A rare case of spontaneous inguinal faecal fistula as a complication of incarcerated Richter's hernia with brief review of literature

Iatrogenic enterocutaneous fistula following an incarcerated Richter's femoral hernia misdiagnosed for an inguinal abscess: A case report

INTRODUCTION AND IMPORTANCE

As the Richter's hernia contains anti-mesenteric intestinal wall, patients usually do not present with obstructive symptoms. Consequently, this leads to delays in diagnosis and increased morbidity and mortality. Early detection and surgical treatment are therefore paramount to improving outcomes.

CASE PRESENTATION

A 51-year-old female presented with an incarcerated Richter's femoral hernia misdiagnosed as inguinal abscess that underwent incision and drainage. This developed into an enterocutaneous fistula (EC Fistula) and was eventually complicated by peritonitis, requiring laparotomy and herniorrhaphy. Post-operative recovery was uneventful.

CLINICAL DISCUSSION

In advanced stages, Richter's femoral hernia may present with obstructive symptoms as in other incarcerated hernias. Richter's hernias may eventually present with obstructive symptoms in their advanced stages. Their relatively asymptomatic nature increases the risk of complications, such as enterocutaneous fistula.

CONCLUSION

This case highlights how an incarcerated Richter's femoral hernia in a female misdiagnosed as an abscess delayed treatment, increased patient morbidity with development of an enterocutaneous fistula and peritonitis, and mandated surgical exploration to control sepsis and repair the hernia.

Enterocutaneous fistula due to a Richter's hernia after a Tenckhoff catheter removal

Richter's hernia is a rare type of hernia that occurs when the antimesenteric intestinal wall protrudes through a defect in the abdominal fascia leading to ischaemia, gangrene, bowel perforation and enterocutaneous fistulae. In this article, we describe a rare case of enterocutaneous fistula due to a Richter's hernia after a Tenckhoff catheter removal. This type of complication has not been previously reported in the literature. An 82-year-old man presented with a 1-day history of enteric content at the Tenckhoff catheter insertion site. Seven weeks earlier, the catheter was removed due to peritonitis. Removal was performed using open technique, and the fascia was not closed. Computed tomography revealed a small incarcerated hernia and subcutaneous fluid collection at the previous catheter insertion site. He underwent laparoscopy, which showed a Richter's hernia with perforation of the ileum causing an enterocutaneous fistula. A laparoscopic enterectomy was performed using a primary mechanical anastomosis. The hernia was repaired by primary suture without a mesh because of wound enteral contamination and the small size of the hernia. Richter's hernia has a misleading clinical presentation and contributes to high rates of morbidity and mortality. A secure myofascial closure during catheter removal may reduce the chances of this complication.

Richter's Type Recurrent Indirect Inguinal Hernia, an Extremely Rare Occurrence: A Case Report

Background

Richter’s type recurrent indirect inguinal hernia remains to be an extremely rare entity reported scarcely. It may present with grave complications in the absence of symptoms and signs of intestinal obstruction. The aim of this study is to report a rare case of Richter’s hernia after a previously repaired indirect inguinal hernia.

Case Presentation

A 31-year-old male farmer came up with complaints of colicky abdominal pain and two episodes of vomiting. He had a previous right inguinal surgery. A physical examination revealed a full abdomen with right inguinal tenderness and oblique surgical scar. Abdominal ultrasound showed a bowel segment entrapped in the deep inguinal ring of the inguinal canal. Right inguinal exploration was done, and the finding was a gangrenous Richter’s type recurrent indirect inguinal hernia. The patient was discharged and improved on the seventh post-operative day after resection and anastomosis.

Discussion

Richter’s hernia is a rare form of hernia that occurs when the anti-mesenteric border of the bowel is partly trapped in a tight hernial ring. Its rarity, combined with the fact that it may present in the absence of typical symptoms and signs of intestinal obstruction and local physical findings, poses a diagnostic challenge which often end up with complications like gangrenous bowel at the time of diagnosis.

Conclusion

Richter’s hernia can occur in an extremely rare form as Richter’s type recurrent indirect inguinal hernia. A high degree of suspicion, an early referral and timely imaging on the provider's side may prevent mortality and morbidity.

Spontaneous enterocutaneous fistula in a patient with femoral hernia: a case report

BACKGROUND

Enterocutaneous fistula commonly occurs in the post-operative setting. However, a handful of cases have been reported to occur secondary to strangulation of hernia, mostly femoral due to the narrow femoral ring through which this type of hernia passes through.

CASE PRESENTATION

We encountered a case of spontaneous fecal fistula, which occurred in the setting of an incarcerated femoral hernia. The patient did not develop peritonism, or obstruction, throughout the course of the disease. The hernia ruptured on day 7 of incarceration. Exploratory laparotomy under epidural anesthesia revealed a femoral hernia with ileum as content, arising approximately 20 cm from the ileocecal junction. Reduction of the contents was done, and a resection performed along with repair of the hernia.

CONCLUSION

As very few literature describe the formation of spontaneous fecal fistula, we discuss the presentation in this report.

FEMORAL HERNIA: UNCOMMON, BUT ASSOCIATED WITH POTENTIALLY SEVERE COMPLICATIONS

BACKGROUND

Although the laparoscopic access is becoming the preferable treatment for femoral hernia, there are only few studies on this important subject.

AIM

To assess the outcomes of the totally extraperitoneal laparoscopic (TEP) access in the treatment of femoral hernia.

METHODS

Data of 62 patients with femoral hernia who underwent herniorrhaphy were retrospectively reviewed. The diagnosis of femoral hernia was established by clinical and/or imaging exams in 55 patients and by laparoscopic findings in seven.

RESULTS

There were 55 (88.7%) females and 7 (11.3%) males, with female to male ratio of 8:1. The mean age was of 58.9±15.9 years, ranging from 22 to 92 years. Most patients (n=53; 85.5%) had single hernia and the remaining (n=9; 14.5%) bilateral, making a total of 71 hernias operated. Prior lower abdominal operations were recorded in 21 (33.9%) patients. Conversion to laparoscopic transabdominal preperitoneal procedure was performed in four (6.5%). Open herniorrhaphy was needed in two (3.2%), one with spontaneous enterocutaneous fistula in the groin region (Richter's hernia) and the another with incidental perforation of the adjacent small bowel that occurred during dissection of hernia sac. There was no mortality.

CONCLUSION

Femoral hernia is uncommon, and it may be associated with potentially severe complications. Most femoral hernias may be successfully treated with totally extraperitoneal laparoscopic access, with low conversion and complication rates.

Fecal Scrotal Abscess Secondary to Spontaneous Retroperitoneal Perforation of Ascending Colon

Introduction

Fecal abscess or enterocutaneous fistulas of the scrotum are rare and are invariably the result of incarcerated bowel loop in inguinal hernia. Spontaneous perforation of the colon (SPC) having no definite cause is also rare. Much rarer is posterior colonic perforations causing an extensively large retroperitoneal abscess. Similarly, spread of retroperitoneal abscess to the thigh or scrotum has rarely been reported. We report a case of spontaneous posterior perforation of ascending colon resulting in large retroperitoneal abscess eventually causing scrotal abscess, which resolved on conservative treatment and drainage of the scrotal fecal abscess. Case Presentation. A 20-year-old male presented with gradually increasing noncolicky pain right side abdomen with nonprojectile vomiting, obstipation, and progressive abdominal distension. Clinically, the abdomen was tender with guarding over the right side with signs of inflammation on the right side back with no associated hernia. On conservative treatment, he was gradually improved but developed right side scrotal abscess a week later. CT abdomen showed a large retroperitoneal collection having multiple internal air lucencies, displacing ascending colon and caecum medically with discontinuity in the posterior wall of ascending colon. The large retroperitoneal collection was extending from right pararenal and posterior perihepatic soft tissue planes to the right iliac fossa and thigh. On drainage of the scrotal abscess, about 350 ml of fecal contents was evacuated. The patient gradually recovered and was discharged on conservative treatment with an uneventful 4-year follow-up.

Conclusion

Diagnosis of retroperitoneal perforation of the colon is often delayed due to the absence of peritoneal irritation. An extensively large retroperitoneal abscess may spread the infection to the scrotum and thigh due to extreme pressure, possibly by dissecting away the transversalis fascia through a deep ring along the side of the spermatic cord. Timely performed CT/MRI can avoid delay in the diagnosis of retroperitoneal abscess and further spread of infection.

Fistulating Richter's Hernia of Groin with Necrotizing Soft Tissue Infection: A Lethal Combination

Strangulation of groin hernia can result in significant morbidity and mortality. Spontaneous external fistulation following strangulation is rare and typically occurs with Richter's hernia. Spreading Necrotizing Soft Tissue Infection (NSTI) secondary to Enterocutaneous Fistula (ECF) is an ominous sign, further worsening its prognosis. Early diagnosis and prompt surgical treatment is crucial to improve outcome. Herewith the authors are presenting a case of neglected inguinal hernia. It was complicated with ECF formation and rapidly spreading NSTI of flank. He underwent resection and anastomosis of the gangrenous bowel, anatomical repair of the hernia along with soft tissue debridement of flank region. This patient however succumbed to sepsis with multi organ dysfunction. Significant delay in seeking medical care led to dismal outcome.

Spontaneous Enterocutaneous Fistula Resulting from Richter's Hernia

Richter's hernia is due to the entrapment of a part of circumference of the bowel wall. As the bowel continuity is maintained, the patients usually do not have intestinal obstruction. Some patients with Richter's hernia may present with enterocutaneous fistula either spontaneous or due to surgical intervention mistaking the obstructed hernia to be inguinal abscess. This is more so in developing countries due to lack of awareness among the masses or due to the delay in seeking medical attention. Presenting here is a case of a 53-year-old male patient with enterocutaneous fistula which occurred spontaneously and sought medical attention only after about three years of repeated discharge of yellowish fluid from the left inguinal region. Magnetic resonance fistulogram confirmed the diagnosis of enterocutaneous fistula. Laparotomy with resection and primary anastomosis of the fistulous bowel was done. Patient recovered uneventfully without any complications or recurrence.

A case report of spontaneous umbilical enterocutaneous fistula resulting from an incarcerated Richter's hernia, with a brief literature review

BACKGROUND

Richter's hernia is a high-risk ischaemic gastrointestinal disorder that is typically diagnosed in a delayed manner due to a lack of obvious symptoms. Spontaneous umbilical enterocutaneous fistula (ECF) resulting from an incarcerated Richter's hernia is extremely rare.

CASE PRESENTATION

A 62-year-old female presented with a chief complaint of recurrent umbilical region infection for the preceding 20 months with no symptoms of ileus. Preoperative CT and fistulography revealed an incarcerated Richter's hernia complicated by an ECF. Exploratory laparotomy revealed a loop of the distal ileum adherent to the umbilical region that was retrieved back into the abdominal cavity. Side-to-side ileo-ileal anastomosis was performed using a 75 mm linear stapler to remove the affected ileum segment. The internal hernia ring was closed using plication sutures instead of via mesh repair due to the patient's small defect and infection risk.

CONCLUSION

Richter's hernia can be observed at any age but is particularly common in frail, elderly patients. This nonspecific clinical and laboratory findings of this condition are associated with a high misdiagnosis rate, resulting inrelatively high mortality. Abdominal CT and gastrointestinal imaging are recommended if Richter's hernia is suspected. Timely surgical intervention is crucial for reducing mortality and improving prognosis.

Spontaneous entero-labial fistula complicating Richters hernia: Report of a case

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Spontaneous entero-labial fistula complicating Richters hernia occurring in an adult female is rare in Africa.

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Spontaneous faecal fistula in inguinal region following rupture of strangulated Richter’s hernia especially in female adults is uncommon.

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It can occur even in absence of obstructive symptoms

Background

Richter's hernia is defined as a type of hernia in which only part of the circumference of the antimesenteric border of a bowel wall is incarcerated within the hernia sac leading to ischemia, gangrene and perforation of the hollow viscus. Richter's hernia is known to cause strangulation without obstruction due to involvement of only a part of the circumference of a bowel wall. Inguino-labial Richter's hernia presenting with the complication of spontaneous entero-cutaneous fistula is rare.

Aim

This is to report a case of spontaneous entero-labial fistula complicating Richters hernia occurring in an adult female.

Case report

A 61-year-old woman presented with a history of sudden generalized abdominal pain. She had a prior history left inguino-labial swelling of six years duration, which was initially reducible but became irreducible two weeks prior to presentation. There was associated discharge from the swelling a few days later. She was pale and febrile. Her temperature was 39.2 °C, pulse rate was 110 per minute and blood pressure was 130/60 mmHg. A diagnosis of left inguinolabial hernia was made.

She was resuscitated and an exploration of the groin swelling was made. A rupture of the anti-mesenteric border of the ileum with strangulated preperitoneal fat was found. She had resection and anastomosis of the ileum.

Conclusion

Spontaneous faecal fistula in inguinal region following rupture of strangulated Richter's hernia especially in adults is uncommon and can occur even in absence of obstructive symptoms. In presentation of any groin swelling, there is need for an early accurate diagnosis followed by prompt treatment. The delay in its diagnosis and management may result in this rare complication of spontaneous faecal fistula. This reflects the state of health care in the developing world and needs to be addressed by the concerned authorities.