Richter`s Hernia with Unique Presentation as Obstructed Inguinal

Richter's Hernia with Unique Presentation
Obstructed Inguinal hernia with Bowel Perforation
as
Prajakt V. Patil*, Manmohan M. Kamat**, Milan M. Hindalekar***
Abstract
In a Richter's hernia, the antimesenteric border of intestine must protrude into the
hernial sac but never to the point of involvement of entire circumference of the
intestine. It has most commonly occurred at the femoral, inguinal sites and rarely at
trocar insertion site in laparoscopic surgery. Critical in repair is the assessment of
intestine for viability. Sometimes as it is impossible to adequately assess and resect
the bowel through inguinal incision it is required to perform a midline laparotomy to
assess and complete the procedure. A diagnostic laparoscopy may prove to be helpful
to assess the bowel. Early operative intervention is the mainstay of successful
management of Richter's hernia and awareness of this disease and its misleading
clinical presentation is of utmost importance.
Introduction
I
n Richter's hernia only a part of
circumference of bowel wall is trapped
but the complete circumference is never
involved. Only antimesenteric border of
the small intestine is incarcerated in the
deep inguinal ring and hence, intestinal
obstruction may be absent, but gangrene
of the bowel wall may occur.
The earliest known reported case of
Richter's hernia occurred in 1598,
described by Fabricius Hildanus8 with the
first scientific description being given by
August Gottlob Richter in 1778, who
presented it as "the small rupture." In
1887, Sir Frederick Treves gave an
excellent overview on the topic and
proposed the title "Richter's hernia".8
More often these hernias are
diagnosed in the sixth and seventh
*Assistant Professor,**Honorary Professor,
***Honorary Professor and Head of Department,
Department of General Surgery, Dr. R. N. Cooper
Municipal General Hospital, Vile-Parle, Mumbai
Bombay Hospital Journal, Vol. 54, No. 1, 2012
decades of life. They comprise 10 per cent
of strangulated hernias11 rarely can occur
in the neonates.10 Their common sites are
the femoral ring, deep inguinal ring, and at
incision site,11 at trocar sites after
laparoscopic procedures (10-mm or larger
ports).5 Most surgeons now routinely close
the fascia of these sites to prevent the
herniation. Unusual occurrences are at
the insertion site of the drainage tube
following open abdominal surgery,7 as
Spigelian hernia,3 through the sacral
foramen.4 The most-often entrapped part
of the bowel is the distal ileum, but any
part of the intestine may be incarcerated.
These hernias progress more rapidly to
gangrene than other strangulated hernias,
and obstruction is less frequent. 9
Compared with patients with other
hernias, patients with Richter's hernias
had greater preoperative delay, rate of
bowel resection, length of hospital stay,
and postoperative morbidity and mortality
rates. Early operative intervention is
155
mainstay of successful treatment.
We present the case report of an
individual who presented with obstructed
inguinal hernia with clinical features of
intestinal obstruction and on exploration
was found to have a Richter's hernia with
bowel perforation in the hernial sac. Such
an instance is infrequent with few cases
being reported.
Case report
A 35 year old male presented in emergency
department with complaints of right sided groin
swelling with abdominal pain, vomiting since 2 days.
Clinical examination revealed a large right sided
obstructed inguinal hernia probably complete
enterocoele with features of intestinal obstruction.
There was Hypovolaemic shock with septicaemia.
Haematological examination revealed low
haemoglobin with neutrophilic leucocytosis.
Biochemistry revealed a state of renal failure and
hypoalbuminaemia. Abdominal radiograph revealed
air fluid levels.
Hypovolaemia was corrected with blood and
fluid transfusions. The patient was subjected to
exploratory laparotomy as an emergency procedure.
As there was evidence of clinical features of bowel
obstruction, with history of 2 days and irreducibility,
no further investigations were carried out.
An inguinal right sided skin crease incision was
taken and it was extended to the base of scrotum. In
view of infected fluid seen in the hernial sac and
obstructive band at the deep ring, bowel loop
appearing dusky, it was decided to do a midline
laparotomy for adequate assessment of bowel and to
decide on the resectability. At exploratory
laparotomy, large sac was revealed with constriction
at level of deep ring with infected seropurulent fluid
and terminal ileal loop with necrotic omentum. The
terminal ileal loop region involved was 3 feet from IC
Region with antimesenteric border involved and
segment being gangrenous and necrotic. There was a
1 x 0.5 cm perforation at antimesenteric involved
border. So a diagnosis of an obstructed Richter's
hernia with bowel perforation was made. Rest of
small and large bowel was normal. The right testis
was atrophic. No other visceral pathology was seen.
In view of above findings, resection of perforated
and gangrenous loop with ileo-ileal anastomosis was
done in 4 layers with non absorbable silk sutures. In
156
view of atrophic testis, a right orchidectomy was done
and Bassini repair was done.
Intraoperatively blood pressure was maintained
with colloids, blood transfusion, and inotropic
support. Post operatively, ventilatory support and
inotropic support was continued for 2 days. Patient
went in diuretic phase of renal failure with persistent
hypotension inspite of inotropic support. Gradually
with conservative management the patient's renal
status improved. He was given total parenteral
nutrition from post surgery day 5 for 10 days which
was increased step wise with return of bowel
peristalsis. He made an uneventful recovery with
correction of Hypoalbuminaemia and renal
parameters. Serial estimation of renal and
haematological parameters was done till they
returned to normal. He was discharged after 4 weeks
of hospitalisation.
Histopathology revealed acute inflammatory
changes in resected ileal segment with no evidence of
tuberculosis, typhoid or malignancy. The patient was
followed up after 2 weeks and has made full
uneventful recovery.
Discussion
Richter hernia is not very common,
may have rare presentation also. The
commonest presentation is in the sixth
and seventh decades and rarely in
neonates.11, 10 Our patient presented in the
third decade. Commonest sites are the
inguinal, femoral regions and at site of
incisional trauma. Other site is of
laparoscopic trocar insertion, especially
10 mm port.11, 5 Rarely, it occurs at site of
drain insertion following exploratory
laparotomy for abdominal pathology,7 or
through sacral foramen4 too. It may be
associated with Spigelian hernia.3 The site
in our patient was inguinal region.
The diagnosis of Richter's hernia is
difficult because of the innocuous
development of signs and symptoms and it
is associated with a high mortality rate.
Awareness of this relatively rare surgical
entity is important.9 Our patient presented
Bombay Hospital Journal, Vol. 54, No. 1, 2012
with intestinal obstruction due to
obstructed inguinal hernia. The usual
presentation is dull aching abdominal
pain, vomiting and groin swelling. The
presentation may be as bowel obstruction.
The laparoscopic trocar site hernia may
present with crampy pain and swelling at
port site.5 Rare presentation might be as
intestinal tuberculosis,2 as a scrotal
abscess6 or bowel perforation.7 About 10%
present with strangulation11
There are no diagnostic investigations
though radiographs may show intestinal
obstruction. CT Scans may show dilated
bowel loops with evidence of entrapped
loop of bowel in sac.14 In our case only
radiographs were done which revealed
bowel obstruction {Fig.-1}.
These hernias progress more rapidly to
gangrene than other strangulated hernias,
and obstruction is less frequent.11 Our
patient presented with intestinal
obstruction with bowel perforation in the
hernial sac. The antimesenteric border
partial circumference was involved with
atrophic right testis {Fig.-2}, {Fig. -3}
Fig. 2 :Richter hernia seen
Fig. 3 : Perforation seen in Richter hernia
There have been cases were scrotal
abscess6 has resulted from Richter hernia.
Fig. 1 : Abdominal erect radiograph showing
small bowel obstruction
No other investigation was done. Since
presentation is as an emergency and rare
case hence probably special radiological
investigations are not carried out.
The most-often entrapped part of the
bowel is the distal ileum, but any part of
the intestinal tube may be incarcerated.
Bombay Hospital Journal, Vol. 54, No. 1, 2012
The gold standard technique for repair
is the preperitoneal approach, followed by
laparotomy and resection if perforation is
suspected.11 In case of a neonate, hernial
sacs it could be dealt with by suturing the
sac from within the abdomen at the time of
laparotomy.10 For Richter's hernia at
trocar site, treatment is reduction of the
bowel that is incarcerated and then repair
of the fascial defect. Repair can be by open
157
or laparoscopic means. A laparoscopic
hernia repair is acceptable treatment at
the time of diagnosis, especially in the
obese patient, as long as the incarcerated
bowel is not compromised or frankly
ischaemic. 5 In our case a midline
laparotomy was carried out with resection
and ileo-ileal anastomosis.This was
because of acute emergency presentation
with features of hypovolaemia and
septicaemia.
percut. techniques. February 2003; 13(1):55-8.
6.
W. Y. Tail, C. C. Chen 2. Scrotal abscess
resulting from Richter's hernia. Pediatric
surgery international. February 1990, Volume
5, No 2
7.
k. Iwase, J. Igachi, S. Mikata, Y. Tanaka. Ileal
Perforation Due to a Richter Hernia at the Drain
Insertion Site Following an Operation for
Idiopathic Rectal Perforation: Report of a Case.
Today, January 2000, Volume 30, Number 1.
8.
Steinke, Wolfgang MD *; Zellweger, Rene MD.
Richter's Hernia and Sir Frederick Treves: An
Original Clinical Experience, Review, and
Historical Overview. Annals of Surgery.
November 2000,232(5):710-18.
9.
Kadirov S, Sayfan J, Friedman S. Richter's
hernia-a surgical pitfall. Jan 1996;182(1):
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