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Spontaneous Evisceration of Incisional Hernia with Strangulation of Small Bowel: A Life Threatening Complication

Spontaneous evisceration of abdominal viscera is a rare complication of incisional hernia which could pose a serious threat to life if intervention is delayed. We report a case of a 62-year-old female with a history of curative resection for stage 1 endometrial adenocarcinoma 3 years ago, presenting with spontaneous evisceration of incisional hernia with strangulation of small bowel. Immediate resuscitation followed by emergency surgery was mandatory. During surgery, priority should be given to release the strangulation as soon as possible and the type of repair would depend on the viability of the bowel and the anatomy of the incisional hernia.


Introduction
Incisional hernias arise through a defect in the musculofascial layers of the abdominal wall in the region of a postsurgical scar. Spontaneous evisceration of abdominal viscera is a rare complication of incisional hernia which could pose a serious threat to life if intervention is delayed [1][2][3]. We report a case of a spontaneous evisceration of incisional hernia with strangulation of small bowel.

Case Presentation
A 62-year-old obese female presented with spontaneous rupture of incisional hernia for 4 hours duration. She had a history of curative total abdominal hysterectomy and bilateral oophorectomy for stage 1 endometrial adenocarcinoma 3 years ago. She was also treated with adjuvant chemoradiation. Subsequently, she developed a surgical site infection and with breakdown of skin and subcutaneous tissues and was treated with repeated wound debridement and second-ary suturing. She did not have diabetes mellitus or other long-standing medical comorbidities. She had noticed a bulge in the lower abdomen which was progressively enlarging in size over a period of 7 months and did not seek treatment.
On admission, she did not have fever or features of intestinal obstruction. She was haemodynamically stable. Her abdomen was pendulous with a large incisional hernia over the Pfannenstiel incision. A loop of grossly congested and oedematous small bowel was seen eviscerating through a small defect in the skin suggestive of early strangulation ( Figure 1).
Her blood investigations including full blood count, serum electrolytes, renal functions, and clotting profile were normal. She was resuscitated and planned for emergency surgery.
As the first step during surgery, the strangulation was released by enlarging the skin defect which was 3 cm in diameter ( Figure 2). Fortunately, the bowel was viable without any evidence of gangrene. Thereafter, an elliptical incision was made over the incisional hernia incorporating the defect. A large (10 cm in diameter) abdominal wall defect was identified with extensive adhesions. Careful adhesiolysis was performed and the bowel was reduced into the peritoneal cavity. The defect was closed and an on lay mesh repair was performed. She had an uneventful recovery and was discharged on the 5 th postoperative day. At one month following surgery, she had complete wound healing and was able to perform her normal day-to-day activities.

Discussion
We report an unusual presentation of spontaneous rupture and evisceration of incisional hernia with strangulation of small bowel. This is a rare complication of an abdominal incisional hernia, which is a defect in the abdominal wall that lies close to a scar from a previous full-thickness abdominal incision [2,3]. Similar case reports published after 2010 are summarized in Table 1. Similarly, rupture and evisceration of parastomal hernias have also been reported [4]. There are multiple risk factors for developing incisional hernias, such as advanced age, wound infection, diabetes mellitus, poor nutrition, malignancy, obesity, and any condition that causes a chronically raised abdominal pressure [5]. Our patient had several risk factors such as older age, obesity, malignancy and history of wound infection, and repeated wound debridement following initial surgery. Furthermore, the adjuvant chemoradiation would have also resulted in poor wound healing and caused the development of the incisional hernia.
In the majority, incisional hernias are identified incidentally on examination. Nevertheless, delay in repair of incisional hernias can lead to major complications such as bowel incarceration, strangulation, ischaemia, and even bowel necrosis and perforation [2]. However, spontaneous rupture and strangulation is an unusual complication [5].
Spontaneous rupture of an incisional hernia may be sudden or gradual. Sudden rupture occurs due to a steep rise in pressure in the abdominal cavity (e.g., coughing and lifting heavy objects) [6]. On the contrary, gradual rupture occurs following an ulcer on the dependent part of the sac of the hernia. Large incisional hernias are more prone to rupture due to the thin hernia sac, with atrophied overlying skin [6].
Eviscerated hernias must be treated immediately in order to prevent bowel strangulation and obstruction. If the bowel is viable, primary mesh repair may be performed. As an alternative, primary closure without a mesh followed by delayed secondary mesh repair may also be performed [7]. In the event of bowel gangrene, a laparotomy with bowel resection and anastomosis would be required [7]. We performed a primary mesh repair, because the bowel was viable after releasing the strangulation and the patient had a satisfactory outcome. An onlay mesh repair was performed as opposed to a retrorectus repair as we were more familiar with the onlay technique, and furthermore, the rectus sheath was considerably thinned out making retrorectus dissection difficult.   Case Reports in Surgery  Nitroglycerine intravenous infusion to lower the blood pressure. Emergency surgery: a loop of small bowel was found adherent to superior aspect of the hernial defect and was dissected free. Hernial sac with redundant skin was excised and large hernial defect of about 10 × 8 cm in size was closed by polypropylene mesh underlay repair Postoperative period was uneventful except for a minor stitch abscess at the lower end of the wound that cleared in 3 days. Discharged on the 8th day at 2-year follow-up, no recurrence was noted.

Conclusion
We report a patient with an incisional hernia who presented with spontaneous evisceration and strangulation of small bowel. Immediate resuscitation followed by emergency surgery was mandatory. During surgery, priority should be given to release the strangulation as soon as possible, and the type of repair would depend on the viability of the bowel and the anatomy of the incisional hernia.

Data Availability
The data used to support the findings of this study are included within the article.

Consent
Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Conflicts of Interest
All authors declare that they have no conflicts of interest.