A 66-year-old woman suffered a seatbelt injury in a traffic accident while driving. She had undergone cesarean section via a low midline incision 20 years earlier. Upon admission by way of a local hospital, her blood pressure was 93/54 mmHg, pulse rate was 117 beats/min, respiratory rate was 26 breaths/min, and body temperature was 35oC. She received transfusion of four units of packed red blood cells. On physical examination, she was found to have abdominal distension with signs of diffuse peritoneal irritation and a horizontal bruise (the seatbelt sign) on the lower abdomen (
Fig. 1). Abdominal computed tomography revealed small bowel herniation through the lower abdominal wall, extravasation from mesenteric vessels, intra-abdominal free air, fluid collection in the anterior abdominal wall adjacent to the herniated bowel, and a stable aortic dissection just above the aortic bifurcation (
Fig. 2). The patient’s injury severity score was 27. She underwent emergency laparotomy, which revealed massive small bowel herniation as large as the size of the abdominal wall defect through the cesarean midline incision, multiple perforations of the small bowel with spillage of bowel contents, and mesenteric lacerations with active bleeding (
Video 1). The herniation extended transversely in both directions from the low midline. Simultaneously, an MLL was found tunneled into the anterior aspect of the anterior sheath of the abdominal wall, and the lesion conformed to the seatbelt injury at the lower abdomen. We performed primary repair of the small bowel and mesentery and hernioplasty for TAWH. Septic shock developed immediately thereafter, with aggravation of skin ischemia along the seatbelt sign (
Fig. 3A and
3B). Wide excision and debridement of the skin and subcutaneous tissue were performed on hospital day (HD) 4, and then negative-pressure wound therapy (NPWT) with vacuum was applied subsequently (
Fig. 3C). Her serum C-reactive protein and procalcitonin levels decreased from 31.51 mg/dL and >100 ng/mL, respectively, on HD 4 to 21.62 mg/dL and 35.15 ng/mL, respectively, on HD 6, and the sepsis subsided gradually. The excised wound was approximated piecemeal with NPWT, and by HD 81, it had completely healed without skin grafting, since the patient was obese and had redundant skin and subcutaneous tissue (
Fig. 4). Unfortunately, she died of aspiration pneumonia on HD 125.