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Strangulated Small Bowel Hernia within a Prolapsed Colostomy Stoma 1

Case report An 83-year-old man was admitted with an 8-hour history of a painful prolapsed colostomy. Two . years previously he had undergone a Hartmann's procedure for a moderately differentiated adenocarcinoma of the distal sigmoid colon (Dukes C) which caused acute large bowel obstruction. The second stage procedure to restore bowel continuity was not performed because of respiratory problems. The colostomy prolapsed 6 months after the first operation but no action was taken as it functioned well.On this admission with acute abdominal pain, examination revealed a dusky blue prolapsed colostomy some 9 x 13 cm with superficial ulceration at its apex. A right pleural effusion was also noted and confirmed by a chest radiograph. Abdominal radiography showed a loaded proximal colon. Exploration was performed under general anaesthetic. The anterior wall of the prolapsed colostomy was incised and revealed 60 em of gangrenous small bowel contained between the two walls of large bowel (Figures I and 2). A small incision was made in the abdominal wall lateral to the colostomy stoma in order to deliver the small bowel. The gangrenous 60 em was resected and end-to-end anastomosis performed; 22 em of necrotic -prolapsed large bowel was also resected and the colostomy refashioned. . The patient made an uneventful recovery. Histology confirmed full thickness ischaemic necrosis of both small and large bowel. The pleural fluid was aspirated and contained adenocarcinoma cells. In view of the patient's age