PMC5524317_01
Computed tomography scan of abdomen and pelvis. Large, broad-based ventral hernia (8.4-cm x 5.9-cm) containing ileum, cecum, appendix, and some ascending colon, with dilatation of proximal small bowel loops without passage of contrast into normal caliber exiting loops of colon, concerning for high grade small bowel obstruction. Within the hernia sac, the appendix is slightly dilated to 7.5 mm, with two appendicoliths found within the lumen. The bowel walls within the hernia sac are thickened, with prominent fat stranding. There are two adjacent fluid collections, measuring 10.8 x 4.9 x 10.4-cm and 1.4 x 3.8 x 5.2-cm, containing locules of gas, suggestive of abscess.
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Computed tomography scan demonstrated a dilated appendix with appendicoliths, thickening of the neighboring small bowel walls with fat stranding, and two adjacent abscesses, consistent with ruptured appendicitis within her incarcerated ventral hernia (Fig. 1).
Computed tomography scan of abdomen and pelvis. Ventral hernia with wide neck (6.6 x 6.0-cm), containing multiple loops of small bowel, including the cecum. No evidence of obstruction or dilated loops of bowel. Thickening present of the bowel wall along the terminal ileum. A localized fluid collection is seen within the subcutaneous fat between the skin surface and the hernia sac, measuring 10.0 x 9.0 x 3.0-cm.
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She was found to have two connecting abscesses within the hernia sac, requiring multiple readmissions for incision and drainage and intravenous antibiotics (Fig. 2).
Barium gastrointestinal follow-through study. Contrast advanced through the small intestine without delayed progression. At three-hours, barium to opacified the upper- and mid-small bowel, terminal ileum, and right colon, with cutaneous contrast extravasation overlying the right lower quadrant anteriorly, at the apex of a large ventral hernia.
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After five months of ongoing drainage, she underwent an upper gastrointestinal barium follow-through study, which demonstrated an enterocutaneous fistula at the hernia apex (Fig. 3).
Computed tomography scan of abdomen and pelvis. Large fluid collection (12.3 x 9.6 x 4.7-cm) with air-fluid level identified within the anterior abdomen and pelvis, extending through the anterior abdominal wall musculature into the subcutaneous fat of the anterior abdominal wall. A Jackson-Pratt drain is present within the subcutaneous fat of the anterior abdominal wall, surrounded by diffuse stranding.
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Despite the use of drains in the subcutaneous space, the patient developed a superficial abscess that was managed with open drainage (Fig. 4).