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.
Mrs. B. O. is a 40-year-old petty trader. She is para 1+0 with one living male child. She achieved menarche at 14 years of age. She has a regular 28 days menstrual cycle with 4 days menstrual flow, and her last menstrual period was on January 15, 2014. She presented at the gynecology clinic of University of Nigeria Teaching Hospital on January 22, 2014 with complaints of masses protruding from her vagina and anus of 24 months duration. The protrusions started 5 months after a spontaneous unsupervised delivery at home of a live male baby. The concomitant protrusions occurred spontaneously. They were usually noticed while straining, sneezing, coughing or in standing position, but often receded spontaneously while in a recumbent position. There was associated low back pain, urinary frequency, and constipation. There was no chronic cough, weight lifting, dysuria, abdominal swelling, or similar family history. About 6 months prior to the presentation, the condition became associated with weight loss and difficulty in holding her stool. The vaginal protrusion no longer receded spontaneously in recumbent position and then required manual reduction. On examination, she appeared generally well. There were no abnormal findings on the examination of the chest, abdomen, central nervous system, and the musculoskeletal system. Pelvic examination showed a protrusion of the entire uterus from the vagina. The protrusion was reducible with associated mild cystocele []. There was no demonstrable stress incontinence. The cervix was healthy looking and the os was parous. The uterus was normal sized, retroverted, and mobile. The adnexa were free. Rectal examination showed a concomitant mass (rectum) protruding from the anus []. There was associated fecal incontinence, but the rectal mucosa was normal. A diagnosis of concomitant occurrence of uterovaginal prolapse (procidentia) and rectal prolapse was made. The hemoglobin concentration, white cell count, urinalysis, culture of her midstream urine, stool analysis and culture, and abdominopelvic ultrasound showed no abnormality. In view of her parity and desire to retain her reproductive function, she and her husband were counseled for open abdominal sacrohysteropexy with synthetic mesh and rectopexy, which they consented to. Following the above investigation results which were available within 2 weeks from her first clinic visit, she was admitted into the ward for the above surgery. While in the ward, she was reviewed by the general surgeons who commenced her on a 1-day mechanical bowel preparation alongside with antibiotics bowel preparation, using the oral neomycin and metronidazole for antibiotics bowel preparation. She had an overnight fasting prior to the day of surgery and was placed on intravenous fluid (normal saline) to ensure adequate rehydration. She received intravenous ceftriaxone and metronidazole as preoperative antibiotics medication. She subsequently had a successful surgery done by a combined team of gynecologists and general surgeons. The surgical procedure briefly involved a general anesthesia/endotracheal intubation; peritoneal cavity entered via a midline sub-umbilical incision; synthetic mesh sutured to the back of the cervix with the other end sutured to a prominent part of sacral promontory (sacrohysteropexy); rectum lifted and sutures taken to secure the sides to the sacrum with a synthetic mesh that provided added reinforcement (rectopexy).\nThe postoperative period was uneventful and she is being follow-up in the gynecologic clinic. Her last clinic visit, before this report was on June 30, 2014; she had no complaint and was happy with the procedure.