Spontaneous evisceration of the appendix through an incisional hernia at rest.

To cite: West C, Richards J, Sujendran V, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2016217585 DESCRIPTION A 70-year-old man presented to accident and emergency (A&E) department with spontaneous rupture of his incisional hernia, which occurred at rest. He previously had an emergency open abdominal aortic aneurysm repair. Postoperatively he developed a large incisional hernia. On arrival at A&E department, it was evident that his hernia had eroded through the skin, with his appendix and some greater omentum protruding through the defect (figure 1). There were no clinical features of obstruction or strangulation. He underwent preoperative CT scanning to delineate the anatomy and facilitate operative planning (figure 2); this confirmed a large defect measuring 18×15 cm containing the bowel and omentum, and evisceration of the appendix. He underwent an emergency incisional hernia repair with open appendectomy. Given the size of the myofascial defect, a bridging mesh was required to achieve closure. As a result of concern over contamination, a decision was made to use a collagen mesh (Permacoll) rather than a synthetic mesh. An abdominal binder was applied postoperatively. He was discharged on day 6 and reviewed 7 weeks later; there is no evidence of recurrence or infection. Evisceration of an appendix through an incisional hernia is rare and is usually associated with severe pain. Spontaneous evisceration through an abdominal wall hernia is more likely on a background of an acute (eg, coughing, exertion) or chronic (eg, ascites) rise in intra-abdominal pressure and is associated with significant morbidity and mortality. This is the first case we have come across that occurred at rest in the absence of ascites.