Hernia (2011) 15:705–707
DOI 10.1007/s10029-010-0710-z
C A S E RE P O RT
An unusual case of inguinal hernia with spontaneous evisceration
Muneer A. Zaz · T. Dass · A. Muhee · U. Kawoosa
Received: 22 March 2010 / Accepted: 11 July 2010 / Published online: 30 July 2010
© Springer-Verlag 2010
Abstract Spontaneous evisceration is a very rare and
potentially fatal complication of abdominal wall hernia. It
has been commonly reported in the case of umbilical hernia
in patients with chronic liver disease with tense ascites.
With other hernias, such as incisional hernia and inguinal
hernia, the complication has been reported only once. Here
we present a case report of spontaneous evisceration in an
inguinal hernia in a patient with comorbid chronic obstruc-
tive airway disease. Management of the condition using
prosthetic mesh repair risks mesh infection, while the use
of non-prosthetic repair risks recurrence of the hernia due
to the absence of stout natural tissues. Use of a biological
mesh for the condition seems quite plausible. Thorough
saline washes of the eviscerated organ, excision of
redundant/unhealthy skin and strict adherence to the
fundamental principles of hernia repair is desired in
managing the condition.
Keywords Inguinal hernia · Complication · Spontaneous
evisceration
M. A. Zaz (&) · T. Dass
Department of Surgery, SKIMS Medical College Hospital,
Bemina, Srinagar, Jammu and Kashmir 190010, India
e-mail: munnzah@yahoo.com
T. Dass
e-mail: tufaleahmed@gmail.com
A. Muhee
Department of Surgery, FVSc and AH, Shuhama,
Jammu and Kashmir, India
e-mail: amatulmuhee@gmail.com
U. Kawoosa
Department of Surgery, Government Medical College,
Srinagar, Jammu and Kashmir 190010, India
e-mail: gemeniusva@yahoo.com
Introduction
The groin is the most common location for an abdominal
wall hernia. Of all groin hernias, 95% are hernias of the
inguinal canal. Inguinal hernias are nine times more com-
mon in males than females. The overall lifetime risk of
developing a groin hernia is approximately 15% in males
and less than 5% in females [1]. As almost all diagnosed
inguinal hernias are operated on, the natural course of an
untreated inguinal hernia is scarcely known. Spontaneous
recovery has never been described in adults [2]. Inguinal
hernia can be complicated by hernia content incarceration,
strangulation, and, very rarely, spontaneous evisceration
[3].The estimated risk of an inguinal hernia to incarcerate/
strangulate is 0.3–3% per year [4]. The literature docu-
ments the occurrence of spontaneous evisceration of
abdominal wall hernias in the form of a few case reports
only. More commonly, this complication has been reported
among patients with tense ascites secondary to chronic liver
disease. Its occurrence in the case of inguinal hernia in an
otherwise healthy patient has been reported only once. This
case report from the Sheri-Kashmir Institute of Medical
Sciences in Kashmir, India, documents a further instance of
spontaneous evisceration in an inguinal hernia in a patient
with comorbid chronic air way obstructive disease.
Case report
A 65-year-old farmer with a history of chronic smoking and
comorbid chronic obstructive airway disease, presented to
our hospital with evisceration of a loop of small bowel from
his left groin. Further enquiry revealed a progressively
increasing swelling at the site of evisceration for 8 years.
Except for some little discomfort and a dragging sensation,
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Fig. 1 Left incarcerated inguinal hernia with spontaneous eviscera-
tion. The eviscerated bowel was healthy with only a few scattered
areas of edema and congestion
the swelling had not bothered the patient until the swelling
became irreducible in the last 1.5 years. However, the
patient gained comfort by hot fomentations and rubbing of
oil on the swelling. The patient was clear about the recent
appearance of ulceration at the most prominent part of the
swelling. In the morning of the day of presentation, the
patient, while straining at stools, eviscerated intestines from
the area (Fig. 1). The patient was shifted to the hospital
with the eviscerated bowel covered with a white cloth.
Upon examination, the vitals of the patient were stable and
the eviscerated bowel was healthy with a few scattered
areas of edema and congestion. The patient was operated on
a emergency basis and a non-prosthetic repair was per-
formed. The eviscerated bowel was washed with normal
saline before repositing it into the abdomen. The redundant
thinned-out skin was also excised and the wound was
closed over a subcutaneous drain. The drain was removed
on the 2nd post-operative day and the patient discharged on
the 3rd post-operative day; no complications were observed
in 14 months of follow-up.
Discussion
Spontaneous evisceration of abdominal hernias—a rare but
potentially life threatening condition—has been commonly
reported with umbilical hernia in cirrhotic patients with
tense ascites. Apart from that typical clinical setting, spon-
taneous evisceration has been reported in the literature in
cases of umbilical hernia, incisional hernia and indirect
inguinal hernia [5–7]. Our case records a further instance of
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Hernia (2011) 15:705–707
this unusual occurrence in an elderly male with a long-
standing direct inguinal hernia. Signs of impending rupture
of hernias include overlying skin discoloration, ulceration,
or rapid hernia expansion [8]. Understandably, maneuvers/
events that lead to sudden increase in intra-abdominal pres-
sure, such as coughing, straining and forceful abdominal
blows, have been reported as Wnal precipitating factors in
the rupture of ventral hernias.
Operative treatment of inguinal hernia aims to reduce
symptoms or prevent complications [2]. An emergency
operation to treat strangulated inguinal hernia has a higher
associated mortality than an elective operation (5% vs
0.5%). Whether elective operation for all inguinal hernias
would have a signiWcant impact on the life expectancy of
the patients is not yet clear [9, 10].
Certain speciWc considerations while managing the her-
nia ruptures include:
(1) The vascularity of the organ that has eviscerated might
be jeopardized.
(2) The eviscerated structures are almost always contami-
nated.
(3) The hernia contents, which have been impinging on the
overlying skin for a prolonged period, are expected to
be adherent to it, thereby making inadvertent gut injury
more likely while hurriedly attempting to increase the
skin rent for the sake of improving the vascularity of a
compromised gut.
(4) While attempting to repair such hernia on an emer-
gency basis, surgeons are hampered by the absence of
stout natural tissues and by the presence of contamina-
tion, which precludes the use of prosthetic mesh.
(5) The advanced age of the patient or advanced cirrhosis
with tense ascites present in most such reported cases
may further compromise the successful outcome of
emergency hernia surgery in these patients.
(6) The panic associated with spontaneous evisceration,
and the limited surgical experience in managing such
cases, due to rarity of the condition, probably also con-
tribute to more averse outcomes.
The use of biological mesh for the repair of eviscerated her-
nia would seem appealing but the durability of such repairs,
especially for large hernial defects, in addition to the cost
factor involved may undermine this approach, especially in
developing countries. In almost all cases of ruptured hernia,
including the one reported here, non-prosthetic repairs have
been performed. Successful prosthetic repair of an eviscer-
ated incisional hernia has been reported only once [6].
To conclude, spontaneous evisceration of a neglected
abdominal wall hernia, although very rare, has a real risk of
occurrence. Apprehension about adverse operative results
in such cases is also real. However, thorough saline washes
of the eviscerated organ, excision of redundant and
Hernia (2011) 15:705–707
unhealthy skin, and strict adherence to the fundamental
principles of hernia repair, including consideration of the
use of biological mesh, can lead to successful outcomes and
represents the way forward until such time as speciWc
guidelines surface in the literature.
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