Is It Wise To Have Enterocele Repair Surgery Shortly After Umbilical Hernia Surgery

Continuing Teaching Activity

Richter hernia is a herniation of the anti-mesenteric portion of the intestine through a fascial defect. Patients often present with symptoms similar to other incarcerated hernias, such as abdominal discomfort, distention, nausea, and vomiting. The incidence of Richter's hernia has been increasing with the growing popularity of minimally invasive surgery. Operative treatment of these hernias depends on the viability of the involved portion of the bowel and may often require resection in add-on to repair of the fascial defect. This activeness reviews the evaluation and treatment of Richter hernias and highlights the interprofessional team's role in managing patients with this condition.

Objectives:

Draw the pathophysiology of a Richter hernia.
Review the workup of a patient with a Richter hernia.
Summarize the treatment options for a Richter hernia.
Explain the importance of improving care coordination among the interprofessional team to repair the fascial defect and resent the not-viable bowel, which will improve outcomes for patients with Richter hernias.

Access complimentary multiple choice questions on this topic.

Introduction

Richter hernia is a less known entity of the hernia family unit. Although non well known and overall rare, Richter hernias can lead to grave clinical sequelae. A Richter hernia is a herniation of the anti-mesenteric portion of the bowel through a fascial defect. This exact phenomenon explains the oftentimes subclinical symptoms and late presentation. With the appearance of minimally invasive surgery, there was an increment in the incidence of Richter hernias, which has just connected as minimally invasive surgeries have become more than popular. Operative treatment of Richter hernias depends on the viability of the involved bowel and may often require bowel resection in addition to repair of the fascial defect.

Etiology

The Richter hernia gets its name from Baronial Gottlich Richter, who described this hernia in 1785. Before this appointment, in that location were reported cases of a fascial defect that involved the anti-mesenteric portion of the bowel wall. Fabricius Hildanus starting time reported a case similar this in 1598, which was followed by a few reports by Alexis Littre in 1700. Richter was the first to describe this hernia as a "partial enterocele."[one] Equally time passed, others such equally Antonio Scarpa further defined the pathophysiology. Past 1887, Frederick Treves reported a example series of such hernias.

Epidemiology

Richter hernias typically occur in elderly patients between 60 to 80 years old; yet, they can theoretically manifest at any age, and pediatric case reports be. There is a slightly increased incidence in the female population. This predilection may reverberate that femoral hernias occur more than commonly in females than males, and the femoral band is the most common site for a Richter hernia. Estimates are that approximately 10% of all hernias are Richter blazon hernias though this may be under-appreciated.[two]

The near common location for this pathology to occur is in the femoral culvert (36 to 88%), followed by the inguinal culvert (12 to 36%) and abdominal wall incisional hernias (4 to 25%).[three][two] Equally stated above, the increase in laparoscopic and robotic-assisted procedures has led to a rise in Richter type hernias because of unclosed port sites allowing for herniation of a portion of the bowel wall through the small-scale fascial defect.

Pathophysiology

By definition, a Richter hernia is a herniation of merely a portion of the circumference of the bowel wall through the fascial defect. Most commonly, information technology is the anti-mesenteric portion of the bowel. These hernias oft develop in small fascial defects. The defect must be big plenty for a portion of the bowel to protrude through merely not large enough to arrange the entire circumference of the bowel. In many cases, the segment of bowel involved is a segment of the terminal ileum.

The ensuing process results from the incarceration of a portion of the bowel wall. Incarceration of the intestine can lead to strangulation of the claret supply to that portion of the bowel followed by edema and venous congestion, leading to rapid segmental ischemia and gangrene with a reported incidence of necrosis of 69% at the time of operative intervention.[two][4]

History and Physical

Like to the presentation of other incarcerated hernias, patients often present with intestinal discomfort, distention, nausea, and vomiting. The key deviation is the delay in presentation. Because this hernia simply involves a portion of the bowel wall, in that location is non a complete obstruction of the intestinal lumen. Obstructive symptoms rarely present if less than 2-thirds of the bowel wall is involved. Lack of complete obstacle often leads to subclinical symptoms for a menses until the process becomes avant-garde, and there is strangulation of the involved bowel resulting in an intensification of the to a higher place symptoms.

Upon presentation, it is essential to obtain a complete history and physical with particular attention to predisposing factors such as previous hernias and history of minimally invasive surgery. A careful inventory of the patient's medical history should be obtained with detail to comorbid conditions, agile cardiopulmonary disease, and utilise of anticoagulation. When surgical intervention is required, patients may require additional treatment such every bit the reversal of anticoagulation or cardiac risk stratification based upon comorbid conditions.

Evaluation

At that place are many modes past which to evaluate a Richter hernia.

Outside of physical test is the apply of diverse imaging modalities. Ultrasound and computed tomography (CT) scans are useful adjuncts in diagnosis. However, as a Richter type hernia merely involves a portion of the bowel wall, these imaging modalities can outcome in a false-negative result.

The inclusion of laboratory data is requisite, with the evaluation including consummate blood count (CBC) and basic metabolic console (BMP) to evaluate for leukocytosis, thrombocytopenia, or electrolyte derangements. A PT/INR and/or PTT should be obtained to assess for any coagulopathy that needs to exist corrected preoperatively in patients with hepatic dysfunction or patients on anticoagulation.

Treatment / Management

Treatment of Richter hernias depends on clinical status, physical examination, and suspicion of strangulation. Clinically stable patients with reducible hernias should undergo repair in the constituent setting. Strangulated hernias of any blazon are a surgical emergency, and Richter type hernias exercise not deviate from this principle. Immediate operative exploration is required. Simultaneously resuscitation and treatment of sepsis should also be undertaken with intravenous fluids and antibiotics.

The surgical arroyo depends on multiple factors, including the location of the hernia, the clinical status of the patient, and surgeon preference. An open surgical process may be the all-time choice for patients with evidence of hemodynamic instability, obstruction, or strangulation. The placement of the incision depends on the location of the hernia. Midline laparotomy is typically advisable for ventral incisional hernias. Femoral and inguinal Richter blazon hernias may require inguinal incision with a counter laparotomy incision.

Minimally invasive hernia repair with either laparoscopic or robotic techniques should also is a consideration. Because of the need to establish pneumoperitoneum, these approaches are more conducive for hemodynamically stable patients without obstruction or strangulation. Dilated loops of the bowel may foreclose prophylactic laparoscopic admission and provided limited room for establishing pneumoperitoneum. Hemodynamic instability is further exacerbated by pneumoperitoneum considering of decreased venous return. Thus, a minimally invasive approach is often all-time suited for the urgent or constituent setting. Transabdominal preperitoneal (TAPP) and full extraperitoneal (TEP) approaches may be considered for inguinal or femoral defects. Various methods of minimally invasive ventral hernia repair are possible, including preperitoneal or intraperitoneal approaches.

Regardless of the surgical approach, surgeons must be careful to appraise for bowel viability. Whatsoever questionable bowel should undergo resection and anastomosis undertaken. One group proposed that if the portion of ischemia is a pocket-sized, coin-similar lesion involving less than half of the bowel wall circumference, this may exist invaginated, and the new edges reapproximated.[four] The bowel may be assessed for color and peristalsis though this does not correlate with viability, and thus the recommendation is for evaluation by standard methods.[v] Methods to evaluate bowel viability include intravenous injection of fluorescein and utilise of a Forest's lamp. A more modern approach to the Wood's lamp is the intravenous injection of indocyanine green and an infrared angiography evaluation.[6] One may too assess for arterial flow using a Doppler.

Repair of the hernia defect depends on the defect. The current standard of care for repairing most hernias, including femoral, inguinal, and incisional hernias, involves the placement of a prosthetic mesh. All the same, as there is ofttimes strangulated bowel requiring bowel resection in Richter type hernias, mesh placement is controversial. Ultimately, the decision of whether to place mesh and type of mesh depends on the surgeon's clinical judgment.

Differential Diagnosis

When evaluating Richter type hernias, the clinician must keep a broad differential diagnosis in mind. As previously discussed, these patients often present with abdominal pain. They rarely have symptoms of complete obstruction and may have vague symptoms. Differential diagnosis should include intestinal wall masses such as lipomas and abscesses. Consideration should be given to ileus and bowel obstruction along with their potential underlying causes (i.due east., adhesions, hernias, intraluminal masses). It is often unknown until surgical intervention whether patients have a Richter type hernia. Thus differential diagnosis should include a strangulated hernia involving the complete bowel lumen, especially if presenting with sepsis and astute obstacle.

Prognosis

Subsequently successful hernia repair, in that location is always the potential for recurrence. Modifiable patient run a risk factors for recurrence include elevated BMI, smoking, diabetes, and steroid use. Risk factors related to surgery and technique include surgical site infection, development of seroma, tissue overlap, and surgeon experience.[7] As Richter hernias are often incisional hernias from prior procedures, there is a detail risk of recurrence with the repair of these defects estimated at 11%, with obesity as the well-nigh significant take chances factor.[8]

Complications

Because of the initial lack of obstructive symptoms, Richter hernias may undergo chronic incarceration and, if left unaddressed, may nowadays as an enterocutaneous fistula. Various published instance reports with rare presentations of Richter type hernias have included colocutaneous fistula afterward inguinal hernia repair and laparoscopic gastric bypass.[9][10] These complicated presentations often require more extensive repair and recovery due to laparotomy and takedown of the fistula. Jayamanne et al. reported a case of Richter hernia through a perineal incision after proctectomy, which led to multiple trips to the operating room and difficulty with wound closure.[11]

Postoperative and Rehabilitation Care

Recovery after Richter hernia repair is centered around modifying risk factors for recurrence. Patients should be advised to refrain from smoking and heavy lifting. Connected attention to weight is a strong recommendation, as obesity is a risk factor for the development of hernias. An intestinal binder can be used in the postoperative period for comfort only is not necessary.

Deterrence and Patient Didactics

The surgeon should educate patients pre-operatively about expectations regarding surgery, mail-operative pain, and the recovery process.
Surgeons should educate patients about the surgical procedure including risks such as haemorrhage, infection, damage to surrounding structures, need for farther surgery, and recurrence.
Patients should receive counsel that a bowel resection may be necessary, depending on the contents of the hernia.
As role of this discussion, a review of the risks associated with resection and anastomosis such every bit anastomotic leak is in gild.
If high-run a risk comorbid conditions are present such as immunosuppressive therapy (i.e., chemotherapy, steroids, etc.) or inflammatory bowel disease, and so the surgeon may hash out the risk of possible ostomy prior to surgery.
Postoperative pain expectations should be reviewed which are particular to each surgeon. Surgeons should review activeness restrictions post-obit surgery. As discussed above, activeness restrictions should include no heavy lifting for 4 to vi weeks after surgery. The surgeons should counsel patients to refrain from activities that increase intra-intestinal force per unit area and smoking cessation.

Enhancing Healthcare Team Outcomes

Richter hernias are hard to diagnose as herniation of the anti-mesenteric portion of the bowel wall rarely results in complete luminal obstruction. Equally discussed, because of this, patients with an incarcerated Richter hernia may take a prolonged subclinical course and may present but when the process is advanced, and there is a loftier run a risk for bowel ischemia. Due to this, there is a crucial need for interprofessional discussion. When patients with abdominal pain nowadays to the emergency department, and in that location is suspicion for an incarcerated hernia, which may even be strangulated, it is essential for emergency medical staff to involve the surgical team as early every bit possible. If in that location is a business for strangulation, the consulting surgeon may proceed to the operating room based on physical examination rather than pursuing imaging studies. The mortality rate surrounding strangulated Richter hernias is 17%; thus, one must have a loftier index of suspicion and keep Richter type hernias in the differential when considering patients with abdominal pain.[2] [Level 5]

Review Questions

Figure

Richter hernia following laparoscopy. Image courtesy S Bhimji Doc

References

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3.: Chen West, Liu L, Huang H, Jiang M, Zhang T. A case report of spontaneous umbilical enterocutaneous fistula resulting from an incarcerated Richter's hernia, with a brief literature review. BMC Surg. 2017 Feb 13;17(one):15. [PMC free article: PMC5307766] [PubMed: 28193213]
4.: Horbach JM. Invagination for Richter-type strangulated hernias. Trop Doct. 1986 October;16(iv):163-eight. [PubMed: 3775845]
5.: Horgan PG, Gorey TF. Operative assessment of intestinal viability. Surg Clin Northward Am. 1992 Feb;72(one):143-55. [PubMed: 1731381]
6.: Karampinis I, Keese M, Jakob J, Stasiunaitis V, Gerken A, Attenberger U, Post S, Kienle P, Nowak K. Indocyanine Green Tissue Angiography Can Reduce Extended Bowel Resections in Astute Mesenteric Ischemia. J Gastrointest Surg. 2018 December;22(12):2117-2124. [PubMed: 29992520]
seven.: Siddaiah-Subramanya M, Ashrafi D, Memon B, Memon MA. Causes of recurrence in laparoscopic inguinal hernia repair. Hernia. 2018 December;22(6):975-986. [PubMed: 30145622]
eight.: Sauerland Due south, Korenkov 1000, Kleinen T, Arndt M, Paul A. Obesity is a risk factor for recurrence subsequently incisional hernia repair. Hernia. 2004 February;8(1):42-six. [PubMed: 13680307]
nine.: Habib Faridi S, Siddiqui B, Amanullah Khan M, Anees A, Ali SA. Suprapubic Fecal Fistula Due To Richter's Inguinal Hernia: A Example Report and Review of Literature. Iran J Med Sci. 2013 Jun;38(2):129-31. [PMC gratis article: PMC3700059] [PubMed: 23825893]
10.: Alfa-Wali M, Leuratti L, Efthimiou E. Diaphragmatic Richter'southward blazon of hernia involving the transverse colon afterwards laparoscopic gastric bypass: an unusual complexity. Surg Obes Relat Dis. 2013 Jul-Aug;9(4):e60-2. [PubMed: 23433754]
11.: Jayamanne H, Stephenson BM. Perineal Richter's herniation following proctectomy. Ann R Coll Surg Engl. 2017 Nov;99(8):e244-e245. [PMC gratis article: PMC5696938] [PubMed: 29022799]