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 secondary 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.\nOn 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 ().\nHer blood investigations including full blood count, serum electrolytes, renal functions, and clotting profile were normal. She was resuscitated and planned for emergency surgery.\nAs the first step during surgery, the strangulation was released by enlarging the skin defect which was 3 cm in diameter (). 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 5th postoperative day. At one month following surgery, she had complete wound healing and was able to perform her normal day-to-day activities.
A 17-year-old boy slipped in the bathroom and landed on his gluteal region. When he got up, he developed pain in his lower abdomen and noticed bleeding from his rectum along with mass. He was taken to a nearby hospital where they documented it to be prolapsed omentum which was digitally repositioned and was referred to our centre. On examination at our centre, about 3 h after his fall, he had tachycardia but was haemodynamically stable. Abdomen examination revealed tenderness in the lower abdomen with no peritoneal signs. There were no bruises or evidence of pelvic fracture. A rectal examination showed only blood and no mass was seen. A magnetic resonance imaging (MRI) of the abdomen was performed which picked up a tear in the rectum about 2–3 cm just above the peritoneal reflection with the omentum plugging it [Figure and ]. On repeated questioning, he denied any history of rectal instrumentation or abnormal sexual activity. He had no history of constipation or rectal prolapse. He had undergone an appendectomy many years ago. He was administered broad spectrum antibiotics and taken up for a diagnostic laparoscopy during which a 3 cm transverse tear in the left anterolateral aspect of the rectum just at the peritoneal reflection with the omentum plugging it was seen with minimal contamination []. There were no underlying faecoliths. The omentum and pelvic cavity were irrigated with copious saline. The tear was repaired in two layers [] using four ports, one 10 mm and three 5 mm. A covering loop sigmoid colostomy was added. He made an uneventful post-operative recovery. Eight weeks later, a rectal contrast study was done which showed no leak of contrast, and a sigmoidoscopy to rule out an underlying pathology was normal following which his colostomy was closed. Three months following the last surgery, he is doing well. He was repeatedly questioned but denied any direct trauma, in any form that could have caused the injury.