Richter hernia results from herniation of the antimesenteric wall of the bowel without compromising its lumen. Insidious onset and misleading symptoms lead to delay in diagnosis and a high mortality. We report a case of Richter hernia, after ventriculoperitoneal shunt placement which was later reduced and the defect closed laparoscopically.Key Words: Richter hernia, Complication, Laparoscopic management. CASE HISTORYA 33-year-old man with hydrocephalus requiring multiple ventriculoperitoneal (VP) shunt revisions presented with persistent vomiting for 3 days after his most recent shunt revision. This revision involved placement of the peritoneal portion of the VP shunt via a mini-laparotomy. He had been discharged home within 24 hours of the surgery. He presented to the emergency department because of his unremitting symptoms and progressive lethargy. On examination he appeared lethargic and dehydrated. His abdomen was soft but minimally distended, no masses were palpable, and no tenderness could be elicited. A nasogastric tube was placed, with an immediate return of 1 L of coffee ground appearing fluid.A shunt series reported "mild kinking" of the tube, however demonstrated abnormal bowel gas patterns consistent with small bowel obstruction. Subsequent computed tomography scan of the abdomen demonstrated "mild to moderate gaseous and fluid distention of multiple loops of small bowel with a focal transition point near the ventriculoperitoneal shunt catheter entrance likely due to an adhesion" (Figure 1). Pneumatosis of the duodenum and proximal bowel and scattered foci of possible portal venous gas were also noted. There was not an obvious herniation of the small bowel.Because of the concern for a mechanical small bowel obstruction due to the VP shunt insertion, the patient was taken to the operating room urgently. Diagnostic laparoscopy was performed, and a loop of small bowel was seen to be herniated through the anterior abdominal wall at the site of the VP shunt surgical site (Figure 2). The bowel appeared viable and was reducible with minimal traction. A significant fascial defect was noted around the VP shunt tube (Figure 3), which was closed with interrupted nonabsorbable sutures using the laparoscopic technique. The peritoneal end of the shunt was observed to remain functional after this repair. The bowel that had initially appeared congested rapidly returned to normal appearance and peristalsis. The pneumatosis and small amount of portal venous gas were felt to be benign findings (Figure 4).The patient made an uneventful recovery and was discharged on postoperative day 2 tolerating oral intake. His follow-up visit 2 weeks after discharge was unremarkable for complications. Since then, he has been seen by his primary care physician, with no complaints related to his surgery. DISCUSSIONRichter hernias comprise 10% of strangulated hernias. This entity was first described in 1598 by Fabricius Hildanus, and again in 1887 by Sir Frederick Treves, whose observations and interpretation are the basis of ou...
In minimally invasive surgery, the surgeon and the assistant rely on a single laparoscopic video view for performing different clinical roles. The assistant is tasked with manipulating the camera view so as to maintain a global, panoramic view of the operation. The surgeon needs to remain focused on the operation, requiring a detailed close-up view. We use the term role-specific video imaging to describe the need to provide separate views for the assistant and the surgeon.In this paper we introduce role-specific video imaging for laparosopic surgery. The system is designed to be configurable in the sense that imaging parameters and algorithms can be adjusted in real-time so as to meet the specific needs that arise. The system was evaluated on 4 cases by two surgeons on a Linuxbased 3.2.0 Kernel, with 4GB RAM, and Intel 3.4GHz I7 (2nd generation) microprocessor. Clinical evaluation of the different configuration modes has helped us determine that high-quality role-specific imaging can be achieved for zooming factors that are larger or equal to 2x2 with bilinear interpolation, while maintaining 30 frame per seconds for the panoramic and closeup views. In future work, in order to minimize interaction with the surgical team, the system will be upgraded to incorporate tracking of the operating instrument during surgery.
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