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

Abstract

BackgroundRichter’s hernia is a high-risk ischaemic gastrointestinal disorder that is typically diagnosed in a delayed manner due to a lack of obvious symptoms. Spontaneous umbilical enterocutaneous fistula (ECF) resulting from an incarcerated Richter’s hernia is extremely rare.Case presentationA 62-year-old female presented with a chief complaint of recurrent umbilical region infection for the preceding 20 months with no symptoms of ileus. Preoperative CT and fistulography revealed an incarcerated Richter’s hernia complicated by an ECF. Exploratory laparotomy revealed a loop of the distal ileum adherent to the umbilical region that was retrieved back into the abdominal cavity. Side-to-side ileo-ileal anastomosis was performed using a 75 mm linear stapler to remove the affected ileum segment. The internal hernia ring was closed using plication sutures instead of via mesh repair due to the patient’s small defect and infection risk.ConclusionRichter’s hernia can be observed at any age but is particularly common in frail, elderly patients. This nonspecific clinical and laboratory findings of this condition are associated with a high misdiagnosis rate, resulting inrelatively high mortality. Abdominal CT and gastrointestinal imaging are recommended if Richter’s hernia is suspected. Timely surgical intervention is crucial for reducing mortality and improving prognosis.

Richter Paraumbilical Hernia Managed by Invagination: A Case Report and Review of Literature

“…Diagnosis of Richter hernia is never difficult, as usually made by CT scan of the abdomen, or intraoperatively when CT scan was not done preoperatively like in our case scenario [1]. Also, it may be detected by CT Fistulogram in cases presented with just fistulous opening draining intestinal content of the entrapped bowel loop [2]. Management of Richter hernia differs according to condition of the entrapped bowel, as just application of packs soaked in warm saline is the sole treatment if the bowel is viable.…”

“…Repair of the defect is mandatory to prevent recurrence but, mesh placement is controversial. Mesh repair in most studies were done in case of no ischemia, while were avoided in setting were infection may occur as in ischemic or perforated bowel [2]. In our case we preferred not to do mesh repair due to ischemic bowel with some toxic fluid in the sac which may increase the risk of infection.…”

“…Any gastrointestinal organ may be in the content of Richter hernia but, the commonest is distal ileum in majority of cases. Based on the fact stated by Richter that the defect of this particular hernia must be small enough to prevent passage of entire bowel loop with a firm edges, Richter hernia occurs mostly at femoral ring ( 71%) , deep inguinal ring (23%), with the least incidence at ventral hernia (6%) also port sites of laparoscopic surgery became a common site for such type of hernia [2,5].…”

“…Symptoms and signs of intestinal obstruction depends on the part entrapped from circumference of bowel wall, as it occurs with the entrapment of about 2/3 of the circumference. Progression into strangulation and ischemia present generally as fever and tense tender hernia with redness of overlying skin, it is a common complication of Richter hernia especially when associated with normal flow of intestinal content without obstruction, as this delay the diagnosis leading to gangrene and may be perforation with enterocutaneous fistula [2].…”

“…It has different presentation from painless abdominal swelling up to enterocutaneous fistula. Its management is variable according to condition of the entrapped bowel, while mesh placement is controversial [2]. Here we are reporting a rare case of Richter paraumbilical hernia with a short review of the related literature regarding different presentations and modalities of treatment.…”