High clinical suspicion with early intervention in RICHTER'S hernia can prevent gangrene of the intestine. Diagnostic laparoscopy (to assess the bowel) with Laparoscopic Inguinal Hernia repair is a safe and feasible minimally invasive surgical approach with early recovery

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

2. Case History
• 67 year old Female Patient presented in emergency with
symptoms of Abdominal Pain, Distension and Vomiting.
• She used to have similar episodes since past 3 years with
history of Swelling of right Lower Abdomen which used to
reduce by itself and symptoms subsided.
On Examination
On Evaluation, patient’s parameters were as follows:
• Tachycardia + Generalised distension of Abdomen with
tenderness and guarding.

3. 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.

4. • 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.

5. 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.

6. 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.

7. Discussion
• Richter’s 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%).

8. • 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

9. • 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

10. 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

11. Intra – Operative Imaging

12. Intra – Operative Imaging

13. WE WISH HER A
HEALTHY FUTURE
AHEAD!
For Appointments, Call: +91-8695000000 | 24X7 Emergency: +91-9891424242
H Block, Chauma Village, Sector 1, Palam Vihar, Chauma, Haryana 122017
Metro Hospital, Palam Vihar by Park Group of Hospitals