Incarcerated and perforated stomach found in parastomal hernia: a case of a stomach in a parastomal hernia and subsequent strangulation-induced necrosis and perforation
An 81-year-old male patient was admitted to a surgical ward with acute onset of severe abdominal pain, vomiting and abdominal distension. Clinical examination found circulatory instability, a peritoneal abdomen and increased leucocyte count and C-reactive protein on laboratory reports, with several litres of fluid aspirated after insertion of a nasogastric tube.\nHis past medical record included rectal cancer 19 years ago managed with rectal resection and subsequently fitted left lower quadrant colostomy. He had developed a large PSH over a period of several years. Due to the patients’ reluctance to seek medical attention for the hernia, its diameter had increased to ∼20 cm at the time of diagnosis. Surgical correction had been deemed infeasible and a truss was fitted instead to the patient's satisfaction.\nPlain film abdominal x-ray showed not only a large part of the small intestine, but also the stomach located in the PSH with signs of pneumoperitoneum (Fig. ).\nAcute, explorative laparotomy confirmed the finding of displacement of the stomach to the PSH with a 7 cm perforation of the minor curvature secondary to necrosis. Apart from the stomach, the hernia contained most of the small intestine including the omentum as well as part of the colon, all these intestines were found intact.\nThe necrotic stomach tissue was surgically debrided, the defect closed in two layers and a feeding tube placed in the duodenum. The colostomy was moved to the right lower quadrant. The original defect in the lower left quadrant was found beyond repair and was instead enlarged to avoid incarceration in the future. Due to the patient’s severe septic state, further surgery on the abdominal wall or stomach was not attempted.\nThe patient developed a secondary wound infection requiring vacuum-assisted closure, but otherwise had an uneventful 6-week admittance period with full recovery and subsequent discharge.