Strangulated Posterior Rectus Sheath Hernia with Contained Small-Bowel Perforation and Abdominal Wall Necrotizing...

Posterior rectus sheath hernia is an exceptionally uncommon interparietal hernia and may be difficult to recognize because the herniated bowel remains between abdominal wall layers.

A 49-year-old multiparous woman presented with acute severe pain, vomiting, fever, and inflammatory skin changes over a right paraumbilical swelling that had been present for six years. Ultrasound suggested a complicated abdominal wall cyst, whereas computed tomography demonstrated a right rectus sheath hernia. Emergency exploration revealed strangulated and perforated small bowel contained between rectus sheath layers, with enteric leakage into necrotic anterior abdominal wall tissues. Approximately 20 cm of gangrenous bowel was resected and a primary end-to-end anastomosis was performed. The small fascial defect was closed primarily without mesh because of the dirty infected field. The skin and subcutaneous wound were left open after debridement, managed with temporary packing and two further operative debridements, and closed secondarily after infection control. The patient recovered and was discharged in good clinical condition.

Posterior rectus sheath hernia should be considered in atypical abdominal wall masses. Early computed tomography and urgent source control are essential when strangulation, perforation, or necrotizing infection is suspected.