|Year : 2013 | Volume
| Issue : 4 | Page : 288-291
Spontaneous rupture of incisional hernia with transection and perforation of small bowel: A case report
Haricharan Perigela, Vasamsetty Muralikrishna, Bangi Varaprasad, Nagabhushigari Sivaraj
Department of General Surgery, Kurnool Medical College and Hospital, Kurnool, Andhra Pradesh, India
|Date of Web Publication||26-Nov-2013|
Department of General Surgery, Kurnool Medical College and Hospital, Kurnool, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Spontaneous rupture of an abdominal hernia is rare and usually occurs in incisional or recurrent groin hernia. The hernial contents can be covered primarily by mesh repair if the general condition of the patient and local condition of the operative site allows it or it can be covered by skin followed by delayed mesh repair. We report a case of spontaneous rupture of incisional hernia with transection of small bowel and perforation in a 60-year-old woman who had developed hernia following a cesarean operation and was managed by resection and end-to-end anastomosis and herniorrhaphy.
Keywords: Incisional hernia, spontaneous rupture, transection of small bowel
|How to cite this article:|
Perigela H, Muralikrishna V, Varaprasad B, Sivaraj N. Spontaneous rupture of incisional hernia with transection and perforation of small bowel: A case report. J NTR Univ Health Sci 2013;2:288-91
|How to cite this URL:|
Perigela H, Muralikrishna V, Varaprasad B, Sivaraj N. Spontaneous rupture of incisional hernia with transection and perforation of small bowel: A case report. J NTR Univ Health Sci [serial online] 2013 [cited 2020 Mar 28];2:288-91. Available from: http://www.jdrntruhs.org/text.asp?2013/2/4/288/122175
| Introduction|| |
The incidence of incisional hernia following cesarean section by vertical incision is 3.1%.  Rupture as a complication may occur in any type of hernia with increased incidence in incisional and groin hernias.  Only few cases of spontaneous rupture of abdominal hernia has been reported in the literature.
The site of rupture is different in different studies. Hartley  and Hamilton  reported rupture through lower midline incision, while Aggarwal  found herniation after upper abdominal surgery following perforated duodenal ulcer. We report a case of spontaneous rupture of incisional hernia following a cesarean operation.
| Case History|| |
A 60-year-old woman came to casualty with a history of bowel loops outside the abdominal cavity since past 1 day [Figure 1]. There was no history of trauma. Past history of three cesarean sections was recorded, with the last one 30 years ago. She developed incisional hernia 2 years after the last surgery. Although she was advised repair of incisional hernia, she refused. On examination, she was slightly anemic and had pulse 98/min and BP 110/72 mmHg. The respiratory and cardiovascular systems were normal. Abdominal examination revealed a loop of small intestine of about 15 cm coming through incisional hernia developed in infraumbilical midline incision. The bowel was transected at one point, and above it there was a perforation. Skin was thin, atrophic, and avascular. Routine investigations were within normal limits except Hb%, which was 8 gm%. The diagnosis of spontaneous rupture of incisional hernia with transection and perforation of small bowel was made.
The patient was shifted to emergency operation theater. Elliptical infraumbilical incision was given encircling previous incision. The constriction point over the skin was released [Video 1] [Figure 2], [Figure 3]. Resection of the transected bowel and perforated area was done followed by end-to-end anastomosis [Figure 4], [Figure 5]. After removing all the atrophic, avascular, and scarred skin, herniorrhaphy was done with no.1 prolene sutures [Figure 6]. Postoperative recovery was uneventful. Suture removal was delayed, and it was done on 15 th postoperative day. Wound healed well without infection. After 15 days of follow-up, the patient was asymptomatic.
|Figure 2: Patient in the operation theater with skin lifted to show the constricted portion|
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|Figure 3: Figure showing curved artery forceps through the ruptured site of the skin|
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|Figure 4: Figure showing resection of segment of small intestine with transected portion and perforation|
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|Figure 5: Figure showing end-to-end anastomosis of the small intestine after resection|
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|Figure 6: Figure showing the closure of the skin wound after herniorrhaphy|
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| Discussion|| |
Incisional hernia following cesarean section has been associated with vertical midline incision, wound infection, malnutrition, and poor surgical technique.  Other associated factors include additional operative procedure, presence of postoperative abdominal distension, intra-abdominal sepsis, residual intra-abdominal abscess, wound dehiscence, and postoperative fever.
Complications such as adhesions, incarceration of bowel, and intestinal obstruction are well documented in association with incisional hernia, but spontaneous rupture is rarely reported in literature.  Although theoretically spontaneous rupture can occur with any type of abdominal hernia, it is more commonly reported in incisional hernia. 
Large incisional hernia is contained only by its sac and thin atrophic avascular skin. Larger the hernia, more atrophic and avascular is the overlying skin, and, this, along with thin sac leads to higher chances of rupture of incisional hernia.  Neglect for early operative intervention or delay in seeking the treatment for incisional hernia increases the risk of rupture.  The rupture may be sudden, following any event that can increase the intra abdominal pressure like coughing, lifting heavy weight, straining at defecation, and micturition, or it may be gradual after developing an ulcer at the fundus.  Other factors that can contribute to rupture of a hernia are friction by the patient's external corset or abdominal support, lack of adhesions between the bowel, and the hernial sac allowing the bowel to act as a hammerhead upon the skin.  In our case, rupture of incisional hernia occurred because of sudden increase in intra-abdominal pressure due to excessive coughing and thin atrophic avascular skin covering of the hernia. Delay in seeking prior surgical treatment for incisional hernia was also a contributed factor.
Rupture of abdominal hernia demands emergency operation. The hernial contents can be covered primarily by mesh repair if the general condition of the patient and local condition of the operative site allows the same or it can be covered by skin followed by delayed mesh repair. 
To use a permanent synthetic mesh or biologic mesh for incisional hernia repair depends on various factors. In a prospective study, Tang and coworkers investigated the immediate repair of major abdominal wall defects after extensive tumor excision in patients with abdominal wall neoplasm. The authors studied 27 cases and concluded that biological mesh was an ideal alternative to synthetic mesh for abdominal wall restoration after tumor resection, especially in situations of infection or contamination.  Ghazi et al., retrospectively reviewed all patients who required the reconstruction of complex abdominal wall defects (165 patients in 7 years). Mesh was used in 81.8% of cases, 77% of those being acellular dermal matrices. The authors found that the recurrence rate was similar for synthetic and biomesh reconstructions; however, the complication rates were higher when synthetic mesh was used.  Biologic grafts represent a major advancement in complex hernia repair. Further investigation regarding the appropriate indications, performance of the grafts based on individual properties such as cross-linking and potential complications are needed. Given the high cost of most of these materials and the limited available data, biologic mesh should be used judiciously and only when permanent synthetic mesh is inappropriate, such as in the contaminated field.
| Conclusion|| |
Spontaneous rupture of abdominal hernia is a very rare complication, and it usually occurs in incisional and recurrent groin hernia. The rupture of abdominal hernia demands emergency surgery. This case is presented for its rarity as spontaneous rupture is associated with transection of small bowel and perforation and to emphasize the need for early operative intervention to prevent this avoidable rare complication of incisional hernia. As there was local contamination, synthetic mesh could not be used and because of the high cost and non-availability of biologic mesh, it was also not considered.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]