Perforated appendicitis within a spigelian hernia

A woman in her 90s presented to the emergency department with new onset pain in a long standing right spigelian hernia. She was febrile and mildly hypotensive. CT scan demonstrated a hernia containing small and large bowel with significant fat stranding and thus proceeded to operative management via an open appendicectomy and suture repair of the hernia. There are few similar cases in the literature, with the predominance being suture repair, a roughly even split between open and laparoscopic approaches.