Richter's Hernia with Unique Presentation as Obstructed Inguinal hernia with Bowel Perforation

*Assistant Professor,**Honorary Professor, ***Honorary Professor and Head of Department, Department of General Surgery, Dr. R. N. Cooper Municipal General Hospital, Vile-Parle, Mumbai

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

n Richter's hernia only a part of Icircumference 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, 8described by Fabricius Hildanus 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 8proposed the title "Richter's hernia".

More often these hernias are

diagnosed in the sixth and seventh

decades of life. They comprise 10 per cent 11of strangulated hernias rarely can occur

10in the neonates. Their common sites are

the femoral ring, deep inguinal ring, and at 11incision site, at trocar sites after

laparoscopic procedures (10-mm or larger 5ports). 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 7following open abdominal surgery, as

3Spigelian hernia, through the sacral 4foramen. 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, 9and obstruction is less frequent.

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

155Bombay Hospital Journal, Vol. 54, No. 1, 2012

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

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 11, 10neonates. 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 11, 510 mm port. Rarely, it occurs at site of

drain insertion following exploratory 7laparotomy for abdominal pathology, or

4through sacral foramen too. It may be 3associated with Spigelian hernia. 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 9entity is important. Our patient presented

Bombay Hospital Journal, Vol. 54, No. 1, 2012156

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 5port site. Rare presentation might be as

2intestinal tuberculosis, as a scrotal 6 7abscess or bowel perforation. About 10%

11present with strangulation

There are no diagnostic investigations

though radiographs may show intestinal

obstruction. CT Scans may show dilated

bowel loops with evidence of entrapped 14loop of bowel in sac. In our case only

radiographs were done which revealed

bowel obstruction {Fig.-1}.

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.

These hernias progress more rapidly to

gangrene than other strangulated hernias, 11and obstruction is less frequent. 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 6abscess has resulted from Richter hernia.

The gold standard technique for repair

is the preperitoneal approach, followed by

laparotomy and resection if perforation is 11suspected. In case of a neonate, hernial

sacs it could be dealt with by suturing the

sac from within the abdomen at the time of 10laparotomy. 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

157Bombay Hospital Journal, Vol. 54, No. 1, 2012

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 5ischaemic. 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.

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