Rare Cause of Bowel Obstruction – Case Report of an Appendicular Tourniquet Inside an Ileostomy Reversal Side Hernia Sac

Background The aim of this case report is to outline a rare instance of an appendicular tourniquet presented as bowel obstruction inside an incisional hernia at the ileostomy reversal site (IRS). Material and Methods A 65-year-old female patient presented to our outpatient clinic on a schedule appointment with a profound neglected IRS hernia. She had previously undergone an open low anterior resection with loop ileostomy for rectal cancer. The ileostomy was reversed four months postoperative. The patient was complaining of intermittent mild abdominal pain and constipation which she was managing by her own with laxative. A CT scan was ordered which showed a large hernia containing mostly small intestine protruding from two different hernia sides – one as an IRS incisional hernia and a concurrent middle line incisional hernia. Results In agreement with the patient an operation was schedule, and the patient was to follow a strict diet until the operation date. Two weeks after the initial appointment the patient was admitted to the emergency department with severe abdominal pain and vomiting. The hernia side was found to be red and tender on touch and metallic bowel sounds were heard on osculation over it. An emergency surgery was deemed necessary to examine the cause of the obstructive ileus. A midline incision was chosen and an extensive symphysiolysis was conducted. After mobilization of most of the intestine from the hernia sac, an appendicular tourniquet was discovered. Τhe appendix was fused in a loop strangulating the bowel section under it which started to show signs of ischemia. We continued the symphysiolysis until all the protruding sections where reduced and an appendectomy was also performed. A hernioplasty with dual mesh onlay placement was performed to reinforce the abdominal wall. Conclusion Although a rare occurrence an appendicular tourniquet inside a hernia sac is possible causing irreversible bowel strangulation and subsequent necrotization deeming the condition a surgical emergency.