194 An uncommon cause of small bowel obstruction with perforation after a caesarean section

Abstract

Abstract The incidence of small bowel obstruction after any abdominal surgery is 9%, whereas it is only 0.1% after a C-Section. Small bowel obstruction secondary to herniation of a segment of the small bowel beneath the intact rectus sheath and between the rectus muscle is extremely rare. Reviewing the literature revealed that less than five cases were reported. Here we present a 39-year-old female six days post caesarean section presented with abdomen pain, distension, and not opening bowels. The blood investigations showed White blood cells 15.42x109/L and C-reactive protein 286mg/L. She was hypotensive and tachycardic. On clinical examination, the abdomen was distended and peritonitic. The Computed tomography of the abdomen and pelvis with contrast showed there is small bowel obstruction with multiple loops of proximal dilated bowel with a transition point within the pelvis and in midline a small inferior umbilical or incisional hernia containing a knuckle of small bowel with a moderate amount of pneumoperitoneum and free fluid. She underwent an emergency laparotomy and was found to have four quadrants of purulent peritonitis. In addition, a 3cm defect in the midline peritoneum allowed herniation of approximately 30cm of small bowel into preperitoneal space between the recti with ischaemia and perforation at the neck of the hernia. She had small bowel resection anastomosis, and the peritoneal defect was formally closed to prevent re-herniation of bowel loops. The NICE guidelines recommend not closing the peritoneum during the c-section. However, this case is an example of severe postoperative morbidity, which could be avoided by peritoneal closure.