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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 8  |  Page : 69-70

Spontaneous evisceration through an incisional hernia: A rare complication in surgical practice


1 Department of Surgery, School of Medical Sciences, University of Cape Coast; Cape Coast Teaching Hospital, Cape Coast, Ghana
2 Department of Surgery, School of Medical Sciences, University of Cape Coast, Ghana

Date of Web Publication3-Jan-2017

Correspondence Address:
Ayokunle Osonuga
School of Medical Sciences, University of Cape Coast, Cape Coast
Ghana
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2250-9658.197444

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  Abstract 

Incisional hernias complicate 2-20% of laparotomies. They rarely eviscerate spontaneously and pose a serious threat to the protruding bowel and the patient's life if timely intervention is not instituted. We report a case of spontaneous rupture of an incisional hernia in a 56-year-old female who underwent laparotomy 20 years before presentation at the Accident and Emergency Department of the Cape Coast Teaching Hospital. An emergency laparotomy was done where extensive adhesions between the bowel and the anterior abdominal wall were noted after initial resuscitation. The bowel was then returned into the peritoneal cavity, and the fascia closed with nylon 2. Excess lax and thinned out skin was trimmed and the skin closed with vicryl 0 and recovery was uneventful. Neglect for early operative intervention or delay in seeking the treatment for an incisional hernia increases the risk of rupture. Once ruptured, timely repair of the defect can be done if no gangrenous segment is found.

Keywords: General surgery, incisional hernia, spontaneous evisceration


How to cite this article:
Osei-Tutu E, Osonuga A. Spontaneous evisceration through an incisional hernia: A rare complication in surgical practice. N Niger J Clin Res 2016;5:69-70

How to cite this URL:
Osei-Tutu E, Osonuga A. Spontaneous evisceration through an incisional hernia: A rare complication in surgical practice. N Niger J Clin Res [serial online] 2016 [cited 2020 Aug 10];5:69-70. Available from: http://www.mdcan-uath.org/text.asp?2016/5/8/69/197444


  Introduction Top


An incisional hernia is a partial internal abdominal wall defect that is in proximity to the scar of a previously closed full thickness ventral abdominal wall incision. [1] They continue to be a significant problem for patients as well as surgeons, complicating between 2% and 20% of laparotomies. [2],[3] The highest incidence, however, occurs following lower midline and transverse incisions. [1] Spontaneous evisceration is a rare but serious complication of an incisional ventral hernia. [2],[3],[4] Particularly, thin-walled large incisional hernia may ulcerate at its fundus so that omentum/bowel protrudes through the defect. [4]

We report a case of spontaneous rupture of an incisional hernia in a 56-year-old female who underwent laparotomy 20 years before presentation.


  Case Report Top


A female patient presented to the Accident and Emergency Centre of the Cape Coast Teaching Hospital with an acute abdominal pain, vomiting, and protrusion of viscus through an incisional hernia. She initially tried reducing the eviscerated viscus, but to no avail and reported to the hospital 4 h after the incident occurred. She had had five episodes of vomiting; vomitus initially containing clear secretions which later became bilious. Three days prior to presentation, she noticed an ulcer distal to the site of the incision which was subsequently associated with swelling and a foul smelling discharge. The past medical history revealed patient had abdominal surgery over 20 years ago. She could not recall the exact procedure. Two years after the surgery, she developed two protrusions in her lower abdomen in proximity to the scar. There was no history of trauma or application of herbal medicine on the hernia. She had a chronic cough and had lost considerable weight.

Clinically, the patient appeared cachectic and mildly dehydrated. On examination, she had pallor but was afebrile and hemodynamically stable. Abdominal examination revealed generalized tenderness. There was a subumbilical midline scar. About 40 cm of the small intestine loop was protruding through the anterior abdominal wall, and this loop was congested but healthy at large [Figure 1]. There was a discharge of serosanguinous fluid. Just superior to the eviscerated bowel was an intact incisional hernia, about 10 cm diameter. A hernia was nontender and was reducible through a wide, easily palpable defect in the anterior abdominal wall [Figure 1]. The skin overlying the hernia was thinned out.
Figure 1: Ruptured incisional hernia with bowel evisceration at presentation

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The patient was diagnosed with a ruptured incisional hernia and was planned for emergency exploration after resuscitation. Hematological examination revealed hemoglobin of 11.1 g/dL, white blood cell count was 8 × Í10 9 /L and platelets 238×Í 10 3 /L. The patient was rehydrated with intravenous fluids until urinary output was adequate. Antibiotics (ceftriaxone, ciprofloxacin, and metronidazole) and an analgesic (paracetamol) were given and the patient was prepared for operation. At operation, eviscerated ileum which was viable was seen. A laparotomy was done where extensive adhesions between bowel and the anterior abdominal wall were noted. Some adhesiolysis was done and the abnormal fascia was excised. The bowel was then returned into the peritoneal cavity, and the fascia closed with nylon 2. Excess lax and thinned out skin was trimmed and the skin closed with vicryl 0. Recovery was uneventful. An HIV serological test done after patient's consent was obtained turned out to be positive for HIV 1. She was counseled referred to the medical team for management of the HIV infection. The patient was discharged on the 4 th postoperative day and was to dress wound daily at nearby clinic. She was to return on the 10 th postoperative day for stitch removal.

Follow-up - Patient was lost to follow-up upon discharge from the hospital.


  Discussion Top


Longstanding incisional hernias have been associated with many complications such as adhesions, incarceration of bowel, gangrene of bowel, and intestinal obstruction. [2],[3],[4],[5] Spontaneous rupture of an incisional hernia is a rather rare occurrence and to the best of our knowledge, this is the 1 st time it is being reported in Ghana.

A large incisional hernia is usually contained by a thin sac and atrophic avascular skin. [5] The continuous friction between a hernia and the abdominal wall, the hernia and external garments, in combination with moisture and warmth, is likely to cause dermatitis and lead to ulceration. In addition, some patients may apply traditional herbal medicines in an attempt to treat a hernia, and this often causes inflammation, necrosis and sometimes gangrene of the skin resulting in ulcers which may precipitate spontaneous rupture of a hernia. [5],[6],[7],[8] The rupture may be sudden following an increase in intra-abdominal pressure such as during bouts of coughs, straining at defecation and micturition, during pregnancy and vaginal deliveries and lifting heavy weights. [6],[7]

In our patient, rupture was probably precipitated by damage to the overlying skin which was stretched, thinned and ulcerated. The immediate precipitant for our patient, however, was likely to be a sudden increase in intra-abdominal pressure due to a chronic cough. Though poor wound healing has been associated with immunodeficiency states, [9] the role of HIV infection as an etiological factor for the spontaneous rupture of an incisional hernia is unclear and needs to be further evaluated.


  Conclusion Top


Neglect for early surgical intervention for incisional hernias as well as all other hernias increases the risk of many avoidable complications. Early repair of incisional hernias is therefore advocated to help reduce the morbidity, mortality associated with the complications of these hernias as well as the recurrence rates associated with emergency repair of these hernias.

Acknowledgments

We wish to acknowledge our teachers Prof. S. A. Debrah and Prof G. A. Rahman for their technical support and suggestions while preparing this paper.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Luijendijk RW. Incisional Hernia: Risk Factors, Prevention and Repair. Scheveningen, Netherlands: Drukkerij Edauw & Johannissen; 2000. Available from: http://www.repub.eur.nl/pub/20985/000608_LUIJENDIJK,%20Roland%20Wouter.pdf. [Last accessed on 2014 Dec 06].  Back to cited text no. 1
    
2.
Sailaja S, Umadevi K, Rathod PS, Shruti S, Bafna UD. Spontaneous evisceration of an incisional hernia presenting one year after primary surgery. Online J Health Allied Sci 2013;12:15.  Back to cited text no. 2
    
3.
Tsavdaris G, Hotzoglou N, Kosmidis A, Karakatsanis A, Keokos N. Spontaneous ruptured incisional hernia. Hellenic J Surg 2012;84:187-8.  Back to cited text no. 3
    
4.
Gupta RK, Sah S, Agrawal SC. Spontaneous rupture of incisional hernia: A rare cause of a life-threatening complication. BMJ Case Rep 2011. bcr1120103486. doi: 10.1136/bcr.11.2010.3486.  Back to cited text no. 4
    
5.
Kshirsagar AY, Vasisth GO, Dwivedi P, Nikam YP. Spontaneous rupture of incisional hernia: A rare life-threatening complication of incisional hernia. Int J Biomed Adv Res 2013;4:565-6.  Back to cited text no. 5
    
6.
Martis JJ, Shridhar KM, Rajeshwara KV, Janardhanan D, Jairaj D. Spontaneous rupture of incisional hernia-a case report. Indian J Surg 2011;73:68-70.  Back to cited text no. 6
    
7.
Hamilton RW. Spontaneous rupture of an incisional hernia. Br J Surg 1966;53:477-9.  Back to cited text no. 7
    
8.
Mudge M, Hughes LE. Incisional hernia: A 10 year prospective study of incidence and attitudes. Br J Surg 1985;72:70-1.  Back to cited text no. 8
    
9.
Eke N. Spontaneous rupture of an incisional hernia. Highland Med Res J 2006;4:86-8.  Back to cited text no. 9
    


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