What is Richter Hernia?
A Richter hernia is a less common type of hernia. While it’s not well-known and considered rare, this type of hernia can cause serious health problems. A Richter hernia occurs when a specific part of the bowel (the part that’s opposite the mesentery, a membrane in the abdomen) pokes through a weak spot in the abdominal muscles. This is why its symptoms often aren’t noticeable and why it is usually detected quite late.
Interestingly, the rates of Richter hernias have increased with the rise of minimally invasive surgeries, and this trend continues as these procedures become more popular. Treatment for a Richter hernia depends on the condition of the trapped bowel section. It often involves surgery to not only repair the hernia but also to remove the affected section of the bowel if it has been significantly damaged.
What Causes Richter Hernia?
The Richter hernia is named after August Gottlich Richter, who first described this type of hernia in 1785. A hernia is a health condition when an organ or fatty tissue squeezes through a weak spot in a nearby muscle or connective tissue. In the case of the Richter hernia, only a part of the intestinal wall pushes through a weak spot, specifically, the part that is not attached to the membrane that connects the intestines to the abdominal wall.
Before 1785, there were recorded cases of similar conditions. Fabricius Hildanus was the first to report such a case in 1598, and others like Alexis Littre also made similar reports in 1700. However, Richter was the first to identify and label this specific condition as a “partial enterocele,” which we now know as a Richter hernia.
Over the years, the understanding of this condition evolved. Antonio Scarpa added more details to our understanding of how this hernia works. By 1887, Frederick Treves reported a collection of cases of Richter hernias, further improving our knowledge of this unique type of hernia.
Risk Factors and Frequency for Richter Hernia
Richter hernias usually develop in older people between the ages of 60 and 80, but they can theoretically occur at any age. There are even some reports of these hernias in children. They are slightly more common in women than in men, likely because femoral hernias are more frequent in females and this is where Richter hernias often occur. It’s estimated that about 10% of all hernias are of the Richter type.
- The most common place for the occurrence of this type of hernia is the femoral canal (36 to 88% of cases).
- They also occur in the inguinal canal (12 to 36% of cases).
- Abdominal wall incisional hernias also account for a percentage of Richter hernia cases (4 to 25%).
The increase in the numbers of laparoscopic and robotic-assisted procedures have contributed to the rise of Richter type hernias, as port sites that have not been closed up can allow a portion of the bowel wall to protrude through a small defect in the tissue.
Signs and Symptoms of Richter Hernia
Patients suffering from incarcerated hernias often experience abdominal discomfort, bloating, nausea, and vomiting. However, the symptoms may not be instantly severe in the case of a hernia that involves only a part of the bowel wall. Unless two-thirds of the bowel wall get affected, the symptoms might not be very severe due to lack of complete blockage of the intestine. Because of this, some patients may not realize that they have a hernia until the symptoms intensify due to strangulation of a part of the bowel.
When patients present these symptoms, a thorough history and physical examination should be done, with special attention to any previous hernias or history of minimally invasive surgery. Doctors also need to understand a patient’s medical history in detail, including any existing conditions, heart or lung diseases, and any blood-thinning medications they may be taking. This information is necessary as these conditions and medications may need to be addressed if surgical treatment is required.
Testing for Richter Hernia
If your doctor suspects a Richter hernia, they will start by examining you physically. However, they may also use imaging techniques, such as ultrasound and computed tomography (CT) scans. These are additional tools that can help your doctor make the diagnosis. It’s important to note, though, that because a Richter hernia only affects a part of your bowel wall, these imaging tests might not always show the hernia, which can lead to a false-negative result.
Along with these imaging tests, your doctor will also need to run some laboratory tests. These tests will typically include a complete blood count (CBC) to check for any abnormalities in the number of white or red blood cells and platelets in your body, and a basic metabolic panel (BMP) to check if your body’s chemical balance is within its normal range. Any imbalances may imply leukocytosis (an excess of white blood cells), thrombocytopenia (a low platelet count), or electrolyte derangements (imbalance in the body’s sodium, potassium, or other minerals).
Your doctor will also want to run a test known as PT/INR and/or PTT. This is especially important for patients with liver problems or for those who are taking blood-thinning medications, as this test helps to determine the blood’s ability to clot. If needed, any clotting issues can then be addressed before surgery is considered.
Treatment Options for Richter Hernia
The treatment for Richter hernias, a specific type of hernia, depends on your health status, the physical examination, and if it’s suspected that the hernia may be cutting off blood flow, a condition known as “strangulation”. If you have a reducible hernia, meaning it can be manually pushed back into your abdomen, and you’re otherwise healthy, surgery can be planned according to your schedule. However, if it’s believed that the hernia is strangulated, immediate surgery is required. In the meantime, any infection will need to be treated with intravenous fluids and antibiotics.
The surgical approach chosen will depend on various factors such as where the hernia is, your health status, and surgeon preference. An open surgical procedure, where a large incision is made in your abdomen, might be the best option if you show signs of being unstable, have a blockage, or the hernia is strangulated. The cut is usually made at the same location as the hernia. However, minimally invasive surgeries, those that use a few small cuts rather than one large one, might also be an option. With either robotic or laparoscopic techniques, these are best for patients who are stable and whose hernia is not obstructed or strangulated.
An essential part of any surgical approach is checking the blood supply to your intestines. Surgically removing any part of the intestine without a proper blood supply is usually necessary. Your surgeon may use techniques such as injecting a dye and then using a special lamp or camera to see the blood supply, or they may use a Doppler ultrasound to listen for blood flow.
The repair of the hernia itself depends on the size and location of the hernia. The current standard for most hernias is to use a mesh to help support the area. However, in the case of Richter type hernias, which often involve strangled intestines that need to be removed, the use of mesh is not always the best option. The decision on whether to use mesh and what type of mesh to use is up to the surgeon’s best judgment.
What else can Richter Hernia be?
When a doctor is looking at possible cases of Richter type hernias, there are several other conditions they might need to rule out since patients often report abdominal pain. Unlike some other types of hernia, Richter type doesn’t typically have clear symptoms of complete obstruction, meaning the symptoms can be quite vague.
The different conditions that doctors might consider include:
- Fatty lumps (lipomas) in the abdomen wall
- Abscesses, which are collections of pus
- Ileus, which is a lack of movement in the intestines that can lead to a blockage
- Bowel obstruction and what might be causing it (for example, scar tissue (adhesions), other types of hernia, or growths within the intestines)
- Strangulated hernias involving the whole bowel, particularly if the patient is showing signs of blood poisoning (sepsis) and acute obstruction.
It can be difficult to know if a patient has a Richter type hernia until they undergo surgery. Therefore, these different conditions should be considered as part of the diagnostic process.
What to expect with Richter Hernia
After a hernia is successfully repaired, there’s always a chance that it could happen again. Certain factors that patients can change, like having a high Body Mass Index (BMI), smoking, diabetes, and the use of steroids, can increase the chances of the hernia coming back. The risk can also be affected by factors related to the surgery itself and the technique used, like an infection at the surgery site, development of a lump filled with fluid (seroma), overlap of tissue, and how experienced the surgeon is.
Richter hernias, which are often hernias that occur at the site of a previous surgery, are particularly prone to coming back. The risk of these types of hernias recurring after repair is estimated to be about 11%, with obesity being the most significant risk factor.
Possible Complications When Diagnosed with Richter Hernia
Richter hernias, unlike other hernias, might not show any initial signs of blockage or obstruction. If ignored, they can become severely lodged (chronically incarcerated) and may eventually develop into a tunnel between the intestine and skin (an enterocutaneous fistula). Some unusual cases of Richter type hernias have been reported where a tunnel formed between the colon and skin (colocutaneous fistula) after either inguinal hernia repair or laparoscopic gastric bypass. These complicated situations often need extensive surgery and longer recovery periods because the surgery involves opening the abdomen (laparotomy) and disconnecting the fistula. For instance, Jayamanne and his team reported a case where a Richter hernia developed through a cut in the area between the anus and genitals after a surgery to remove the rectum (proctectomy). This complication led to several return trips to the operating room and challenges with wound closure.
Common Issues:
- Chronic incarceration of the hernia
- Formation of an enterocutaneous fistula
- Formation of a colocutaneous fistula after hernia repair or gastric bypass
- Need for extensive repair and recovery after a laparotomy
- Multiple trips to the operating room
- Difficulty in wound closure
Recovery from Richter Hernia
Recovering from a Richter hernia repair operation involves addressing the factors that may cause the hernia to recur. It’s advised that patients stop smoking and avoid carrying heavy loads. Maintaining a healthy weight is greatly encouraged, as being overweight increases the chances of developing hernias. For comfort after the surgery, an abdominal binder might be used, however, it isn’t obligatory.
Preventing Richter Hernia
Before a surgery, the doctor should explain what to expect during and after the operation, including any pain and the recovery process. They should also talk about what the surgery involves, as well as potential risks like bleeding, infection, damage to nearby body parts, the possibility of needing more surgeries, and the chance that the problem might come back.
If the hernia contains bowel, then the patient might need a bowel resection — this is when a part of the bowel is removed. Your doctor will explain the risks that come with this, including a problem called anastomotic leak, which is when fluid leaks out from where the surgeon stitched the bowel back together.
If you have certain health conditions that make you more likely to get infections — like if you’re taking medicines such as chemotherapy or steroids that lower your immune system’s strength, or if you have inflammatory bowel disease — the doctor will discuss the possibility of needing an ostomy before surgery. An ostomy is a surgically created hole in the body for the discharge of body wastes.
They should also discuss what to expect in terms of post-surgery pain. This will differ depending on who is doing the surgery. Doctors will remind you of any limits to your activity after surgery. As mentioned before, patients are advised not to lift heavy objects for four to six weeks after the operation. They will also need to avoid activities that put a lot of pressure on the abdomen and should quit smoking to help the healing process.
