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Abstract Background Incisional hernia appendicitis is a rare form in which the vermiform appendix is located within the hernial sac. It is seen in less than 1% of inguinal hernia. Most often, the cases are misdiagnosed as incarcerated or strangulated hernia. Case presentation A 59-year-old female with history of hysterectomy 10 days ago for fibroid, came to the emergency department with diffuse abdominal pain and severe vomiting and absolute constipation for 3 days. Abdominal U/S was done and revealed inflamed fat within the hernia sac along with minimal collection. A defect was seen at the anterior abdominal wall measuring about 2.4 cm passing bowel loops and collection. CT scan with IV contrast revealed an inflamed appendix passing through the incisional hernia. Conclusions Appendicitis within a hernia sac is unusual with the incidence being 0.13% of all acute appendicitis. Acute hernia appendicitis is almost never been diagnosed prior to surgery. Most often, the diagnosis is incarcerated or strangulated hernia. The differential diagnosis should include hernia sac appendicitis for patients with signs of inflammatory process ongoing at the hernia sac.