A rare presentation of a strangulated Richter's Umbilical Hernia

A thirty-year-old female presented to the emergency department with a history of acute onset of pain in the region of umbilicus of three days duration. Examination of the abdomen revealed a tender and indurated swelling in the region of the umbilicus. The skin overlying the swelling and around the umbilicus was erythematous.

Ultrasound performed on the patient revealed a rounded, smooth, hyperechoic structure with twinkling artifacts and posterior acoustic shadowing at the deep subcutaneous plane of the anterior abdominal wall at the umbilicus. Superficial to this hyperechoic structure, a note was made of a subcutaneous anechoic collection with internal septations. The posterior acoustic shadowing impeded the assessment of deeper layers of the abdominal wall.

Background

A Richter hernia is defined as herniation of the anti-mesenteric portion of the bowel through a fascial defect [1]. Richter hernia typically occurs in elderly patients of 60 to 80 years of age with female preponderance [2]. The most common location for this pathology is in the femoral canal, followed by inguinal hernias and ventral or umbilical hernias [3]. These hernias often develop in small fascial defects which are not large enough to accommodate the entire bowel circumference. In many cases, a segment of the ileum is involved. The hernia can lead to incarceration and strangulation of the affected bowel followed by gangrene and necrosis [2] [4].

Clinical Perspective

The typical presentation is similar to other incarcerated hernias, patients often present with abdominal pain, distention, nausea, and vomiting. The main difference is the delay in the presentation because this hernia only involves a portion of the bowel wall. The lack of complete obstruction often leads to subclinical symptoms for some time until there is the advancement of the process and strangulation of the involved bowel resulting in an intensification of the above symptoms[1]. Therefore in addition to the patient’s history and clinical examination, ultrasonography and computerized tomography can help establish the diagnosis[5]. The early detection of hernia complications using Multidetector computed tomography can help in preserving the bowel viability and improve the patient outcome[6].

Imaging perspective

The key imaging finding of Richter hernia is herniation of the antimesenteric wall of the bowel and not the entire wall circumference. Imaging studies can demonstrate the parietal defect and look for signs of strangulation. Ultrasound and Computed Tomography are most used in establishing the diagnosis [5]. The diagnosis may remain presumptive until confirmed at surgery.

Outcome

Strangulated Richter’s hernia needs emergent surgery. The main goal is to reduce systemic toxin load from the gangrenous tissue [2]. In our patient emergent surgery was done. On exploration, it was found that part of the circumference of an Ileal loop was entrapped in the umbilical sac and was gangrenous and contained hard solidified fecal matter. Resection of the gangrenous small bowel segment and end-to-end anastomosis was performed. The therapeutic options include an invagination procedure without opening the intestine or resection-anastomosis depending on the extent of circumferential bowel wall involvement and presence of perforation[3][7]. An Ultrasound scan can identify the incarcerated wall segment, and a Computed tomographic examination can show the contents of the hernia's sac, thus helping in the preoperative management and differentiation from abdominal mass or abscess[8][9]. After successful hernia repair, there is always the potential for recurrence depending on surgical and patient risk factors[10].

Teaching points

This case report serves to bring into light this rare imaging appearance of a strangulated Richter Umbilical hernia.