Rare and unusual case of perforated appendicitis in a Spigelian hernia

Given the prolonged history, clinical findings of localising abdominal wall abscess and raised inflammatory markers, the patient was treated with initial fluid resuscitation and broad-spectrum antibiotics. Serial examination over the next 4hours following initiation of treatment showed reduction in the demarcated erythaema but ongoing tenderness; subsequently, a CT of the abdomen and pelvis revealed gas-containing subcutaneous collection, with gas within the fascial planes, mimicking a necrotising fasciitis infection ( figure 1 ). A literature search identified eight cases of Spigelian hernias containing an acute appendicitis, with one demonstrating a contained perforation in a previously mesh repaired Spigelian hernia. 2-9 In the case of this patient, adhesions most likely secondary to chronic herniation acted to externalise the perforation from the abdominal cavity and avoid faecal peritonitis.