Treatment of delayed jejunal perforation after irreducible femoral hernia repair with open abdomen management and delayed abdominal closure with skin flap approximation

• Delayed bowel perforation may develop after irreducible femoral hernia surgery especially in elderly patients with comorbid disease.
• Open abdomen management with negative pressure therapy and delayed open abdomen closure with skin flap approximation is optimum treatment modality for hemodynamically instable patient.

IntroductionWe show the management of a delayed jejunal perforation, after irreducible femoral hernia operation with the help of negative pressure therapy (NPT) and delayed abdominal closure (DAC) with skin flap approximation in an elderly woman for the first time in the literature.Presentation of caseA 76 year-old woman was admitted to the emergency department with irreducible femoral hernia and ileus. After examining the femoral hernia sac and noting the presence of viable intestine within the hernia sac, a femoral hernia repair with mesh was performed. At postoperative day 1 she started to defecate and oral intake was started. The patient was discharged on postoperative day 3. On postoperative day 8, she was re-admitted to the emergency department with septic shock. The patient underwent reoperation. Septic abdomen and delayed perforation from strangulated part of the jejunum were seen. A jejunostomy was opened and patient was treated with open abdomen management and delayed abdominal closure with skin flap. The ostomy was closed 4 months later.DiscussionThe exact mechanism of delayed presentation of small bowel perforation remains controversial. Delayed intestinal perforation has rarely been reported after blunt abdominal trauma (BAT), conductive burn injuries of the bowel with cautery, or necrosis of strangulated bowel in a hernia sac. Open abdomen (OA) management is a life-saving and challenging strategy in severe generalized peritonitis.ConclusionDelayed bowel perforation may develop after irreducible femoral hernia surgery. OA management with NPT and DAC with skin flap approximation are optimal treatment modalities for the hemodynamically instable patient.