External fecal fistula secondary to ileal perforation in an incarcerated incisional hernia: a rare case report

Incisional hernia is a common complication following abdominal surgery, with an incidence of 10–20% after laparotomy. Although most incisional hernias remain reducible, long-standing hernias may become incarcerated and, rarely, result in bowel perforation with overlying skin necrosis and external fecal fistula formation. We report the case of a 35-year-old woman with a long-standing incisional hernia following a lower segment caesarean section performed six years earlier. She presented with abdominal pain, localized edema, skin necrosis, and fecal discharge from the anterior abdominal wall. Emergency exploratory laparotomy revealed incarcerated ileal loops with a 0.5×0.5 cm perforation located approximately 40 cm proximal to the ileocecal junction and associated fecal contamination. Debridement, diversion loop ileostomy, and source control were performed. Following serial wound debridement, daily papain-urea dressings, clinical resolution of sepsis, and two consecutive sterile wound cultures, a planned second-stage abdominal wall reconstruction with polypropylene mesh was successfully undertaken. The postoperative course was uneventful, and the patient is currently awaiting elective ileostomy closure following nutritional optimization. This case highlights the importance of early recognition, prompt source control, and individualized staged abdominal wall reconstruction in managing this rare and life-threatening complication.