- Email: [email protected]
Richter's Hernia After Laparoscopic Surgery
Images in Gynecological Surgery
Richter’s Hernia After Laparoscopic Surgery Ally Murji, MD, MPH*, Cassandra De Gasperis-Brigante, BSc, and Nicholas Leyland, MD, MHCM From the Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada (Dr. Murji and Ms. De Gasperis-Brigante), and Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada (Dr. Leyland).
A 42-year-old woman underwent laparoscopic resection of endometriosis. Fascia at the 12-mm right lower quadrant port site was sutured abdominally. On the sixth postoperative day, the patient presented with nausea and abdominal pain. A computed tomography scan revealed a transition point at the right anterior abdominal wall (Fig. 1). On laparoscopy, the small bowel antimesenteric border was herniated through the port site peritoneal defect and entrapped in the preperitoneal space, characteristic of a Richter’s hernia [1] (Fig. 2). Although the incidence of trocar site hernias is 0.5%, Richter’s hernias are rare [2]. Richter’s hernias are particularly deceptive because the intestinal lumen may initially remain patent, causing insidious gastrointestinal symptoms
The authors declare that they have no conflicts of interest. Corresponding author: Ally Murji, MD, MPH, FRCS(C), Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, 700 University Ave, 3rd Floor, Toronto, ON M5G 1Z5, Canada. E-mail: [email protected] Submitted July 20, 2016. Accepted for publication July 22, 2016. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2016 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2016.07.019
rather than obvious bowel obstruction [1]. Without prompt treatment, the small bowel may become rapidly gangrenous owing to poor collateral blood supply in the strangulated antimesenteric region [1]. Performing closure of all layers of the abdominal wall with a fascia closure device might have prevented this complication.
References 1. Steinke W, Zellweger R. Richter’s hernia and Sir Frederick Treves: an original clinical experience, review, and historical overview. Ann Surg. 2000;232:710–800. 2. Swank HA, Mulder IM, la Chapelle CF, et al. Systematic review of trocar-site hernia. Br J Surg. 2012;99:315–323.
Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2016
2
Fig. 1 Coronal section of computed tomography scan showing a transition point (arrow) in the right abdominal wall, suggestive of trocar site hernia. Dilation of the mid and distal bowel loops is also seen, suggesting bowel obstruction.
Fig. 2 Laparoscopic image showing the antimesenteric portion of the small intestine entrapped through a peritoneal defect at a port site.
Richter’s Hernia After Laparoscopic Surgery Ally Murji, MD, MPH*, Cassandra De Gasperis-Brigante, BSc, and Nicholas Leyland, MD, MHCM From the Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada (Dr. Murji and Ms. De Gasperis-Brigante), and Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada (Dr. Leyland).
A 42-year-old woman underwent laparoscopic resection of endometriosis. Fascia at the 12-mm right lower quadrant port site was sutured abdominally. On the sixth postoperative day, the patient presented with nausea and abdominal pain. A computed tomography scan revealed a transition point at the right anterior abdominal wall (Fig. 1). On laparoscopy, the small bowel antimesenteric border was herniated through the port site peritoneal defect and entrapped in the preperitoneal space, characteristic of a Richter’s hernia [1] (Fig. 2). Although the incidence of trocar site hernias is 0.5%, Richter’s hernias are rare [2]. Richter’s hernias are particularly deceptive because the intestinal lumen may initially remain patent, causing insidious gastrointestinal symptoms
The authors declare that they have no conflicts of interest. Corresponding author: Ally Murji, MD, MPH, FRCS(C), Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, 700 University Ave, 3rd Floor, Toronto, ON M5G 1Z5, Canada. E-mail: [email protected] Submitted July 20, 2016. Accepted for publication July 22, 2016. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2016 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2016.07.019
rather than obvious bowel obstruction [1]. Without prompt treatment, the small bowel may become rapidly gangrenous owing to poor collateral blood supply in the strangulated antimesenteric region [1]. Performing closure of all layers of the abdominal wall with a fascia closure device might have prevented this complication.
References 1. Steinke W, Zellweger R. Richter’s hernia and Sir Frederick Treves: an original clinical experience, review, and historical overview. Ann Surg. 2000;232:710–800. 2. Swank HA, Mulder IM, la Chapelle CF, et al. Systematic review of trocar-site hernia. Br J Surg. 2012;99:315–323.
Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2016
2
Fig. 1 Coronal section of computed tomography scan showing a transition point (arrow) in the right abdominal wall, suggestive of trocar site hernia. Dilation of the mid and distal bowel loops is also seen, suggesting bowel obstruction.
Fig. 2 Laparoscopic image showing the antimesenteric portion of the small intestine entrapped through a peritoneal defect at a port site.