Ileal Perforation Due to a Richter Hernia at the Drain Insertion Site Following an Operation for Idiopathic Rectal Perforation: Report of a Case

Iwase, Kazuhiro; Higaki, Jun; Mikata, Shoki; Tanaka, Yasushi; Yoshikawa, Masaharu; Kishimoto, Tomono; Torigai, Kei; Kamiike, Wataru

doi:10.1007/pl00010050

Surg Today

2000

DOI: 10.1007/pl00010050

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Ileal Perforation Due to a Richter Hernia at the Drain Insertion Site Following an Operation for Idiopathic Rectal Perforation: Report of a Case

Kazuhiro Iwase

Jun Higaki

Shoki Mikata

et al.

Abstract: A case of a Richter hernia at the insertion site of the drainage tube following open abdominal surgery is reported. A 54-year-old man underwent an emergency operation for an idiopathic rectal perforation. A partial resection of the rectum and drainage using four 10-mm (outer diameter) drainage tubes with round cross sections was performed. Despite an uneventful early postoperative course, an emergency reoperation was required for peritonitis due to a bowel perforation 14 days after removing the drain inserted … Show more

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“…3 Richter hernia is a rare complication of laparoscopic surgery, 5 with trocar sites being an area of potential susceptibility. 2,5 It has been described at a drain insertion site 6 and has been reported at a trocar site into a deep preperitoneal space despite fascial closure. 7 No reports of a Richter hernia after a VP shunt surgery have been published.…”

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Richter Hernia As a Complication of Ventriculoperitoneal Shunt Placement

Sabih

Perez

2014

CRSLS

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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...

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Richter Hernia As a Complication of Ventriculoperitoneal Shunt Placement

Sabih

Perez

2014

CRSLS

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Richter's Hernia in the Laparoscopic Era

Boughey

Nottingham

Walls

2003

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques

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Richter's hernia can occur at trocar sites after laparoscopic procedures, and 10-mm or larger ports are the usual culprits. Most surgeons now routinely close the fascia of these sites to prevent herniation. The usual presentation is of crampy abdominal pain with nausea and vomiting. Treatment is reduction of the bowel that is incarcerated and then repair of the fascial defect. We describe four cases of Richter's hernia after laparoscopy, two that were repaired by open procedure and two that were repaired laparoscopically, and review the literature. A laparoscopic hernia repair is acceptable treatment at the time of diagnosis, especially in the obese patient, as long as the incarcerated bowel is not compromised or frankly ischemic.

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Drainage as a rare cause of intestinal incarceration

et al. 2005

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Silicone drains are often placed in the abdominal cavity for prophylactic reasons. One complication resulting from drainage includes visceral herniation at the drain site of the abdominal wall defect. An 82-year-old woman underwent a laparotomy for a large pelvic mass. After the operation, she developed small bowel incarceration, which was caused by aggressive drain extraction. Subsequent surgical treatment resulted in the patient's full recovery. This case emphasises the unusual causative mechanism of intestinal obstruction. Drains should be placed carefully in the abdominal cavity in strictly selected cases, only when it is reasonable to do so.

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Ileal Perforation Due to a Richter Hernia at the Drain Insertion Site Following an Operation for Idiopathic Rectal Perforation: Report of a Case

Cited by 3 publications

References 1 publication

Richter Hernia As a Complication of Ventriculoperitoneal Shunt Placement

Richter Hernia As a Complication of Ventriculoperitoneal Shunt Placement

Richter's Hernia in the Laparoscopic Era

Drainage as a rare cause of intestinal incarceration

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