parkmetrohospital

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METRO CURING STORY
RICHTERS HERNIA WITH IMPENDING STRANGULATION
SUCCESSFULLY TREATED BY LAPAROSCOPIC SURGERY
Consulting Doctor
Dr. Arun Bhardwaj
Senior Consultant Unit Head Laparoscopic, GI
Bariatric Surgeon
MBBS, MS (Gen surgery) , DNB (Gen Surgery), FNB
(Minimal Access Surgery),FIAGES, MRCS England,
FACS USA, FALS Bariatric Surgery
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Case History

• 67 year old Female Patient presented in emergency
  withsymptoms of Abdominal Pain, Distension and
  Vomiting.
• She used to have similar episodes since past 3
  years withhistory of Swelling of right Lower
  Abdomen which used toreduce by itself and
  symptoms subsided.

On Examination

• On Evaluation, patients parameters were as
  follows
• Tachycardia Generalised distension of Abdomen
  with tenderness and guarding.

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Pre-Operative Course

• The patient was admitted Management for
  Intestinal obstruction commenced with Ryle's tube
  and Foley's insertion, IV antibiotics, fluids and
  analgesics.
• Blood investigations were normal with counts
  raised to 12800
• CT scan showed herniation of small intestine in
  the right inguinal with proximal dilatation and
  distal collapse.
• The patient passed multiple loose stools with
  flatus and seemed to have been relieved from
  obstruction.

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• WBC counts became normal with stable vitals.
• Since the obstruction seemed relieved and
  elective surgeries were being avoided due to
  rising covid cases in pandemic, decision taken to
  continue conservative management
• Her vitals continued to be stable but her abdomen
  had persistent generalised tenderness and
  guarding.
• As her abdomen was not settling , the decision
  was taken to go ahead with Diagnostic Laparoscopy
  and proceed accordingly.

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Intra-Operative Findings

• Herniation of part of the anti-mesenteric border
  of the mid ileal segment into the right inguinal
  canal (RICHTER'S INDIRECT INGUINAL HERNIA) with
  IMPENDING STRANGULATION.
• Proximal small bowel was distended with distal
  loops of intestine collapsed.
• Herniated small intestine loop was reduced into
  the peritoneal cavity and vascularity was
  assessed.
• Intestinal loop was congested and edematous but
  no evidence of gangrene was present.
• LAPAROSCOPIC TAPP (Trans-abdominal
  Pre-peritoneal) RIGHT INGUINAL HERNIA REPAIR was
  performed using 15 X 13 cms polypropylene mesh.

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Post-Operative Course

• Her WBC counts were raised significantly to
  29,000 (despite being on IV tazact, metrogyl and
  amikacin) with tachycardia and generalised
  abdominal tenderness.
• To avoid prosthetic mesh infection, Tazact was
  stopped and patient started on IV meropenem
  (broad spectrum antibiotic).
• She responded well and her abdominal symptoms
  improved with WBC counts gradually coming down to
  normal limits.
• She was started orally on POD3 and discharged on
  POD5.

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Discussion

• Richters hernia is herniation of the
  anti-mesenteric portion of the bowel through a
  fascial defect.
• This exact phenomenon explains the often
  subclinical symptoms and late presentation.
• Richter hernias typically occur in elderly
  patients between 60 to 80 years of age.
• It is rare type of hernia accounting to
  approximately 10 of all hernias.
• The most common location is the femoral canal (36
  to 88), followed by the inguinal canal (12 to
  36) and abdominal wall incisional hernias (4 to
  25).

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• Patients often present with abdominal discomfort,
  distension, nausea, and vomiting.
• The key difference is the delay in presentation.
  Because this hernia only involves a portion of
  the bowel wall, there is not a complete
  obstruction of the intestinal lumen. Lack of
  complete obstruction often leads to subclinical
  symptoms for a period until the process becomes
  advanced, and there is strangulation of the
  involved bowel.
• There is reported incidence of gangrene and
  necrosis in 69 patients at the time of operative
  intervention

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• An open surgical procedure may be the best option
  for patients with evidence of hemodynamic
  instability, obstruction, or strangulation.
• A minimally invasive approach is often best
  suited for the urgent or elective setting.
  Transabdominal preperitoneal (TAPP) and total
  extraperitoneal (TEP) approaches may be
  considered for inguinal or femoral defects.
• Early intervention in our case prevented the
  intestine from becoming gangrenous and allowed us
  to perform Laparoscopic TAPP repair

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• Take Home Message

High clinical suspicion with early intervention
in RICHTER'S hernia can prevent gangrene of
intestine. Diagnostic laparoscopy (to assess the
bowel) with Laparoscopic Inguinal Hernia repair
is a safe and feasible minimally invasive
surgical approach with early recovery
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Intra Operative Imaging
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Intra Operative Imaging
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WE WISH HER A
HEALTHY FUTURE
AHEAD!
Metro Hospital, Palam Vihar by Park Group of
Hospitals
For Appointments, Call 91-8695000000 24X7
Emergency 91-9891424242H Block, Chauma
Village, Sector 1, Palam Vihar, Chauma, Haryana
122017