Our patient sustained a high-energy trauma caused by a fall from a large height. This trauma gave rise to the TAWH and associated devascularisation of the small bowel, necessitating bowel resection. Low energy trauma can lead to smaller TAWHs, which can easily be missed on physical evaluation. Handlebar injury is an example of a low energy trauma that can lead to TAWH [
2,
11,
12]. This smaller TAWH can and often will be treated secondarily due to delayed diagnosis. The diagnosis of a TAWH on physical examination can be difficult; because of its rare occurrence, a diagnosis of TAWH is not often considered. With TAWHs, the elastic skin remains intact. In our patient, the TAWH was not diagnosed by physical examination, and the very tender right hemi-abdomen was thought to be associated with intra-abdominal lesions. Because life-threatening intra-abdominal injuries can occur after high-energy trauma, a CT scan should be used as a diagnostic method [
13]. The CT scan in this case led to the diagnosis of TAWH after careful examination of the abdominal wall and also to multiple haematomas in the mesentery and a spleen laceration. The strong shear forces had split the three layers of the lateral abdominal wall and the peritoneum. With the routine use of CT scans after blunt trauma, TAWH will be accurately diagnosed more often. TAWH can be operated on by an incision overlying the defect, but in this case, a midline exploratory laparotomy was necessary for the associated intra-abdominal injuries. A late diagnosed TAWH has also been operated on laparoscopically [
14]. In addition, because of the associated intra-abdominal injuries, delayed exploration of the TAWH was not a treatment option in our case [
15]. We combined the primary closure in the anatomical layers with an intraperitoneal mesh because the fascia was stretched out by the trauma and the hernia was very large. We used a composite mesh because the inner side was in direct contact with the bowels. In a recent review of the open treatment of incisional hernia, the pooled infection rate for mesh use was 10.1% [
16]. Also, in a recent retrospective study of 206 open sublay mesh repairs with intraperitoneal placement of a composite mesh, the infection rate was 10.2% in a 9.5-year period [
17]. In our case, resection of a small bowel section could have increased the risk of a mesh infection. The high infection rate has to be weighed against the risk of recurrence. In a series of eight acutely repaired TAWHs without mesh, three developed a recurrent hernia after 8 months [
6]. In another series of seven acute repairs of TAWHs, the repair attempt was only successful in two patients [
18]. Thus, the acute repair of a large TAWH should not be underestimated because of the associated injuries and the risk of a recurrence.