Bowel sounds were present. The clinical timeline of events is summarized in Table 1.
2.3 Diagnostic assessment
Ultrasonography revealed a 3 cm × 3 cm anterior abdominal wall defect in the right iliac fossa with herniation of omentum and bowel loops, without strangulation or obstruction. Contrast-enhanced computed tomography (CECT) further revealed a 1.85-cm defect in the right Spigelian fascia, 6.2 cm lateral to the linea alba, with a 7.5 cm × 4.5 cm sac containing viable small bowel loops and omentum suggestive of a traumatic Spigelian hernia.
Additionally, a 6.48 cm × 8.24 cm × 6.95 cm right adnexal cystic lesion was identified with fat attenuation and peripheral calcifications, suggestive of a mature cystic teratoma [Figures 1–3]. The differential diagnosis included rectus sheath hematoma and abdominal wall lipoma; however, these were ruled out based on clinical history and imaging.
2.4 Therapeutic intervention
The patient underwent an open surgical exploration through an 8-cm curvilinear incision over the swelling in the right iliac fossa. The subcutaneous tissue was dissected to reveal the hernia sac and contents, including viable bowel loops and omentum, which were reduced back into the peritoneal cavity [Figure 4].
Intraoperatively, a 10 cm × 8 cm right ovarian mass was identified, for which a right ovarian cystectomy was performed, and the specimen was sent for histopathological examination. The fascial defect of nearly 2 cm was repaired using the sublay technique. A synthetic polypropylene mesh of size 12 cm × 12 cm was positioned in the preperitoneal space to reinforce the Spigelian fascia, ensuring tension-free reconstruction [Figure 5]. A closed suction drain was placed in the preperitoneal plane.
2.5 Follow-up and outcomes
The postoperative course was uneventful. The patient was discharged on postoperative day 5, and follow-up at 3 months showed complete wound healing with no recurrence.
2.6 Patient perspective
The patient reported relief from symptoms and expressed satisfaction with overall management and outcome.
3 Discussion
The "handlebar hernia" represents a unique mechanism of blunt trauma in which a low-velocity, high-pressure impact by a small-surface-area object causes localized disruption of the abdominal wall musculature, including the transversus abdominis and internal oblique, without exceeding the elastic threshold of the skin.
[3-
5]The Spigelian aponeurosis represents an anatomical weakness between the rectus sheath and the semilunar line.
[5,
6]It can be classified into high-energy and low-energy injuries. The diagnosis is challenging based on physical examination alone, as the overlying skin and subcutaneous fat mask the fascial defect.
[7,
8] The "handlebar sign, " a localized ecchymosis, is a useful clinical indicator of potential underlying injury; however, its absence does not rule out underlying visceral or fascial injury.
[3] CECT has emerged as the gold standard for diagnosis, as it allows precise visualization of myofascial rupture and identification of vascular or visceral damage.
[2,
7] In our case, CECT was instrumental in identifying the hernia and characterizing the adnexal mass.
Surgical management remains a subject of debate regarding the ideal timing and technique.
[2,
9] It involves open exploration to rule out concurrent intra-abdominal injuries.
[7,
10] However, laparoscopic and robotic repairs are gaining traction as it is advantageous to identify occult contralateral defects.
[7,
10]In this case, a clean surgical field and absence of bowel compromise supported the safe use of prosthetic mesh, in accordance with recent literature.
[2,
5] The sublay repair is favored for its biomechanical superiority, as intra-abdominal pressure helps secure the mesh against the posterior abdominal wall.
[2]Ovarian dermoid cysts can occasionally mimic or be associated with hernia sacs, in sliding hernias or in cases involving parasitic dermoid locations.
[11,
12] In this instance, trauma-focused imaging facilitated simultaneous management of a large mature ovarian teratoma that might have led to acute complications, such as torsion or rupture.
[11,
13] Although such pathology is exceedingly rare, incidental discovery during exploration necessitates meticulous excision.
[11,
13] The successful management of both the traumatic Spigelian hernia and the ovarian pathology highlights the importance of comprehensive clinical and radiological assessments in trauma settings.
4 Conclusion
Traumatic Spigelian hernias following bicycle handlebar injuries are rare and require a high index of clinical suspicion after focal blunt abdominal trauma. The "handlebar hernia" mechanism should prompt CECT imaging to confirm the diagnosis and evaluate associated injuries or concomitant pathology. Open surgical repair with sublay mesh reinforcement remains a safe and effective strategy for restoring abdominal wall integrity.
© 2026 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow on behalf of Higher Education Press
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