A 53-year-old man undergoes a reversal of a loop colostomy. He recovers well and is discharged home. Ten days later, he is readmitted with symptoms of vomiting and colicky abdominal pain. On examination, there is a swelling at the loop colostomy site, which is tender. What is the most likely underlying diagnosis?
A. Haematoma
B. Intra-abdominal adhesions
C. Anastomotic leak
D. Anastomotic stricture
E. Obstructed incisional hernia
Correct Answer: E. Obstructed incisional hernia
Explanation:
The most likely diagnosis in this scenario is obstructed incisional hernia. Here’s why:
Key Clinical Features:
- Vomiting and colicky abdominal pain:
- These are classical symptoms of bowel obstruction.
- Swelling at the loop colostomy site:
- Suggestive of a hernia at the previous surgical site.
- Tenderness over the swelling:
- Indicates possible strangulation or obstruction of the hernia.
Another Explanation:
In this scenario, the most probable diagnosis is an obstructed incisional hernia. The presence of a tender swelling, accompanied by symptoms of intestinal obstruction, makes this diagnosis highly likely. Immediate surgical exploration is crucial. Loop colostomy reversals are particularly susceptible to this complication due to the increased likelihood of postoperative wound infections at the surgical site.
Acute incisional hernia:
Postoperative hernias can occur after any surgical procedure involving entry into a cavity containing viscera, with the abdominal region being the most frequently affected. This condition arises when the deep layer of the wound fails to heal properly, allowing internal viscera to protrude.
Management depends on the clinical condition of the patient and the timing of the hernia in relation to the surgery. Signs such as bowel obstruction or tenderness at the hernia site necessitate urgent surgical intervention to avoid bowel necrosis. Mature incisional hernias with a wide neck and no symptoms may be managed conservatively or scheduled for elective repair.
Risk factors for postoperative incisional hernias include:
- Wound infections after surgery
- Prolonged use of steroids
- Obesity
- Chronic coughing
Why Other Options Are Less Likely:
- A. Haematoma:
- While a haematoma at the surgical site can cause swelling and tenderness, it is less likely to cause vomiting, colicky pain, or bowel obstruction.
- B. Intra-abdominal adhesions:
- Adhesions are a common cause of bowel obstruction but are less likely to present with a localized swelling at the colostomy site.
- C. Anastomotic leak:
- A leak usually presents earlier in the postoperative period with systemic signs of sepsis (fever, tachycardia, peritonitis), not localized swelling and tenderness.
- D. Anastomotic stricture:
- This may cause bowel obstruction but would not lead to a tender, localized swelling at the colostomy site.
Incisional Hernia after Colostomy Reversal:
- The site of a previous colostomy is a weak point in the abdominal wall.
- After reversal, it is prone to developing an incisional hernia due to weakened tissue and increased intra-abdominal pressure.
- Herniation of bowel at this site can lead to obstruction or strangulation, explaining the patient’s symptoms.
Conclusion:
The combination of localized swelling, tenderness at the previous colostomy site, and symptoms of bowel obstruction strongly suggests an obstructed incisional hernia. This is a surgical emergency requiring prompt intervention.