Spontaneous small bowel evisceration through an umbilical region incisional hernia with features suggestive of Richter-type involvement in an HIV-positive patient: a case report.

Introduction and importance: Spontaneous bowel evisceration through a ventral hernia is a rare surgical emergency. Most reported cases involve primary umbilical hernias in the setting of chronic ascites. In contrast, cases involving incisional hernias are uncommon and poorly described. Richter-type involvement in spontaneous evisceration is not well described in this context. Case presentation: A 41-year-old human immunodeficiency virus (HIV)-positive male with a history of multiple laparotomies for a sigmoid volvulus and intra-abdominal sepsis presented with an irreducible umbilical region incisional hernia, followed by spontaneous rupture and small bowel evisceration. Clinical assessment and imaging demonstrated no features of complete bowel obstruction, although inflammatory markers were elevated. At laparotomy, approximately 25 cm of small bowel had herniated through a 3 cm fascial defect. The eviscerated segment involved the anti-mesenteric border and appeared dusky, with features suggestive of Richter-type involvement. Segmental bowel resection with primary anastomosis and primary hernia repair without mesh were performed. The postoperative course was uneventful. Clinical discussion: Spontaneous bowel evisceration can occur in incisional hernias, although it is rarely reported. Prior laparotomies, sepsis, and immunocompromised states may contribute to abdominal wall failure and reduced skin integrity. Richter-type involvement may progress to ischemia without the classical features of obstruction. Conclusion: Spontaneous evisceration through an incisional hernia is a rare but life-threatening complication. Early recognition and urgent surgical intervention are essential. Consideration should be given to early elective repair of incisional hernias in high-risk patients to prevent complications.