Small bowel herniation through a caesarean section wound presenting as cellulitis: A case report

A 39-year-old woman (gravida 2, para 1; body mass index 30 kg/m 2 ) with a prior Caesarean section presented for elective lower segment Caesarean section at 39 weeks of gestation. Her medical history included toxic nodular goitre managed with thyroidectomy and ongoing levothyroxine therapy; no other comorbidities or drug allergies were noted. Surgery was performed under regional anaesthesia. Intraoperative adhesions required sharp and blunt adhesiolysis for uterine access. A fatty cyst was identified at the uterovesical junction, consistent with a finding noted on antenatal ultrasound. The cyst was decompressed, tissue sent for microbiological culture, and the cavity oversewn following review by a second consultant. Histopathological analysis was consistent with a benign peritoneal inclusion cyst, a finding which was to be confirmed by the authors from operative records. A healthy infant was delivered; Caesarean section wound closure was performed in standard layers without closure of visceral and parietal peritoneum. The patient was discharged on postoperative day 2. On postoperative day 3, the patient re-presented with a one-day history of right iliac fossa pain, three episodes of vomiting, and progressive wound erythema. She was apyrexial and haemodynamically stable. Examination revealed localised right lower quadrant tenderness and blanching erythema with induration extending from the suprapubic region to the right anterior superior iliac spine — well beyond the incision margins. The Caesarean section wound itself was clean, dry, and intact. Bowel sounds were present throughout. Haematological investigations showed haemoglobin 94 g/L, white cell count 16.35 × 10 9 /L, neutrophils 12.9 × 10 9 /L, and C-reactive protein 116 mg/L. The initial clinical impression was cellulitis with possible pelvic collection; intravenous broad-spectrum antibiotics and tinzaparin were commenced. Computed tomography of the abdomen and pelvis with intravenous contrast was performed after the initial clinical assessment favoured cellulitis. Imaging demonstrated herniation of small bowel through the rectus musculature, with features consistent with early bowel obstruction; the anterior rectus sheath appeared intact on cross-sectional imaging, indicating that the defect was at the level of the rectus muscle and underlying peritoneum rather than the fascial layer itself. This investigation excluded a primary diagnosis of superficial wound infection and identified the correct surgical diagnosis, enabling planned operative intervention [9] . The case was discussed with the on-call radiologist and colorectal surgical team before proceeding. Tinzaparin was withheld in anticipation of surgery. Informed consent was obtained, including discussion of the potential need for bowel resection and anastomosis. At laparotomy (re-opening of the Caesarean section scar), copious free intraperitoneal fluid was identified. The anterior rectus sheath was intact externally. Small bowel was found adherent to and herniating through a divarication of the rectus muscle and peritoneum, with proximal distension and surrounding inflammatory change ( Fig. 1 ). Adhesiolysis was performed by blunt dissection and hydrodissection, resulting in immediate resolution of distension. The bowel was inspected in full by the attending colorectal surgeon: it was viable throughout with no evidence of ischaemia, perforation, or necrosis; no resection was required. Fig. 1 Intraoperative photograph demonstrating small bowel herniation. Small bowel protruding through the rectus abdominis divarication at laparotomy, with evidence of proximal distension prior to reduction. Fig. 1 Intraoperative photograph demonstrating small bowel herniation. Small bowel protruding through the rectus abdominis divarication at laparotomy, with evidence of proximal distension prior to reduction. Omentum was mobilised and placed underneath the rectus abdominis. The abdominal cavity was irrigated with warm saline. The rectus sheath was repaired with polydioxanone 1 loop suture, subcutaneous tissue with poliglecaprone 3–0, and a subcutaneous drain placed. Skin was closed with staples following betadine wash. Estimated blood loss was under 50 mL. The drain was removed at 48 h. Intravenous antibiotics were stepped down to oral therapy. Recovery was uneventful and the patient was discharged on postoperative day 4. Alternate staple removal was performed at day 10 and complete removal at day 12. At outpatient follow-up the wound had healed well with no complications, no recurrence of herniation, and no further gastrointestinal symptoms. Table 1 summarises the timeline of the case. Table 1 Clinical timeline. Time Point Event Antenatal Uterovesical fatty cyst noted on routine ultrasound Day 0 (index surgery) Elective lower segment Caesarean section under regional anaesthesia; intraoperative adhesiolysis; uterovesical cyst decompressed and oversewn; standard layered closure without peritoneal closure; healthy infant delivered Day 2 Discharged home in satisfactory condition Evening, day 2 (at home) Patient notices a small area of erythema and bruising on lower abdomen; nausea develops — retrospectively consistent with onset of herniation Day 3 (morning) Worsening right iliac fossa pain, three episodes of vomiting, and progressive wound erythema; presented to obstetric triage Day 3 (admission) Examination: blanching erythema to right anterior superior iliac spine, induration, intact wound; apyrexial; white cell count 16.35, C-reactive protein 116. Initial impression: cellulitis. Intravenous antibiotics and tinzaparin commenced Day 3 (afternoon) Computed tomography of abdomen and pelvis: small bowel herniation through rectus musculature with early obstruction; anterior rectus sheath externally intact. Multidisciplinary discussion with radiology and colorectal surgery Day 3 (evening) Examination under anaesthesia; laparotomy (re-opening of Caesarean section scar); adhesiolysis and hydrodissection; hernia reduced; bowel viable throughout; omentum mobilised beneath rectus abdominis; rectus sheath repaired with polydioxanone 1 loop suture; subcutaneous drain placed Day 4 (postoperative day 1) Drain removed; intravenous antibiotics stepped down to oral; uneventful recovery Day 7 (postoperative day 4) Discharged; alternate staple removal planned day 10, complete removal day 12 Follow-up Wound fully healed; no recurrence; no further complications Clinical timeline.

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Written informed consent was obtained from the patient for publication of the case report and accompanying images.

Table 2 documents the five cases of small bowel herniation through a Caesarean section fascial wound, all presenting with wound erythema in the early postoperative period. The index case presented as apparent cellulitis — a rare but potentially life-threatening diagnostic pitfall. Table 2 Summary of all reported cases of small bowel herniation through Caesarean section wounds. Case Author (Year) Age / Parity Type Day Operative Findings Outcome 1 Van der Wal et al. [5] 38 / G3P2 Elective Day 4 Large rectus defect; densely adherent small bowel to rectus sheath; bowel viable Adhesiolysis; reduction; repair. Uneventful recovery 2 Owen & Polson [6] 36 / G1P0 Emergency Day 6 30 cm small bowel above rectus, beneath intact sheath; ischaemic Bowel resection; anastomosis. Uneventful recovery 3 Marchocki et al. [7] 34 / G1P0 Elective Day 8 Strangulated bowel above rectus beneath intact sheath; 34 cm necrotic Bowel resection; anastomosis. Uneventful recovery 4 Plume et al. [8] 25 / G1P0 Emergency Day 2 Small bowel in ∼2 cm inter-suture muscle defect; no necrosis Reduction; defect repair. Uneventful recovery 5 Present case 39 / G2P1 Elective Day 3 Bowel herniating through rectus divarication; viable; distension resolved on release Hydrodissection; reduction; omental patch; repair. Discharged day 4 G = gravida; P = para. Summary of all reported cases of small bowel herniation through Caesarean section wounds. G = gravida; P = para. The pathophysiology is multifactorial. A prior Caesarean section introduces adhesion-prone tissue planes [3] ; intraoperative adhesiolysis disrupts these further; and elevated body mass index is associated with impaired fascial healing and wound complications [4] . In the present case, an additional and surgically important contributing factor was the decompression and oversewing of a fatty cyst at the uterovesical junction. The cyst, identified on antenatal ultrasound and confirmed intraoperatively, was consistent with a peritoneal inclusion cyst — a benign structure arising from entrapment of mesothelial cells within adhesion-related tissue. The surgical steps required to decompress and suture this cyst introduced a localised plane of dissection adjacent to the lower uterine segment peritoneal reflection, disrupting the tissue planes immediately beneath the fascial closure. This created a locus minoris resistentiae — a structurally weakened zone — through which mobile small bowel loops, in the setting of early postoperative ileus and gas redistribution, were able to migrate and herniate. This mechanism has not been described in any prior reported case, and surgeons should be aware that additional intraoperative dissection in the periuterine region, even for benign pathology, may amplify the risk of early postoperative herniation. Collective risk factors present here — prior Caesarean section, adhesiolysis, supplementary cyst dissection, non-closure of peritoneum, and elevated body mass index — likely combined to produce the conditions for herniation. The diagnostic challenge is substantial. In all five reported cases the triad of abdominal pain, vomiting, and wound erythema was present within eight postoperative days. Apyrexia must not be falsely reassuring — fever was absent at presentation in the majority of cases. Three atypical features were diagnostically significant in the present case: erythema extending disproportionately to the right anterior superior iliac spine, gastrointestinal symptoms in the early postoperative period, and markedly elevated inflammatory markers in an apyrexial patient. These features should prompt urgent computed tomography imaging, not empirical antibiotics alone. Computed tomography was decisive: it identified bowel herniation with early obstruction, enabling planned multidisciplinary emergency operative intervention [9] . Radiation exposure is a subordinate concern relative to the risk of delayed diagnosis. Ultrasound is not a reliable alternative for characterising bowel herniation and mesenteric status in the postoperative abdomen. A clear temporal relationship exists between time to surgery and the need for bowel resection. Cases presenting on days 6 and 8 required resection of 30 cm and 34 cm of necrotic bowel respectively [6] , [7] ; cases presenting on days 2, 3, and 4 — including the present case — did not [5] , [8] . Early operative exploration, before the ischaemic threshold is crossed, is therefore critical. The use of hydrodissection in the present case facilitated adhesiolysis whilst minimising serosal trauma and is an adjunct worthy of consideration in similar cases. Whether peritoneal closure at Caesarean section reduces herniation risk is unresolved. The CORONIS [10] and CAESAR [11] trials demonstrated no significant maternal morbidity difference between closure and non-closure. Some evidence links non-closure with denser adhesions at repeat laparotomy [12] . Importantly, in the present case the anterior rectus sheath was intact at laparotomy; herniation occurred through a muscular divarication rather than a formal fascial defect. Standard postoperative advice following Caesarean section includes avoidance of heavy lifting for a minimum of six weeks. Obesity is an independent risk factor for wound complications and incisional hernia after Caesarean section [13] , and in diabetic patients pre-operative glycaemic optimisation reduces wound morbidity following abdominal wall surgery [14] . The most effective preventative strategy remains meticulous repair of all muscular and peritoneal layers, with particular vigilance in patients with prior Caesarean section, significant adhesiolysis, additional periuterine dissection, or elevated body mass index. Multidisciplinary input from obstetrics, radiology, and colorectal surgery was essential to timely diagnosis and safe operative management.

This article was not commissioned and was peer reviewed.

Namrata Gaikwad contributed to patient care, conception of the case report, acquiring and interpreting the data, drafting the manuscript, undertaking the literature review and revising the article critically for important intellectual content. Parveen Verasingam contributed to patient care, conception of the case report, acquiring and interpreting the data and revising the article critically for important intellectual content. Lee Dvorkin contributed to patient care, acquiring and interpreting the data and revising the article critically for important intellectual content. All authors approved the final submitted manuscript.

Caesarean section accounts for approximately 34% of deliveries in England and around 21% globally, with rates continuing to rise [1] , [2] . While wound complications — including infection, haematoma, and dehiscence — are well recognised, herniation of intra-abdominal contents through the Caesarean section fascial wound is exceedingly rare. Incisional hernias are reported in 0.2–0.5% of cases, but frank small bowel herniation with obstruction represents a far smaller subset, with, to the authors' best knowledge, only four prior cases documented in the English-language literature [5] , [6] , [7] , [8] . Its presentation may closely mimic cellulitis, rendering timely diagnosis a significant clinical challenge. A fifth case is reported here, in which operative intervention enabled successful management without bowel resection. The literature is reviewed to define the diagnostic and operative principles relevant to this rare complication, in light of this series of five published cases.

The authors declare that they have no competing interest regarding the publication of this case report.