Management of Strangulated Richter’s Hernia in a Resource-Limited Setting: Report of Two Cases and Literature Review

Introduction

Richter’s hernia is a rarely encountered surgical entity. It is defined as the protrusion and/or strangulation of only part of the circumference of the intestine’s anti-mesenteric border through the hernia orifice, leading to a risk of ischemia, gangrenous bowel, and perforation.^1–4 The most common location of this pathology is the femoral canal (36-88%), followed by the inguinal canal (12-36%) and incisional hernia of the abdominal wall (4-25%).^3–5 The increase in laparoscopic and robotic surgery has contributed to the rise in Richter-type hernias at trocar sites.⁶ Diagnosis of this pathology is challenging in our region due to long admission times, limited availability of abdominal imaging, and varied clinical presentations. The management of Richter's hernia depends on the viability of the incarcerated intestine, which must be assessed; intestinal resection is indicated in the event of necrosis.^5,7 We report two rare cases of Richter's hernia found during emergency exploratory laparotomy; with the first case located in the right inguinal region and the second in the linea alba. Post-operative management was straightforward in both patients, although bowel resection was necessary in the second. These cases highlight the important role of emergency exploratory laparotomy.

This case report has been reported in line with the SCARE Criteria.⁸

Case report

Case 1

A 33-year-old married woman with an obstetrical history of three births, two parities, one abortion, and two cesarean sections (the most recent about four weeks prior) was transferred to the surgical emergency department for rapidly progressive diffuse abdominal pain associated with vomiting and cessation of matter and gas lasting four days. Clinical examination revealed an overweight, afebrile patient with a core temperature of 36.5-37°C. The patient was hemodynamically and respiratory stable with a blood pressure of 130/67 mmHg, pulse rate of 108 beats/min, and respiratory rate of 24 breaths/min, and blood oxygen saturation was 96% on ambient air. Abdominal examination revealed a distended abdomen, and tympany on the percussion, with an old Pfannenstiel-type surgical scar. The examinations of cardiovascular, gynecology, neurology, and pelvic touch were without peculiarities. Following this clinical examination, mechanical intestinal obstruction was suspected. Abdominal X-ray showed signs of small bowel obstruction in the form of distension and hydroaeric levels with a large dilated loop image (Figure 1). Abdominal computed tomography (CT) scan was not performed due to financial constraints; however, other biological tests were normal. The patient was resuscitated with intravenous crystalloid fluids and received intravenous analgesia (Paracetamol 5g/24h, tramadol hydrochloride 300mg/24h) and antibiotic prophylaxis (ceftriaxone 2g/24h). The patient was admitted to the operating room for emergency median laparotomy under general anesthesia in the supine position. Surgical exploration revealed a strangulated loop at the linea alba, located on the anti-mesenteric face of the ileum, 80 cm from the ileocecal valve (Figure 2). The diagnosis of Richter's hernia of the linea alba was confirmed. The incarcerated loop was viable. We proceeded with disincarceration and reintegration of the contents of the hernia, followed by resection of the hernia sac and suture repair of the hernia. The postoperative course was straightforward; antibiotic prophylaxis was discontinued after 96 hours, and early ambulation was recommended. The patient was discharged after seven days of hospitalization and was advised to avoid heavy lifting for 3 months. After six months of follow-up, there was no sign of recurrence, and the patient resumed her daily activities.

Figure 1. Plain X-ray of the abdomen showing distension and hydroaeric levels (red arrows).

Figure 2. Intraoperative view of the hernia sac contents after laparotomy.

Damaged loop on its antimesenteric edge (blue arrow), distension of its proximal part (yellow arrow), and distal flattening (purplish arrow).

Case 2

A 59-year-old married man with a history of painless, spontaneously reducible right inguinal swelling, cough impulse, and chronic constipation for two years; was transferred to the emergency department with a right inguinal swelling that had become very painful, firm, non-reducible, and without cough impulse, which had been evolving for around 72-96 hours. The clinical picture worsened approximately 8-9 hours before admission, with the onset of abdominal distension, vomiting, and cessation of matter and gas. Clinical examination showed the patient to be agitated but without any alteration in consciousness. He was hemodynamically and respiratory stable with a blood pressure of 110/65 mmHg, pulse rate of 120 beats/min, and respiratory rate of 23 breaths/min, and his blood oxygen saturation 98% on ambient air. His core temperature was 37-37.5°C, and his body mass index (BMI) was normal at 23 kg/m². The right inguinal swelling remained painful, non-reducible, and without cough impulse (Figure 3), but the rest of the abdomen was soft and painless to palpation. Biological examination revealed an inflammatory process characterized by neutrophilic leukocytosis of 14,900 cells/μL (reference range: 4,000 – 10,000 cells/μL) and 78.12% neutrophils (reference range: 50-70%), along with an increase in C-reactive protein (CRP) levels to 78 mg/L (reference range: < 6 mg/L). However, renal function tests were normal, and there were no ionic or coagulation disorders. A diagnosis of strangulated right inguinal hernia was suspected, but the patient did not undergo abdominal imaging due to financial constraints. The patient was resuscitated with intravenous crystalloid fluids and received in intravenous, an analgesia (paracetamol 5g/24h, tramadol hydrochloride 300mg/24h) and antibiotic prophylaxis (ceftriaxone 2g/24h, metronidazole 1500mg/24h). The patient was then taken to the operating room for an emergency exploratory laparotomy. An elective oblique right kelotomy was performed under general anesthesia in supine position. Intra-operatively, the loop of the ileum was partially incarcerated on its anti-mesenteric border, 35 and 45 cm from the ileocecal junction, resulting in necrosis of the bowel (Figure 4). The diagnosis of Richter's hernia was confirmed, and elective oblique kelotomy was converted to median laparotomy. The necrotic segment of the ileum was segmentally resected, followed by an end-to-end ileo-ileal anastomosis. Finally, primary repair of the hernia was performed. The postoperative course was favorable; antibiotic prophylaxis and intravenous crystalloids were discontinued after 96 hours, and early ambulation was recommended. Digestive transit resumed 72 hours after surgery, and the patient was discharged on the ninth day. He was advised to avoid heavy lifting for 3 months. After six months of ambulatory follow-up, the patient showed no signs of hernia recurrence, despite resuming normal activities.

Figure 3. Preoperative view of strangulated right inguinal swelling.

Figure 4. Intraoperative view of hernia pouch contents.

Discussion

Richter’s hernia is defined as a rare hernia of the abdominal wall in which a portion of the circumference of the intestinal tract is trapped and strangulated at the hernial orifice.^2,3,5 In 1558, Fabricius Hildanus was the first to report a case of Richter's hernia. However, it was not until 1778 that the German surgeon August Gottlieb Richter provided a scientific description of this surgical entity, which would later take the name “Richter’s hernia”.^4,7,9,10 These two cases of Richter hernia are the first to be documented and reported in our region. In the scientific literature, this hernia is most often diagnosed in patients aged between 60 and 80 years and accounts for up to 10% of all strangulated hernias.^2,3,7,11 The average age of our patients was 46 years (33 and 59 years). The clinical picture depends on the location of the hernia. However, it remains exceptional in our region due to difficult access to abdominal imaging and long admission times to the operating theatre. In our cases, abdominal CT scans were not performed due to financial constraints, so an exploratory laparotomy was performed. We confirmed the diagnoses intraoperatively, consistent with the findings reported by most authors. It is important to note that these hernias can occur on anterior incisions but are more frequently observed in small hernial rings large enough to entrap a small portion of the bowel wall. Both our patients developed a hernia at the natural orifice. The most frequent locations were femoral hernias (72-88%), followed by the inguinal canal (12-24%) and umbilical and linea alba hernias (4-25%).^1,2,4 The clinical presentation of Richter's hernia is highly varied; one of our patients presented with a typical occlusive syndrome, whereas the other had an atypical clinical picture. Because patients rarely present with obstructive symptoms, they tend to progress more rapidly to gangrene than other types of strangulated hernia. Repair is usually approached via the preperitoneal route, with mandatory laparotomy and bowel resection in cases of gangrene or perforation. The silent nature of this hernia presentation and the fact that the patient continues to emit flatulence and stools make it particularly dangerous. At the time of presentation, there is usually ischemia of the affected bowel, and bowel resection is mandatory.^{1,3,4,5,11,13} The necrotic bowel is not the only worrying aspect of these hernias. Other complications described in the literature include spontaneous fistulas from the affected bowel and skin necrosis. Atypical presentations of Richter's hernias have also been reported, such as complications from colonoscopy.^3,5 There have also been cases of Richter's hernia simulating a groin abscess, with the diagnosis only being made during laparotomy or the drainage of inguinal abscesses revealing amylaceous material.¹⁴ These examples highlight the diverse clinical presentation of this pathology. Despite the small size of our study population, we recommend rapid surgical intervention (emergency exploratory laparotomy) in patients presenting suspicious clinical signs in resource-limited environments. This approach can lead to an uneventful recovery. However, more studies are needed to establish a guideline for this pathology in resource-limited settings.

Conclusion

Richter hernia is a rare surgical entity with very high mortality and morbidity. However, this condition has rarely been reported in our region due to limited access to abdominal imaging, long management delays, and varied clinical manifestations. Despite these challenges, our patients achieved favorable operative outcomes, contrary to what is often reported in the literature. Therefore, the management of this pathology in resource-limited settings must be centered on emergency exploratory laparotomy in patients presenting with suspicious clinical signs.

Consent

Written informed consent for publication of the clinical details and clinical images was obtained from the patient.

Checklists and flow charts

Figshare: CARE checklist for ‘Scare 2020 Checklist Article Richter Hernia HNN’.¹⁵

https://doi.org/10.6084/m9.figshare.26027293.v1

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC PAR 4.0 Public domain dedication).

Authors’ contributions

Conceptualization: YBT, OIH, AZ, KI, RS; Data Curation: YBT, OIH, KI, RS; Project Administration: RS; Resources: YBT, RS; Supervision: RS; Validation: YBT, OIH, AZ, KI, RS; Visualization: YBT, OIH, AZ, KI, RS; Writing – Original Draft Preparation: YBT, OIH, AZ, KI, RS; Writing – Review & Editing: YBT, OIH, AZ, KI, RS