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Background and objective: To report the management of an exceptionally severe incarcerated inguinal hernia complicated by extensive abdominal wall and retroperitoneal phlegmon with sepsis, in the absence of bowel perforation, emphasising prolonged damage-control treatment and staged reconstruction.

Method: An adult patient presented with septic shock caused by a long-standing incarcerated inguinal hernia. An extreme purulent phlegmon of the abdominal wall was present, extending retroperitoneally to the renal lodge and destroying perirenal adipose tissue. Emergency surgery was performed after resuscitation and broad-spectrum antibiotics. Operative management included hernia exploration, reduction of the hernia contents, and radical debridement without drainage. Due to massive contamination, definitive hernia repair was deferred. Daily surgical wound revisions under general anaesthesia were required for the first 10 days, followed by six weeks of wound management that included regular deep manual exploration of the retroperitoneal cavity until source control was achieved. Secondary reconstructive surgery was attempted but failed. Definitive repair using mesh was successfully performed during a third- stage procedure after full resolution of infection.

Result: The condition was controlled, resulting in a complete resolution of inflammatory parameters. No intestinal complications occurred. The extensive wound healed by secondary intention. The final mesh repair was successful, with no early recurrence or infectious complications during follow-up.

Summary: Incarcerated inguinal hernias can lead to severe soft-tissue and retroperitoneal infections, even in the absence of bowel perforation. Progressive source control, prolonged damage-control strategies, and delayed definitive reconstruction are essential for survival and durable hernia repair in cases of extreme septic presentations requiring early recognition.