Early Detection and Successful Release of Richter's Hernia in a 5-mm Laparoscopic Port Site

Background

In 1778 August, Gottlob Richter described “the small rupture,” now known as a Richter's hernia, in which only part of the circumference of the bowel is entrapped in the hernia defect. ¹ Port-site Richter's hernias are a rare complication after laparoscopic surgery.^2,3 Port-site hernias have been reported to occur at an incidence of 1.50% to 1.80%. ⁴ One-third of port-site hernias occur within 2 weeks of surgery; and Richter's hernias are found in half of the port-site hernias that develop within this time frame. ⁴ With an increasing use of laparoscopic surgery, the associated complications have to be considered. Richter's port-site hernias can be associated with negative outcomes, including bowel incarceration and ischemia requiring bowel resection.^5–7 Identifying these hernias early in the disease process is imperative to prevent these complications; and studies are now looking into addressing risk factors to prevent their occurrence.^5,6,8,9 For example, as more than 85% of cases occur in port sites 10 mm or larger, closing the fascia in port sites of 10 mm and larger has been recommended to reduce the risk of developing a port-site hernia.^8,9 We present the case of a patient who developed a Richter's hernia in a 5-mm port site and discuss whether preventative measures should be used in smaller port sites to prevent this occurrence.

Case

A 73-year-old woman underwent an elective total laparoscopic hysterectomy and a bilateral salpingo-oophorectomy for early-stage endometrial cancer at a tertiary referral center. She had no history of abdominal surgery and had a body–mass index in the normal range. Four laparoscopic ports were used for the procedure: a 12-mm umbilical port and three 5-mm abdominal ports (one suprapubic and two lateral iliac fossa ports). The patient recovered well, was passing flatus, and was discharged home on day 2 postoperatively. The next day, the patient presented to the emergency department with nausea, persistent vomiting, and no passage of flatus. There was no associated abdominal pain or fever. An abdominal X-ray demonstrated fecal loading, and a conservative management was initiated with the insertion of a nasogastric tube and administration of aperients and intravenous fluids with a diagnosis of postoperative ileus and constipation. On the second day of admission, the abdomen was noted to be more distended, and the feculent material was draining from the nasogastric tube, raising the clinical suspicion of an evolving bowel obstruction. Computerized tomography (CT) with contrast revealed a small bowel obstruction secondary to a Richter's hernia at the right lateral iliac fossa laparoscopic port site (Fig. 1). A subsequent repeated examination of the patient's abdomen confirmed an area of localized tenderness at the involved port site.

OPEN IN VIEWER

FIG. 1.

Computerized tomography of the abdomen and pelvis demonstrating a Richter's hernia (arrow) in the right lateral 5-mm port site.

Under general anesthesia, the right lateral port was opened and extended and there was a careful dissection into the peritoneal cavity to isolate the small bowel loop trapped in the 5-mm port site. A Richter's hernia of small bowel in the right lateral 5-mm port site was identified and released. A careful examination of the involved small-bowel segment found no evidence of injury, the small bowel was intact and viable, and therefore, no bowel resection was required. The peritoneum and the abdominal wall defect were closed in layers using 2-0 Vicryl and PDS sutures. Prophylactic intravenous antibiotics were given. The patient recovered well postoperatively with a gradual return to diet, and she was discharged home 6 days following the hernia repair, without further complications.

Discussion

A Richter's hernia through a port site is a rare complication of laparoscopic surgery; of these, hernias through 5-mm port sites are exceptionally rare. ⁴ This case details the detection and repair of a 5-mm port-site hernia manifesting in a patient 5 days after she underwent a laparoscopic hysterectomy and bilateral salpingo-oophorectomy. This, together with previous case studies, demonstrates that Richter's hernias through 5-mm ports pose a real risk in the setting of laparoscopic surgery.^10,11

Richter's hernias may lead to significant complications, and therefore being aware of the complication is imperative for early recognition and management.^5,6,10 As 5-mm ports are associated with port-site hernias so infrequently, it could easily be overlooked as a differential diagnosis, particularly when presentations are atypical. ¹² In this case, our patient was initially managed conservatively, given the primary differential diagnosis was postoperative ileus, which was supported by the clinical and radiological findings. The CT scan has been shown to be the superior method for differentiating between postoperative ileus and mechanical obstruction and was also demonstrated in our case. ¹³ A low threshold for CT scan was employed and the CT scan correctly identified mechanical bowel obstruction and the accurate diagnosis enabled a prompt intervention to prevent bowel incarceration and ischemia.

In this case, the Richter's hernia was able to be released with extension of the port site and careful dissection down to the trapped loop of small bowel. The surgical options for management of a port-site Richter's hernia, as discussed in the literature, include exploratory laparotomy and laparoscopy or direct extension of the port site, as was employed in this case.^7,10,11,14 A careful examination of the entrapped bowel is required in all techniques to assess the viability of the tissue and the subsequent need for bowel resection if a nonviable bowel is identified. ¹⁴ The potential for conversion to a laparotomy and bowel resection should be considered and planned for in all cases due to the risk of bowel ischemia in a Richter's hernia.

Previous reports have demonstrated that closing the peritoneum and fascia of port sites 10 mm and greater significantly reduces the risk of developing a port-site hernia, although it is not completely protective.^7,9,14 Discussions surrounding the closure of fascia for 5-mm port sites have suggested that it may not be necessary, given the rarity of the complication, the associated technical difficulty in closing the layers, and the anatomical support provided by the anterior abdominal wall muscles.^10,15 It has been, however, suggested that the closure of 5-mm port sites should be considered if the site is used for extensive manipulation causing the port site to enlarge.^10,15 Interestingly, in this case, the left lateral 5-mm port was used for more extensive manipulation than the right, suggesting that the left port site was at a higher risk of developing a hernia. Closure of port sites smaller than 10 mm may be a consideration in the future, given the potential severity of the adverse events associated with port-site hernias.

Richter's hernias in 5-mm port sites are rare, but represent a serious complication of laparoscopic surgery. A port-site Richter's hernia must be included as a differential diagnosis for any patient presenting with signs of a bowel obstruction after a laparoscopic surgery. As demonstrated in this case, there should be a low threshold for a CT scan to ensure that this complication can be correctly identified early in the disease process. Further consideration should be given to the closure of 5-mm port sites to prevent the occurrence of port-site hernias.