An unusual case of incisional hernia

Abstract

An incisional hernia is one that develops in the scar of a surgical incision. There is a risk of strangulation with a narrow neck and large sac. Thin walled hernias may ulcerate and develop intestinal fistula. The long-term incidence in best centers is 10%. Predisposing factors are obesity, age, wound infection and incisions more than 18cms. Common contents are omentum, transverse colon, loops of small bowel and stomach [1]. Although gravid uterus in an incisionsal hernia has been reported earlier[2], the occurrence of incisional hernia 25 years after laparotomy with a pedunculated fibroid uterus as its content is extremely rare (Fig 1). Fig. 1 Incisional hernia (optd) – uterus (left), tumour (right) Case Report Fifty six year old mother of a serving soldier presented with pain and swelling of lower abdomen since six years, increasing in size in last six months. She was also an old case of bronchial asthma over previous ten years and had last child birth in 1970 with twins delivered by Lower Segment Caesarian Section (LSCS). After LSCS she was asymptomatic till 1996 when she noticed a small lump which remained static for six years and started increasing in size over the previous six months. On examination her general condition was good, vitals normal, lungs clear, abdomen soft, swelling in lower abdomen more to right of mid-line, size 20×15cm, not completely reducible, transillumination negative and cough impulse present. A 3 × 2cm gap was felt in linea alba in infra umbilical region on asking the patient to raise her leg or neck in supine position without support of arms. She was diagnosed as a case of irreducible incisional hernia with omentum as its content. Under spinal anaesthesia converted to general anaesthesia, through an infra umbilical incision the sac was defined, opened, uterus was found lying outside the sac with a kidney shaped 12 × 8cm fleshy growth attached to it. Adhesions with parietal peritoneum were released. Bladder was catheterized, dissected free from uterus, planes defined and subtotal hysterectomy with bilateral salpingo-oophrectomy was done. Extra margins of sac with extra-peritoned fat were excised. Rectus shealth and linea alba on each side were dissected and resutured using 1/o prolene with reconstruction of linea alba in two layers. Wound was closed leaving a parietal and pelvic drain. Post operatively the patient made an uneventful recovery. She was discharged on the 13th post op day and has been followed up for 6 months with no recurrence.