Perforation with abdominal wall abscess in a Richter's hernia

Case Discussion

A 30-year-old lady delivered following a caesarian section. Two weeks later, she presented with a passage of stools through her vagina. A left salpingectomy for ectopic pregnancy had been done 5 years ago. She underwent a CT scan to identify a suspected rectovaginal fistula. She became septic and passed small bowel contents through her abdominal wall. CT scan confirmed a ventral hernia with an intra-abdominal wall abscess. There was no conclusive evidence of a recto-vaginal fistula. She underwent a laparotomy. A small bowel perforation with intra-abdominal wall abscess was seen, with part of the lumen of the bowel wall showing necrosis and ischaemic perforation. Following surgical resection and primary anastomosis, drainage of abdominal wall abscess, and de-functioning loop ileostomy, she made a full recovery.

Richter’s hernia is part of the circumference of the bowel wall that is entrapped and strangulated in the hernial orifice and was described by August Richter in 1778. It is often located at the port site after laparoscopy ¹. Radiological diagnosis may be difficult in the early diagnosis of Richter's hernia ². Although recto-vaginal fistula was not demonstrated on CT scan, it remained a possibility. A de-functioning loop ileostomy served a dual purpose in protecting the anastomotic site from leakage in a septic malnourished patient and in treating recto-vaginal fistula ³.

On follow-up, it was confirmed on history and clinical examination that there was no recto-vaginal fistula or that it had healed following diverting stoma ³.