Rare Case of Peritonitis due to Ileal Perforation Secondary to Richter's Type of Obturator Hernia

Rare Presentation of Incarcerated Incisional Richter's Hernia of the Cecum

Richter's hernia, also called a partial enterocele, involves a protrusion of peritoneum with subsequent strangulation or incarceration of only part of the lumen of the anti-mesenteric portion of the small bowel through a fascial defect. We report a rare presentation of incarcerated incisional Richter's hernia of the cecum in a 39-year-old female. The patient presented with acute abdominal pain that gradually improved. Physical examination revealed right lower quadrant tenderness and nodularity just above an abdominoplasty scar. Subsequent computed tomography scan demonstrated a 1 cm by 1 cm hypovascular pocket arising from the cecum with protrusion into the anterior abdominal wall. The hernia was successfully repaired surgically with resolution of symptoms. It is essential for clinicians to be mindful of the diagnosis of Richter's hernia on the differential for abdominal pain as the risk of detrimental outcomes increases with delayed surgical intervention.

Small Bowel Obstruction Due to Incarcerated Obturator Hernia: Successfull Surgical Management with Modified Mesh-Plug Hernioplasty

BACKGROUND Obturator hernia is an uncommon (0.07-1% incidence rate) subtype of hernia of the abdominal wall, with its incarceration being a rare cause of bowel obstruction. Obturator hernia has a higher incidence in elderly women and in malnourished people. This type of hernia has the highest morbidity and mortality rates of all abdominal wall hernias. This article reports a case of an emaciated 93-year-old woman who presented with small bowel obstruction due to incarcerated obturator hernia, successfully managed surgically with a modified mesh-plug hernioplasty. CASE REPORT An emaciated 93-year-old woman presented with diffuse abdominal pain, more intense on the right iliac fossa, radiating to the right thigh, with 8-h evolution and associated with dark-colored vomiting but normal bowel transit. This patient had a surgical history of right Richter´s femoral hernia, strangulated, with previous intestinal resection and a right femoral hernioplasty. A computed tomography (CT) scan revealed an incarcerated obturator hernia on the right side containing a short segment of small intestine. The patient underwent an exploratory laparotomy and a mesh-plug hernioplasty. During follow-up, there was no evidence of recurrence or complications. CONCLUSIONS Obturator hernia diagnosis is challenging due to its rarity and its signs and symptoms being often unspecific. CT scan has the highest sensitivity and is the best diagnostic tool. Surgical management is the only possible treatment for obturator hernia. Awareness of this condition is essential to allow an earlier approach and attempt to mitigate the associated high morbidity and mortality rates.

Obturator hernias: a systematic review of the literature

PURPOSE

Obturator hernias (OH) are extremely rare hernias, accounting for 0.07-1% of all hernias. This is the first systematic review investigating their presentation, imaging, treatment outcomes, and recurrence rate.

METHODS

After a detailed search in electronic search engines, 74 studies matched our criteria. A review of these reports was conducted and the full texts were examined.

RESULTS

A total of 146 patients with a mean age of 78.8 years were included in our analysis, with 40.1%, 29.9%, and 25.2% of patients suffering from either a right, a left or bilateral OH, respectively. OH were associated with non-specific symptoms and signs; bowel obstruction being the most common. Howship-Romberg sign was present in 56.2% of patients. Computed tomography (CT) scan was the most frequently used diagnostic modality, inversely associated with perioperative mortality. Mesh repair demonstrated a significantly improved perioperative morbidity rate, compared with non-mesh repair. Approximately 30% of patients underwent a laparoscopic operation, which was associated with significantly decreased morbidity and mortality rate as well as length of hospital stay, compared with the open repair.

CONCLUSION

OHs are not associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair.