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| CASE REPORT |
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| Year : 2020 | Volume
: 3
| Issue : 4 | Page : 155-157 |
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Inside-out: Spontaneous bowel evisceration, a rare complication of the ventral hernia
Ee Wen Lim, Sabrina Ngaserin, Fung Joon Foo
Department of Surgery, Sengkang General Hospital, Singapore
| Date of Submission | 18-Jun-2020 |
| Date of Decision | 23-Jun-2020 |
| Date of Acceptance | 05-Jul-2020 |
| Date of Web Publication | 30-Nov-2020 |
Correspondence Address:
Dr. Sabrina Ngaserin
Department of Surgery, Sengkang General Hospital, 110 Sengkang East Way, 544886
Singapore
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_25_20
Spontaneous nontraumatic bowel evisceration from a ruptured long-standing abdominal wall hernia is a rare occurrence. Sporadic case reports exist describing bowel evisceration from long-standing ventral herniae, whereby baseline increased intra-abdominal pressure was rendered more pronounced due to sudden increase and/or trauma. Morbidity and mortality rates are significant, and treatment can be technically complex. We present a case of spontaneous small bowel evisceration from rupture of a recurrent ventral hernia in a patient with liver cirrhosis, who was managed with emergent surgical mesh repair and discuss the spectrum of relevant surgical techniques for this unique group of patients.
Keywords: Biological mesh, complex ventral hernia, mesh repair, spontaneous bowel evisceration
How to cite this article:
Lim EW, Ngaserin S, Foo FJ. Inside-out: Spontaneous bowel evisceration, a rare complication of the ventral hernia. Int J Abdom Wall Hernia Surg 2020;3:155-7 |
| Introduction | |  |
Spontaneous nontraumatic bowel evisceration from a ruptured long-standing abdominal wall hernia is a rare occurrence. Sporadic case reports exist, where patients typically have a baseline higher intra-abdominal pressure that is rendered more pronounced acutely or with trauma.[1],[2],[3],[4],[5],[6],[7],[8],[9] Morbidity and mortality rates are significant, and treatment can be technically complex. We present a case of spontaneous small bowel evisceration from a ruptured recurrent ventral hernia in a patient with liver cirrhosis managed with emergent inlay mesh repair and discuss the spectrum of surgical techniques for this unique group of patients.
| Case Report | | |
A bed-bound 65-year-old male presented to the emergency department after sudden, spontaneous evisceration of his bowels during a bed-to-bed transfer. He had a significant past medical history of Child–Pugh's B liver cirrhosis secondary to Hepatitis B infection, with complications including portal hypertension, esophageal varices, and ascites requiring multiple drainage procedures. He had previously undergone primary surgical repair of a strangulated umbilical hernia at another institution 4 years prior, with subsequent exploratory laparotomy for postoperative adhesions. He was conservatively managed for this long-standing recurrent incisional hernia and had been leaking serous fluid from a small wound for a year due to refractory ascites.
On arrival, he was hypothermic, hypotensive, tachypneic, and intravascularly depleted. On examination, there was irreducible eviscerated congested small bowel from a skin defect of 4 cm, with impingement of the mesentery [Figure 1]a, but no bowel ischemia or perforation. He was resuscitated with the immediate goal to treat his critical surgical condition, within the context of ultimate palliation. | Figure 1: Spontaneously eviscerated bowel from a longstanding umbilical and incisional hernia, for which laparotomy and biologic inlay mesh repair was performed. (a) Spontaneous evisceration of bowel at presentation. (b) Intraoperative in-lay mesh anchored to widely retracted fascia. (c) Abdomen in early postoperative period before re-accumulation of ascitic fluid. (d) Abdomen one week after operation
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His skin defect was extended as a limited midline laparotomy incision, and nonabsorbable sutures from the previous operations were seen along the laterally retracted fascia. The small bowel loops were congested and friable but still viable. A total of 2.5 L of ascitic fluid was drained, allowing small bowel replacement into the abdomen. Due to concerns of potential skin and bowel erosion, a biologic mesh was fashioned in 15 cm × 20 cm size and anchored in-lay to the widely retracted fascia [Figure 1]b. The abdomen was closed with drains in situ. Excess skin was purposefully left behind in anticipation of ascitic fluid reaccumulation [Figure 1]c and [Figure 1]d. The patient did not experience any surgical site occurrences, including hernia recurrence, until he passed away 2 years later from pneumonia.
| Discussion | | |
Spontaneous bowel evisceration from a ventral hernia is a rare and notably dramatic occurrence. Few case reports exist describing small bowel evisceration from long-standing umbilical,[1],[2],[3],[4],[5] incisional,[6],[7] parastomal,[8] and inguinal herniae,[9] with predisposing factors of cirrhosis with ascites,[1],[2],[3] pregnancy,[6] and obesity.[5],[7]
Patients typically present in shock related to the vasovagal response from tension generated on the mesentery, hypovolaemia, and sepsis. The skin defect occurs at the most dependent part of the abdominal wall, with surrounding skin possibly demonstrating “herald signs” of chronic neglect such as “paper-thin” skin, ulceration, and necrosis. The patients may display bowel congestion or complications such as strangulation, ischemia, and/or perforation, often requiring bowel resection. Morbidity and mortality rates can be high, usually related to the patient's preexisting moderate to high-risk comorbidities, state of shock, and bowel complications.
In general, surgical strategies for facial re-approximation vary from primary closure, myofascial release techniques, and component separation to free tissue flap reconstruction.[10] Considerations include patient profile, technical and anatomical factors such as morphology (highest risk in a midline location), the extent of fascial defect, degree of contamination, and proximity of bowel.[10] Ideally, the fascial approximation is preferred over bridging repairs, mesh reinforcement preferred over none and should occur as underlay or retro rectus placement,[10],[11] with synthetic mesh the preference in the bridging approach to minimize recurrence.[12],[13]
In all cases, prognostication and consideration of patient's wishes are important when deciding on the extent of surgical intervention and repair. Anticipated serious postoperative risks include compartment syndrome, surgical site occurrences, including mesh infection requiring explantation, bowel erosion with perforation or enterocutaneous fistulation, tissue–mesh interface failure, eventration, and hernia recurrence. Specifically for complex recurrent abdominal wall hernia with large fascial defects ≥20 cm and enhanced risk of surgical site occurrences, the otherwise less favorable “bridging” mesh repair can still be a reasonable option to minimize overall surgical stress and anesthetic time for the critically sick patient. While the on-lay technique infamously results in higher recurrence rates of up to 80%, versus under 20% when fascia is reapproximated,[11],[12] they remain a useful surgical option for the patient-facing immediate risk of mortality in the context of guarded overall prognosis and lifespan.
Challenges associated with the permanent synthetic mesh include risk of infection requiring explantation, contracture, and erosion from inflammatory foreign body response–particularly when the mesh is approximating bowel and/or skin. Meanwhile, absorbable synthetic meshes typically degrade in 90–180 days with a certainty of hernia recurrence. Biological meshes theoretically generate less of foreign body response and are more resistant to infection, and cross-linked materials can last several years.[14] Biosynthetic meshes incorporate the risk-benefit of both groups. That said, the evidence is limited and overall does not support the superiority of biologic over synthetic meshes in contaminated fields when the main concern is surgical site infection.[10],[11],[12],[13],[14]
Other damage control options also include temporary abdominal closure and planned definitive fascial reapproximated closure. Postoperative considerations include gaining control of ascites and monitoring for compartment syndrome. For the group of patients with background end-stage disease, palliation should be a consideration, with reported alternative nonoperative approaches such as fibrin glue.[15]
In general, patients with cirrhosis and ascites have a 20% lifetime risk of developing umbilical herniae.[16] While prior experiences describe mortality rates in elective repair to be as high as 38%, more current findings suggest an early surgical intervention to be a safe preferred approach.[10],[15] Surgeons can be more proactive in offering elective umbilical hernia repair to prevent anticipated complications and progression to life-threatening emergencies.
| Conclusion | | |
Ultimately, all cases of spontaneous bowel evisceration should receive individualized surgical management rooted in the honest risk-benefit discussion, in the context of their background medical condition and prognosis.
Consent to publish photo of patient
The patient involved was an institutionalized resident who suffered from schizophrenia. He was certified incompetent to provide consent. He has no known kin. The consent for his procedure was similarly undertaken by two consultant surgeons and performed in his best interest. At the time of writing, i.e., 2 years after the described events, the patient had passed away. There should not be any distinct identifiers captured on these images.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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