Management of Strangulated Richter’s Hernia in a Resource-Limited Setting: Report of Two Cases and Literature Review

Abstract

Richter’s hernia is a rare type of abdominal wall hernia characterized by high morbidity and mortality. It occurs when the anti-mesenteric border of the bowel is partially trapped in a tight hernial ring. The femoral ring is the most common site, with the ileum being the most frequently involved intestinal segment. However, the advent of laparoscopic surgery has introduced another potential site for Richter’s hernia formation. In our region, this pathological entity is exceptionally diagnosed due to limited access to abdominal imaging and delayed management. Additionally, the wide variety of clinical manifestations resulting from incomplete intestinal obstruction makes it particularly difficult to diagnose. Consequently, it is usually identified during surgery. We present here the case of two adult patients (a 33-yeairs-old woman and a 59-year-old man), the first with a history of surgical procedures and the second with a spontaneously reducible painless inguinal swelling. They were transferred to the surgical emergency department for an acute abdomen with abdominal distension and cessation of matter and gas. Clinical and paraclinical examinations (including hydroaeric level on abdominal X-ray) indicated mechanical intestinal obstruction. Emergency laparotomy, necessitated by the unavailability of abdominal computed tomography due to financial constraints, confirmed the diagnosis of Richter's hernia, with the first case located in the right inguinal region and the second in the linea alba. Surgical management involved reduction of the hernia contents and suture repair in both cases. Despite requiring bowel resection in the second patient, the postoperative course was straightforward. These two rare cases highlight that emergency exploratory laparotomy is the cornerstone of Richter hernia management in resource-limited conditions.