while the very common complication of parastomal hernia following stoma formation has been well studied and documented in the literature , the rare complication of parastomal evisceration has been featured in just four case reports [ 14 ] .
we present this case to bring new attention to this rare and relatively undocumented complication .
a 69-year - old male presented to the emergency room with findings of a necrotizing perianal fasciitis .
his past medical history was significant for chronic obstructive pulmonary disease , partial gastric outlet obstruction , alcohol abuse and a 50 pack / year smoking history .
he was initially brought to the operating room 4 days later for soft tissue debridement and diverting end sigmoid colostomy . after a midline laparotomy incision was made .
the distal sigmoid colon was identified and divided with a gia 75 stapler leaving a distal rectosigmoid pouch .
the proximal end of sigmoid colon was then brought through the cruciate facial defect which had been dilated to three finger widths .
sutures were placed at the level of the skin and not placed at the level of the fascia .
the patient was then transferred to the surgical intensive care unit ( sicu ) in stable condition . on postoperative day 1
, the patients perianal wound was found to have purulent discharge and swabs revealed gram - positive cocci in chains .
on postoperative day 2 , the patients white blood cell count improved from 17 to 15 , and tissue culture revealed alpha hemolytic streptococcus .
the patients wounds appeared to be clean , dressings were changed and the patient was advanced to a regular diet and transferred to the ward . after the original surgery and interval debridement , the patient was transferred to the floor .
his wound cultures grew streptococcus viridians sensitive to cefazolin and his antibiotic regimen was narrowed .
on postoperative day 3 , the patient began having nausea and vomiting . on examination ,
the patient was found to have his colostomy bag filled with multiple loops of small bowel ( fig .  1 ) .
at this point he was diagnosed with an evisceration and was taken back to the operating room emergently for reduction and repair . 

, the stoma bag was removed and illustrated parastomal fascial dehiscence and evisceration ( figs .  2 and 3 ) .
the midline incision was reopened and 100 cm of compromised small bowel was resected with stapled anastomosis . the parastomal defect was then visualized ( fig .  4 ) , repaired with running 2 - 0 vicryl , and the abdominal closure was closed with retention nylon sutures and looped pds in running fashion through the fascia .
the patient was then transferred to a regular surgical ward and discharged to extended care for follow - up anticipating ostomy reversal after healing of perineal wound . 

figure  2:bowel evisceration a. 
 figure  3:bowel evisceration b. 
 figure  4:parastomal defect .
as evident by this case , a colostomy is not always a simple and quick procedure .
a colostomy must be undertaken meticulously and not simply delegated to an intern or junior surgical resident . like all major surgeries
 parastomal evisceration is a very rare complication occurring after stoma formation . 
 we report the case of this complication which occurred within 3 days status post end sigmoid colostomy in a 69-year - old male who initially presented with perianal infection  severe necrotizing fasciitis . 
 this case highlights the significance of the size of a stomatal aperture and should remind general surgeons of the one of dangerous complications indicated by a stomatal aperture that is just a centimeter larger than the accepted ideal size . 
INTRODUCTION
CASE REPORT
DISCUSSION