Sonographic findings in Richter's hernia

Richter supraumbilical hernia managed with invagination: a case report

Introduction and importance

Richter's hernia is an incarceration of the anti-mesenteric border of a segment of bowel through an abdominal wall defect. It primarily affects elderly individuals but can occur at any age, with a slightly increased incidence in females. The increase in laparoscopic and robotic-assisted procedures has led to a rise in Richter's hernias.

Case presentation

A 40-year-old male with a history of laparoscopic cholecystectomy and kidney transplantation presented with a 4-day history of supraumbilical swelling and abdominal pain. The swelling was irreducible and accompanied by mild tenderness, and local signs of inflammation were exhibited. Intraoperatively, a 1.5 cm hernia defect was found, with the sac containing omentum and a portion of bowel segment for which invagination with serosal closure with the Mayo double-breasting technique was done.

Clinical discussion

Richter's hernia presents with abdominal discomfort, bloating, nausea, and vomiting, with a notable feature being the delayed onset of symptoms due to its partial involvement of the bowel wall. Diagnosis can be achieved through a computed tomography (CT) scan or intraoperative exploration. Management of Richter hernia is contingent upon the patient's clinical condition, physical examination, and suspicion of strangulation.

Conclusion

Diagnosis of Richter's hernia demands higher suspicion, particularly in patients with predisposing factors like a history of minimally invasive surgery. Prompt surgical intervention is crucial for reducing mortality and enhancing prognosis, with invagination alone being adequate if ischaemia is confined and mesh placement is unnecessary.

Unusual Richter's Hernia: Impacted foreign body leading to incarceration and perforation - A rare clinical entity

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The knowledge about this type of hernia has especially gained importance in the context of laparoscopic surgery as majority of the laparoscopic port site hernias are characteristically Richter’s type in configuration.

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Clinical suspicion, prompt radiological diagnosis and timely surgery can lead to an uneventful recovery.

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Surgery is the only treatment, but timely surgery remains the golden opportunity.

Introduction & Importance

Richter’s hernia is a clinically deceiving entity as is particularly associated with high morbidity and mortality which can be can be abated by timely diagnosis and surgery. Direct inguinal hernias having a wide neck have lesser chances of incarceration and strangulation when compared to indirect inguinal hernias. The knowledge about this type of hernia is especially important in the context of laparoscopy as majority of the laparoscopic port site hernias are characteristically Richter’s type in configuration. The objective of this report is to highlight the unusual presentation of the case and sine quo non of prompt diagnosis and timely surgery remains the cornerstone of management.

Case presentation

We report a case of Richter’s hernia incarcerated due to an impacted foreign body (match stick) through a direct inguinal hernia. Patient presented with a painful, non-expansile, tender swelling in left groin. Patient was diagnosed with a complicated inguinal hernia and underwent exploration with resection of involved bowel segment and primary repair of hernia.

Clinical discussion

Richter’s hernia is a rare abdominal wall hernia specifically known for its unusual and delayed presentation leading to high rates of morbidity and mortality. Direct inguinal hernias are less prone to complications like obstruction, strangulation and incarceration owing to presence of a wide neck. Clinical suspicion, prompt radiological diagnosis and timely surgery can lead to an uneventful recovery.

Conclusion

Surgery is the only treatment, but timely surgery remains the golden opportunity. Critical in repair is the evaluation of intestinal viability.

Abdominal wall sonography: a pictorial review

The anterior abdominal wall, which is composed of three layers (skin and adipose tissues; the myofascial layer; and the deep layer, consisting of the transversalis fascia, preperitoneal fat, and the parietal peritoneum), has many functions: containment, support and protection for the intraperitoneal contents, and involvement in movement and breathing. While hernias are often encountered and well reviewed in the literature, the other abdominal wall pathologies are less commonly described. In this pictorial review, we briefly discuss the normal anatomy of the anterior abdominal wall, describe the normal ultrasonographic anatomy, and present a wide range of pathologic abnormalities beyond hernias. Sonography emerges as the diagnostic imaging of first choice for assessing abdominal wall disorders, thus representing a valuable tool for ensuring appropriate management and limiting functional impairment.

Strangulated Richter's incisional hernia presenting as an abdominal mass with necrosis of the overlapping skin. A case report and review of the literature

Although rare, clinicians must be alerted of Richter hernias in patients presenting with innocuous gastrointestinal obstruction symptoms, synchronous with an erythematous hernia. An incarcerated incisional hernia located in a previous laparoscopic insertion site further raises suspicion, while timely surgical management is essential to avoid bowel perforation or resection.

Strangulated Richter's Umbilical Hernia - A Case Report

Richter's hernia is an abdominal hernia in which part of the circumference of bowel entrapped in the hernial sac. The segment of the entrapped bowel is nearly always the distal ileum but any part of gastrointestinal tract from the stomach to the colon may become incarcerated. The most common sites for Richter's hernia are the femoral ring (71%), deep inguinal ring (23%) and ventral or umbilical hernias (6%). The growing popularity of laparoscopic surgery has led to a new possible site for development of Richter's hernia. In most cases as less than two thirds of the circumference of the bowel wall is involved, the lumen of the gut remains free and thus features of intestinal obstruction are often absent. Richter's hernia is a deceptive entity whose high death rate can be reduced by accurate diagnosis and early surgery. We report a case of strangulated Richter's umbilical hernia in a 36 years old male.

Incarcerated Inguinal Richter’s Hernia With Ischemic Testis in a Premature Neonate

Richter’s hernia is an uncommon condition of hernia, in which only a portion of the anti-mesenteric bowel wall is entrapped in the hernia orifice. Although it is a well-recognized entity in adults, Richter’s hernia is much less frequently diagnosed in children, especially in the premature neonate. There has been only one report of this special type of hernia in the neonate in the English literature. Its tendencies to early strangulation and frequent lack of obstructive symptoms make it difficult to be diagnosed before operation. The author presents a unique case in which an inguinal hernia with incarceration and ischemic testis has been diagnosed and surgically proven in a premature newborn. Duplex sonography played an important role in the pre-operative diagnosis because there was no significant evidence of intestinal obstruction. The sonographic features and the findings of its complication are described.

Acute painful scrotum

The ability of US to diagnose the pathogenesis of the acute scrotum is unsurpassed by any other imaging modality. It is the first imaging performed in patients with acute scrotum. Knowledge of the normal and pathologic sonographic appearance of the scrotum and proper sonographic technique is essential for accurate diagnosis of acute scrotum. High-frequency transducer sonography combined with color flow Doppler sonography provides the information essential to reach a specific diagnosis in patients with testicular torsion, epididymo-orchitis, and testicular trauma.

Spigelian and other uncommon hernia repairs

This article offers an overview of abdominal wall hernias, which are uncommon because of the unusual contents of their sacs. These include: Meckel's diverticulum, segments of the intestinal wall antimesenteric border, the vermiform appendix, the bladder; plus the penetration by the sac within the different muscle layers of the abdominal wall. These hernias present diagnostic difficulties and some are associated with high morbidity, but modern technology may help their prognosis. This article describes their histories and their unique presenting signs and symptoms and suggests up-to-date methods of imaging, as well as surgical tactics and technique.

Sonography of the scrotum

Ultrasonography (US) with a high-frequency (7.5-10-MHz) transducer has become the imaging modality of choice for examination of the scrotum. US examination can provide information valuable for the differential diagnosis of a variety of disease processes involving the scrotum that have similar clinical manifestations (eg, pain, swelling, or presence of mass). The pathologic condition that may be at the origin of such symptoms can vary from testicular torsion to infection to malignancy. The ability of color and power Doppler US to demonstrate testicular perfusion aids in reaching a specific diagnosis in patients with acute scrotal pain. This review covers the anatomy of the scrotum and the scanning protocol for scrotal US, as well as detailed descriptions of disease processes and their US appearances. Newly described conditions such as intratesticular varicoceles and other benign intratesticular cystic lesions are also discussed.

Abdominal wall hernias: a cross-sectional pictorial review

The classification of abdominal wall hernias is often made difficult by confusing eponymous and anatomic nomenclature. In this article, we review the anatomy that defines the various types of hernias. The specific cross-sectional radiologic features required to correctly identify each type are then emphasized. The appropriate clinical context and the merits of the various imaging techniques available for the investigation of abdominal wall hernias are also discussed.

Richter's hernia and Sir Frederick Treves: an original clinical experience, review, and historical overview

OBJECTIVE

To describe the clinical recognition, pathology, and management of Richter's hernia and to review the relevant literature of the past 400 years.

SUMMARY BACKGROUND DATA

The earliest known reported case of Richter's hernia occurred in 1598 and was described by Fabricius Hildanus. The first scientific description of this particular hernia was given by August Gottlob Richter in 1778, who presented it as "the small rupture." In 1887, Sir Frederick Treves gave an excellent overview on the topic and proposed the title "Richter's hernia." To his work-a cornerstone to modern understanding-hardly any new aspects can be added today. Since then, only occasional case reports or small series of retrospectively collected Richter's hernias have been published.

METHODS

The authors draw on their experience with 18 prospectively collected cases treated in the ICRC Lopiding Hospital for War Surgery in northern Kenya between February and December 1998 and review the relevant literature of the past 400 years.

RESULTS

The classic features of Richter's hernia were confirmed in all case studies of patients: only part of the circumference of the bowel is entrapped and strangulated in the hernial orifice. The involved segment may rapidly pass into gangrene, yet signs of intestinal obstruction are often absent. The death rate in the authors' collective was 17%.

CONCLUSION

Richter's hernia is a deceptive entity whose high death rate can be reduced by accurate diagnosis and early surgery. Considering the increasing incidence at laparoscope insertion sites, awareness of this special type of hernia with its misleading clinical appearance is important and of general interest.

Illustrated review of new imaging techniques in the diagnosis of abdominal wall hernias

BACKGROUND

The assessment of abdominal wall hernias has long been a clinical skill that only occasionally required the supplementary radiological assistance of herniography. However, with the advent of cross-sectional imaging, a new range of diagnostic tools is now available to help the clinician in difficult cases.

METHODS

This review explores the ability of computed tomography and magnetic resonance imaging to demonstrate many of the hernias encountered in the anterior abdominal wall. Also discussed is the role of imaging techniques in the management of a variety of hernias.

RESULTS AND CONCLUSION

Cross-sectional imaging techniques are being employed with increasing frequency for the assessment of hernias. Although the anatomical detail can usually be delineated clearly, the accuracy of the various methods and their place in the clinical management of hernias has yet to be fully determined.

Richter's hernia of the splenic flexure: computed tomography appearances

A case of a clinically occult Richter's hernia of the splenic flexure, through an anterior abdominal wall defect, is described. In view of the initial absence of bowel obstruction with a partial or Richter's hernia, and in the absence of physical findings, the importance of computed tomography (CT) in demonstrating abdominal wall lesions is highlighted.