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

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.

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.

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

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).

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