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Metro Curing Story-Hernia Treatment by Laparoscopic Surgery

High clinical suspicion with early intervention in RICHTER'S hernia can prevent gangrene of intestine. <br>Diagnostic laparoscopy (to assess the bowel) with Laparoscopic Inguinal Hernia repair is a safe and feasible minimally invasive surgical approach with early recovery<br>

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Metro Curing Story-Hernia Treatment by Laparoscopic Surgery

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  1. METRO CURING STORY RICHTER’S HERNIA WITH IMPENDING STRANGULATION SUCCESSFULLY TREATED BY LAPAROSCOPIC SURGERY Consulting Doctor Dr. ArunBhardwaj Senior Consultant & Unit Head Laparoscopic, GI & Bariatric Surgeon MBBS, MS (Gen surgery) , DNB (Gen Surgery), FNB (Minimal Access Surgery),FIAGES, MRCS England, FACS USA, FALS Bariatric Surgery

  2. Case History • 67 year old Female Patient presented in emergency withsymptoms of Abdominal Pain,Distension and Vomiting. • She used to have similar episodes since past 3 years withhistory of Swelling of right Lower Abdomen which used toreduce by itself and symptoms subsided. On Examination • On Evaluation, patient’s parameters were as follows: • Tachycardia + Generalised distension of Abdomen with tenderness and guarding.

  3. Pre-Operative Course • The patient was admitted & Management for Intestinal obstruction commenced with Ryle's tube and Foley's insertion, IV antibiotics, fluids and analgesics. • Blood investigations were normal with counts raised to 12800 • CT scan showed herniation of small intestine in the right inguinal with proximal dilatation and distal collapse. • The patient passed multiple loose stools with flatus and seemed to have been relieved from obstruction.

  4. WBC counts became normal with stable vitals. • Since the obstruction seemed relieved and elective surgeries were being avoided due to rising covid cases in pandemic, decision taken to continue conservative management • Her vitals continued to be stable but her abdomen had persistent generalised tenderness and guarding. • As her abdomen was not settling , the decision was taken to go ahead with Diagnostic Laparoscopy and proceed accordingly.

  5. Intra-Operative Findings • Herniation of part of the anti-mesenteric border of the mid ileal segment into the right inguinal canal (RICHTER'S INDIRECT INGUINAL HERNIA) with IMPENDING STRANGULATION. • Proximal small bowel was distended with distal loops of intestine collapsed. • Herniated small intestine loop was reduced into the peritoneal cavity and vascularity was assessed. • Intestinal loop was congested and edematous but no evidence of gangrene was present. • LAPAROSCOPIC TAPP (Trans-abdominal Pre-peritoneal) RIGHT INGUINAL HERNIA REPAIR was performed using 15 X 13 cms polypropylene mesh.

  6. Post-Operative Course • Her WBC counts were raised significantly to 29,000 (despite being on IV tazact, metrogyl and amikacin) with tachycardia and generalised abdominal tenderness. • To avoid prosthetic mesh infection, Tazact was stopped and patient started on IV meropenem (broad spectrum antibiotic). • She responded well and her abdominal symptoms improved with WBC counts gradually coming down to normal limits. • She was started orally on POD3 and discharged on POD5.

  7. Discussion • Richter’s hernia is herniation of the anti-mesenteric portion of the bowel through a fascial defect. • This exact phenomenon explains the often subclinical symptoms and late presentation. • Richter hernias typically occur in elderly patients between 60 to 80 years of age. • It is rare type of hernia accounting to approximately 10% of all hernias. • The most common location is the femoral canal (36 to 88%), followed by the inguinal canal (12 to 36%) and abdominal wall incisional hernias (4 to 25%).

  8. Patients often present with abdominal discomfort, distension, nausea, and vomiting. • The key difference is the delay in presentation. Because this hernia only involves a portion of the bowel wall, there is not a complete obstruction of the intestinal lumen. Lack of complete obstruction often leads to subclinical symptoms for a period until the process becomes advanced, and there is strangulation of the involved bowel. • There is reported incidence of gangrene and necrosis in 69% patients at the time of operative intervention

  9. An open surgical procedure may be the best option for patients with evidence of hemodynamic instability, obstruction, or strangulation. • A minimally invasive approach is often best suited for the urgent or elective setting. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) approaches may be considered for inguinal or femoral defects. • Early intervention in our case prevented the intestine from becoming gangrenous and allowed us to perform Laparoscopic TAPP repair

  10. Take Home Message High clinical suspicion with early intervention in RICHTER'S hernia can prevent gangrene of intestine. Diagnostic laparoscopy (to assess the bowel) with Laparoscopic Inguinal Hernia repair is a safe and feasible minimally invasive surgical approach with early recovery

  11. Intra – Operative Imaging

  12. Intra – Operative Imaging

  13. WE WISH HER A HEALTHY FUTURE AHEAD! Metro Hospital, Palam Vihar by Park Group of Hospitals For Appointments, Call: +91-8695000000 | 24X7 Emergency: +91-9891424242H Block, Chauma Village, Sector 1, Palam Vihar, Chauma, Haryana 122017

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