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

Richter supraumbilical hernia managed with invagination: a case report

Introduction and importance

Richter's hernia is an incarceration of the anti-mesenteric border of a segment of bowel through an abdominal wall defect. It primarily affects elderly individuals but can occur at any age, with a slightly increased incidence in females. The increase in laparoscopic and robotic-assisted procedures has led to a rise in Richter's hernias.

Case presentation

A 40-year-old male with a history of laparoscopic cholecystectomy and kidney transplantation presented with a 4-day history of supraumbilical swelling and abdominal pain. The swelling was irreducible and accompanied by mild tenderness, and local signs of inflammation were exhibited. Intraoperatively, a 1.5 cm hernia defect was found, with the sac containing omentum and a portion of bowel segment for which invagination with serosal closure with the Mayo double-breasting technique was done.

Clinical discussion

Richter's hernia presents with abdominal discomfort, bloating, nausea, and vomiting, with a notable feature being the delayed onset of symptoms due to its partial involvement of the bowel wall. Diagnosis can be achieved through a computed tomography (CT) scan or intraoperative exploration. Management of Richter hernia is contingent upon the patient's clinical condition, physical examination, and suspicion of strangulation.

Conclusion

Diagnosis of Richter's hernia demands higher suspicion, particularly in patients with predisposing factors like a history of minimally invasive surgery. Prompt surgical intervention is crucial for reducing mortality and enhancing prognosis, with invagination alone being adequate if ischaemia is confined and mesh placement is unnecessary.

Incarcerated Richter's congenital umbilical hernia in a young male: A case report

INTRODUCTION AND IMPORTANCE

Richter's hernia is a protrusion of a portion of the circumference of anti-mesenteric side of intestine through the fascial defect. It is a rare type of hernia and typically occurs in elderly patients. Richter's hernia could result in grave complications. The objective of the study was to describe a rare case of incarcerated Richter's congenital umbilical hernia in a 20-year-old male patient.

CASE PRESENTATION

A 20-year-old male presented with a complaint of intermittent crampy peri-umbilical pain of three days duration associated with non-reducible umbilical bulge and vomiting. On examination, there was 4 cm by 4 cm oval, firm, tender, non-reducible mass over the umbilical area without cough impulse. He was kept nothing per os, broad spectrum antibiotic started, consent taken & operated. A loop of the ilium which was mildly ischemic found in the hernia sac. Sac and entrapped intestine were thoroughly cleaned with warm saline and reduction and herniorrhaphy done. The client discharged on the 2nd postoperative day.

CLINICAL DISCUSSION

There have been very few reports of Richter's congenital umbilical hernia. Richter's hernia progresses more rapidly to gangrene than other strangulated hernias however patients often have no intestinal obstruction. Raised suspicion therefore is important to take timely surgical intervention before the disease advance and complications occurred.

CONCLUSION

Richter's hernia has subclinical symptoms and late presentation which could result in grave complications and increased mortality. The early decision for surgery has paramount importance in reducing complication and associated mortality.

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.

Invisible incarcerated umbilical hernia: A case report

Introduction

Umbilical hernia usually manifests as a bulging of umbilicus. Invisible incarcerated umbilical hernia has never been reported.

Case presentation

A 53-years-old obese woman admitted to hospital with abdominal pain and vomitus one day after discharged from other hospital, was managed conservatively as an adhesion small bowel obstruction (ASBO) for seven days. There was history of caesarean section 20 years ago. Abdomen was bloated, there was transverse scar wound in hypogastric region and no signs of external abdominal hernia. Plain abdominal x-ray showed dilated small bowel located in the central part of the abdomen. Abdominal CT scan was done to determine the other cause besides adhesion, it showed incarcerated umbilical hernia and gallbladder stone. Herniorrhaphy and laparoscopic cholecystectomy were performed. During surgery, there was a loop of vital small bowel, trapped in the umbilical defect. Mayo method was performed to close the defect.

Discussion

The other causes of small bowel obstruction should be determined besides adhesion, infectious disease and trauma. Umbilical hernia should be considered in obese women even without bulging in the umbilicus. Abdominal CT scan with oral water-soluble contrast is preferred as diagnostic tool to identify the cause of small bowel obstruction.

Conclusion

Invisible incarcerated umbilical hernia is possible in obese patients. Routine palpation on potential sites of developing hernia and abdominal CT Scan are necessary to be done in obese patients with small bowel obstruction.

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The other causes small bowel obstruction should be determined other than adhesion.

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Umbilical hernia should be considered in obese women even without bulging in the umbilicus.

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Routine palpation on potential sites of developing hernia and abdominal CT Scan are necessary to be done in obese patients with small bowel obstruction.

Ileo-ileal fistula with severe malnutrition caused by strangulated ileus surgery while preserving ischemic ileum: A case report

INTRODUCTION

Entero-enteric fistulas are rare complications that occur in patients with inflammatory bowel disease and other intestinal diseases. In this report, we present an ileo-ileal fistula accompanied by severe malnutrition caused by strangulated ileus surgery while preserving the ischemic ileum in a very elderly patient.

CASE PRESENTATION

A 90-year-old woman underwent emergency surgery without bowel resection for strangulated ileus in another hospital. Minor abdominal pain and slight fever persisted after surgery. She lost weight, losing approximately 10 kg within half a year. She gradually became difficult to move due to dyspnea upon exertion and generalized edema and visited at our hospital. Pleural effusions, ascites and severe malnutrition were observed. An elastic hard mass with mild tenderness was palpated in her abdomen. Computed tomography showed a loop-like ileum and ileo-ileal fistula with adjacent fat stranding. We performed a partial small bowel resection. The resected specimen demonstrated an ileo-ileal fistula and circumferential ulceration in the loop-like adhesion. After the operation, the nutrition status was resolved immediately without any medications.

DISCUSSION

In cases of strangulated ileus, there are no deterministic criteria for evaluating intestinal blood flow. This is the first report of ileo-ileal fistula onset after surgery for strangulated ileus without intestinal resection. Furthermore, this fistula caused severe malnutrition duo to chronic inflammation, ulcer formation, and the blind-loop syndrome.

CONCLUSIONS

When preserving the intestinal tract in the operation of strangulated ileus, the occurrence of entero-enteric fistulas should be considered. Since malnutrition in the elderly is a serious problem, it should be treated promptly.

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.