Incarcerated Richter's congenital umbilical hernia in a young male: A case report

Abstract

Introduction and importance

Richter's hernia is a protrusion of a portion of the circumference of anti-mesenteric side of intestine through the fascial defect. It is a rare type of hernia and typically occurs in elderly patients. Richter's hernia could result in grave complications. The objective of the study was to describe a rare case of incarcerated Richter's congenital umbilical hernia in a 20-year-old male patient.

Case presentation

A 20-year-old male presented with a complaint of intermittent crampy peri-umbilical pain of three days duration associated with non-reducible umbilical bulge and vomiting. On examination, there was 4 cm by 4 cm oval, firm, tender, non-reducible mass over the umbilical area without cough impulse. He was kept nothing per os, broad spectrum antibiotic started, consent taken & operated. A loop of the ilium which was mildly ischemic found in the hernia sac. Sac and entrapped intestine were thoroughly cleaned with warm saline and reduction and herniorrhaphy done. The client discharged on the 2nd postoperative day.

Clinical discussion

There have been very few reports of Richter's congenital umbilical hernia. Richter's hernia progresses more rapidly to gangrene than other strangulated hernias however patients often have no intestinal obstruction. Raised suspicion therefore is important to take timely surgical intervention before the disease advance and complications occurred.

Conclusion

Richter's hernia has subclinical symptoms and late presentation which could result in grave complications and increased mortality. The early decision for surgery has paramount importance in reducing complication and associated mortality.

Highlights

• •Incarcerated Richter's congenital umbilical hernia in a young male
• •Richter's umbilicus hernia among young male client who acquired the hernia from birth is rare.
• •Richter's hernia is a rare type of hernia.
• •It is rare to find an intestinal obstruction in Richter's hernia.
• •Raised level of suspicion is required for timely diagnosis and intervention in Richter's hernia cases.
• •Richter's hernia has subclinical symptoms and late presentation which could result in grave complications.

1. Introduction

Richter's hernia is a protrusion of a portion of the circumference of anti-mesenteric side of intestine through the fascial defect that gets entrapped and strangulated in the hernial orifice (1,2). It occurs in elderly patients between 60 and 80 years old though it manifests at any age (2,3). The prevalence of Richter's hernia is about 10 % of all hernias (2,3). There is a recent increase in the incidence of Richter's hernia with the increased use of minimally invasive surgeries (2,4).

It is a rare hernia family with an insidious pathologic feature often leads to late diagnosis or even misdiagnosis, thus allowing time for bowel necrosis to develop which can lead to grave clinical sequelae (1,2). It progresses more rapidly to gangrene than other strangulated hernias. However, patients often have no intestinal obstruction (3). Richter's hernia could result in grave complications such as gangrenous bowel (5), perforation, post-necrotic abscess, enterocutaneous fistula, and even death (1,3).

Richter's umbilical hernia for young male patient who acquired the hernia from birth is rare and educationally interesting. This is a case of incarcerated Richter's congenital umbilical hernia in a 20- year-old young male client from southwest Ethiopia who managed surgically and discharged on the 2nd post operative day. The objective of the study was to describe a rare case of incarcerated Richter's congenital umbilical hernia in 20 - year - old male patient. This case report has been reported in line with the SCARE 2020 criteria (6).

2. Case presentation

A 20-year-old male client from southwest Ethiopia presented to the emergency department in June 2023 with a complaint of intermittent crampy, peri-umbilical pain of three days duration associated with non-reducible umbilical bulge, and vomiting of ingested matter of 03 to 04 episodes per day but no fever. He passed loose stool and flatus and has no abdominal distention. He had similar illness 08 months ago and managed conservatively at the emergency and discharged with improvement with an appointment for elective surgery, but he was lost from follow up. He had history of bulge at the umbilicus since birth, and the bulge increased with straining and heavy lifting and reduced by itself when at rest. This client arrived to the local health center 4-h after the onset the illness. He was given ciprofloxacin 500 mg taken per os two times per day but not improved. He has arrived at our hospital with a referral paper.

On physical examination, vital signs were; blood pressure 120/80 mmHg, pulse rate 64 beats/min, respiratory rate of 16 breaths/min and temperature 36.5 °C. Abdominal examination revealed that abdomen moves with respiration and normo-active bowel sound. There was 4 cm × 4 cm oval, firm, tender, non-reducible mass over the umbilical area without cough impulse. The overlying skin was hyper pigmented but not hot and erythematous.

The complete blood count; White Blood Cell (WBC) of 7150/mm³, a hematocrit of 43.11 % and platelet count of 442, 000/mm³. Abdominal Ultrasound revealed that there was umbilical defect measuring 1.8 cm through which mesenteric fat protrudes (Done 08 months ago). Abdominal Computed Tomography (CT) scan was not done since it was not available in the setup. With the initial diagnosis of incarcerated umbilical hernia, the team decided the need of emergency surgery. Intravenous (IV) line was secured, kept nothing per os (NPO), put on maintenance fluid (MF) and single dose of broad spectrum antibiotics given. A written informed consent was taken. Under general anesthesia and patient in supine position, reduction and herniorrhaphy was done by a senior surgeon with the assistance of a general practitioner through a supra-umbilical (Richter's hernia) incision at a general hospital. Intra-operatively there was a loop of the ileum with a 50 % circumference entrapped in the umbilical hernia sac in the anti-mesenteric side (Fig. 1) and the sac contained dark hemorrhagic fluid. No adhesion of the sac and bowel.

Fig. 1.

Intra-operative image showing the loop of the ilium with 50 % circumference entrapped in the internal hernia ring in the anti-mesenteric side.

There was a small segment of ileum with mild ischemia on the anit-mesenteric side (Fig. 2) which later became pink after warm saline application. The defect in the abdominal wall was about 2.0 cm.

Fig. 2.

Intra-operative image showing mildly ischemic intestine (arrow head) on the anti-mesenteric side.

The sac and entrapped intestine were thoroughly cleaned with warm saline solution and a Penrose drain left in the subcutaneous space. Based on the intra-operative finding a diagnosis of Richter's hernia was made. Postoperatively, he was kept nothing per os, put on maintenance fluid alternatively of normal saline, ringers lactate and 5 % dextrose in normal saline for 24 h. Ceftriaxone 1 g intravenously two times a day, and tramadol 50 mg IV as needed was given until the 2nd postoperative day. The postoperative period was uneventful. The client was discharged on the 2nd postoperative day. There were no postoperative complications in the past two months while on a follow-up at the surgical referral clinic.

3. Discussions

Richter's hernia is a protrusion of a portion of the circumference of the anti-mesenteric side of intestine through fascial defect that gets entrapped and strangulated in the hernial orifice (1,2). This phenomenon explains the often subclinical symptoms and late presentation of patients with Richter's hernia (2). It has an insidious pathologic feature often leads to late diagnosis or even misdiagnosis, thus allowing time for bowel necrosis to develop which can lead to grave clinical sequelae (1,2). This hernia only involves a portion of the bowel wall, there is no complete obstruction of the intestinal lumen. More commonly less than two-third of the bowel wall involved (2).

Richter's hernia is a rare type of hernia and typically occurs in elderly patients (2,3,7). There are increasing reports of port-site associated Richter's hernias with the recent increased use of laparoscopic procedures (4). Richter's hernia progresses more rapidly to gangrene than other strangulated hernias though patients often have no intestinal obstruction (3).

The most common sites of presentation for Richter's hernia are the femoral ring (71 %), deep inguinal ring (23 %) and ventral or umbilical hernias (6 %) (1,3,8). The most commonly reported hernia content is a segment of the distal ileum, but any portion of the gastrointestinal tract can become involved (3).

Richter's hernia could result in grave complications such as gangrenous bowel (5), perforation, post-necrotic abscess, enterocutaneous fistula and even death (1,3). Raised level of suspicion is crucial to take timely surgical intervention before the disease advances and complications occur (5). Abdominal ultrasound and computed tomography (CT) scan are a useful adjunct in the diagnosis of Richter's hernia (1,2).

The management depends on the nature of the bowel; viable bowel, necrotic bowel and presence of peritonitis with other complications (1). Reduction of the content and repair of defects is done if the bowel is viable (1). Segmental resection and anastomosis is done if the bowel is necrotic and involves >50 % of the circumference and bowel viability is not returned with warm saline and 100 % oxygen (9). Laparotomy is necessary in the case of peritonitis from perforation and other associated complications (5,7,10,11).

Congenital umbilical hernias are caused by the arrest of the normal spontaneous closure of the umbilical ring, resulting in a defect in the fascia covered by skin (12). Umbilical hernias in adults are mostly acquired defects in >90 % of cases and most frequently occurred in the fifth or sixth decades of life (13).

A case of incarcerated Richter's congenital umbilical hernia in 20 –year – old male patient was presented in this report. There were cases of Richter's umbilical hernia (7,10).

4. Conclusion

Richter's hernia has subclinical symptoms and late presentation which could result in grave complications and increased mortality. Raised level of suspicion and consideration of the entity in the differential diagnosis will reduce complications. The early decision for surgery with the evidences of clinical diagnosis and auxiliary investigations has paramount importance in reducing complication and associated mortality.

Authors' contribution

Anteneh Messele, MD.

Involved in the conception and design of the study, drafting and revising of the article and final approval of the version to be submitted and also involved in direct surgical management of the case.

Suleman Hassen, MD.

Involved in the conception and design of the study, drafting and revising of the article and final approval of the version to be submitted and also involved in direct surgical management of the case.

Sisay Mengistu, MD.

Involved in the design of the study, drafting and revising of the article and final approval of the version to be submitted.

Tesfahun Mengistu, MD.

Involved in the design of the study, drafting and revising of the article and final approval of the version to be submitted.

Bethelhem Yaynemsa, MD.

Involved in the design of the study, drafting and revising of the article and final approval of the version to be submitted.

All authors are agreed to be accountable for all aspects of the manuscript.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in Chief of this journal on request.

Ethical approval

The case report has been submitted for the Ethical Review Committee and approved as ethically sound.

Funding

No funding.

Registration of research studies

Not applicable.

Guarantors

Anteneh Messele Birhanu.

Suleman Hassen Mohammed.

Declaration of competing interest

No potential conflict of interest relevant to this article was reported.

Availability of Data and Materials.

The authors of this manuscript are willing to provide any additional information regarding the case report upon official request.

Biographies

Anteneh Messele Birhanu (MD, MPH), Assistant Professor, Department of Medicine, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia.

Suleman Hassen Mohammed (MD⁺), Sisay Mengistu Mohammed (MD⁺) and Tesfahun Mengistu Abebe (MD⁺) are Assistant Professors of General Surgery, Department of Surgery, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia.

Bethelhem Yaynemsa Sequr (MD) is a Lecturer and General Medical Practitioner, Department of Medicine, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia.