Complexities in the management of a Richter's supraumbilical hernia with colocutaneous fistula in a patient with morbid obesity: A case report with a review of literature.

Abdominal wall Richter's hernia is rare. The usual presentation is with irreducibility, obstruction and strangulation. Occasionally, enterocutaneous fistula containing small bowel has been reported. Management is frequently difficult due to emergency presentation and contamination. A 60-year-old male with a history of suture repair of umbilical hernia presented with faecal discharge from a long-standing recurrent hernia in the background of obesity and history of pulmonary embolism. There were no features of peritonitis or obstruction. After optimisation, we took the patient for a diagnostic laparoscopy with curative intent. Diagnostic laparoscopy revealed a Richter's hernia containing transverse colon. The patient was treated with resection of the involved colonic segment, anastomosis, complete excision of the fistula tract along with surrounding skin, negative pressure wound therapy and delayed skin closure. To our knowledge, this is the first report of a spontaneous umbilical Richter's hernia complicated with a colocutaneous fistula. Management was challenging due to emergency presentation, multiple comorbidities as well as faecal contamination. Minimal access approach may have helped by decreasing the contamination and surgical site infection in the postoperative period.

INTRODUCTION

Richter's hernia was first described in 1785 by August Gottlied Richter, a German surgeon.[1] This rare hernia is characterised by a part of the bowel circumference, usually the anti-mesenteric part, getting trapped in a hernia defect leading to ischaemic necrosis. It presents with pain, obstruction or peritonitis. An enterocutaneous fistula (ECF) is a rare presentation of Richter's hernia.

Here, we describe the management of a supraumbilical, Swiss-cheese Richter's hernia with a colocutaneous fistula in a patient with morbid obesity. We also present a review of literature on abdominal wall Richter's hernia.

CASE REPORT

A 60-year-old male with a body mass index of 48 kg/m2, hypertension, immobility, sleep apnoea and a history of pulmonary embolism presented to emergency with the complaints of discharge of stool from a neglected 10-year-old hernia. He had no pain and features of obstruction. There was a history of suture repair of a supraumbilical hernia 15 years ago.

On examination, there was a lump in the left supraumbilical region with faecal discharge from multiple openings in the skin [Figure 1]. There was cellulitis of the surrounding skin.

Figure 1

Initial presentation with stools coming out of openings in the abdominal wall

General examination revealed tachycardia, hypoxaemia and laboured breathing. Laboratory tests showed leucocytosis, hypoxaemia and hypercarbia. A computed tomography scan showed multiple defects with a composite maximum width of 8 cm. The large hernia sac contained a transverse colon. There was a breach of the colon at one point showing ECF. There were no features of peritonitis or obstruction.

We optimised the patient with continuous positive airway pressure (CPAP) therapy, low-molecular weight heparin (LMWH), pneumatic compression device stockings, chest physiotherapy, nutrition, wound dressing and antibiotics. We operated on him 48 hours after admission.

We did a diagnostic laparoscopy for assessment and planning which showed extensive bowel and omental adhesions around the defect. We did adhesiolysis till the loop of the colon containing the colocutaneous fistula was isolated [Figure 2a]. We divided the two ends with staplers [Figure 2b] and did a stapled intracorporeal anastomosis. We excised the skin with the external openings along with the entire sac. The final fascial defect was 10 cm × 15 cm [Figure 2c] which was closed with a running suture (1-0 PDS) and negative pressure wound dressing (NPWT) was applied [Figure 3].

Figure 2

(a) Colonic loop seen entering the defect (b) Both ends of colonic loop divided with staplers. Swiss-cheese defect is seen (c) Final defect after excision of the skin, subcutaneous tissue and fistula tract

Figure 3

Negative pressure wound therapy applied to the final defect

The patient was in the intensive care unit for 2 days. He showed satisfactory recovery and was discharged on the 10th day. We continued LMWH, CPAP and NPWT. We did secondary suturing of the wound on post-operative day 20.

The patient is on a physiotherapy and weight loss regime. A surgical weight loss is planned once the patient is fit followed by a definitive hernia repair.

DISCUSSION

Abdominal wall is an uncommon site for Richter's hernia. ECF after an abdominal wall Richter's hernia is even rarer. Very few reports exist in the published literature.[234] To our knowledge, there are no reports of a colocutaneous fistula in umbilical Richter's hernia.

The aetiology of Richter's hernia is a defect too small to incorporate the whole bowel circumference. Increased intra-abdominal pressure (IAP) may be a contributing factor.[2] Hence, although the maximum defect width in our patient was 8 cm, the colonic wall that became ischaemic was one of the small defects, as seen in the specimen [Figure 4]. Our patient may have had a high IAP due to obesity and laboured breathing secondary to sleep apnoea. ECF in a Richter's hernia has been attributed to chronic bowel ischaemia and sustained inflammation.[5]

Figure 4

Final specimen showing the colocutaneous fistula

Interestingly, our patient was prone to crying spells. Another patient prone to crying easily presenting with Richter's hernia and ECF has been reported by Chen et al.[2]

The patient had morbid obesity with sleep apnoea. It is known that these patients fare poorly after open surgery and there are higher wound-related complications in patients with obesity. Since the patient was not in obstruction and was haemodynamically stable, laparoscopy was our first choice.

We did an anastomosis because there was no intraperitoneal contamination allowing us to avoid a stoma. Obese patients are reported to have a higher stoma-related complication.

We reduced local sepsis of the presenting wound by antibiotics given for 48 h preoperatively. This limited the extent of the skin and fat excision as well as intraoperative contamination. We routinely use NPWT in contaminated wounds and it has given good results in our hands.

CONCLUSION

This is the first report of an umbilical Richter's hernia complicated with a colocutaneous fistula. Laparoscopy, radical debridement, NPWT and medical optimisation contributed to a good outcome in this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.