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To the Editor.—
I enjoyed reading the case report on "An Unusual Hernia" (235:2813, 1976) in The Journal. The authors suggest that the gastric perforation was secondary to the incarceration and "were surprised that the gastric perforation had occurred within the abdomen rather than within the hernial sac."I would like to suggest that, in my experience, the sequence of events is just the reverse of that postulated by the authors. I believe that peritonitis occurs first (in this case due to gastric perforation), and as a consequence of the peritoneal soiling and resulting ileus, the hernial contents are pushed further into the sac and become irreducible.It is an axiom of abdominal surgery that one should never "explain" a generalized peritonitis on the basis of an incarcerated hernia. To do so usually results in a nonproductive exploration of the hernia while recognition of the true source of difficulty (appendicitis,
Freeark RJ. An Unusual Hernia. JAMA. 1976;236(15):1694. doi:10.1001/jama.1976.03270160018019