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నైరూప్య

Spontaneous inguinal enterocutaneous fistula as a complication of incarcerated Richter

Ranendra Hajong

Introduction: Rarely inguinal hernia may present with rare complication of spontaneous faecal fistula. Non-availability of proper medical care and unawareness of the condition are the major factors having potential for transformation of a relatively benign condition of inguinal hernia into complicated state of incarceration and strangulation. Case 1: A 50 year old female patient presented with passage of faecal material from the left inguinal region since the last one week. It was preceded with the history of a painful swelling in the same region about two weeks back for which incision and drainage was done. Magnetic resonance imaging showed features of left sided direct inguinal hernia with intact femoral canal. The patient did not opt for any surgical intervention, so was managed conservatively. Case 2: A 53 years old man presented to us with history of on and off discharge of yellowish debris from the left groin region since the last three years. Contrast fistulogram with urografin showed communication of the cutaneous opening with the jejunal loops.

Background: Magnetic resonance fistulogram confirmed the diagnosis. Patient underwent lower midline laparotomy. Mid-jejunum was found to be communicating with the fistula in the left iliac region which was dismantled and jejunum was repaired primarily. The fistulous tract was laid open and curetted. Postoperatively the patient developed SSI and was discharged on 14th postoperative day. Richter’s hernia is an uncommon condition in which only a circumference of the antimesenteric bowel wall is incarcerated within the hernia sac leading to ischemia, gangrene and perforation of the hollow viscus. It has an early misleading presentation with tendency to early strangulation and the lack of obstructive symptoms which may lead to delay in diagnosis and hence increased mortality. Any part of intestine may get incarcerated but most commonly involves distal ileum, caecum and sigmoid colon. As only a segment of bowel is involved, luminal continuity is maintained, thus there is only partial intestinal obstruction with minimal clinical signs.

Method:- Crotch hernias may seldom give unconstrained fecal fistula because of Richter's hernia wherein a part of the counter mesenteric outskirt of gut divider is entangled and detained inside the hernia sac prompting ischemic changes and entrail puncturing. Richter's hernia may happen in any hernia destinations however is all the more ordinarily observed in femoral ring. As just a piece of the digestive tract is entangled in Richter's hernia, the patients as a rule don't have obstructive indications and may give late expanded mortality. Absence of attention to the condition and non-openness to clinical consideration may bring about a moderately generous hernia to a confounded strangulated hernia. Richter's hernia happens in femoral rings (72-88%), inguinal trench (12-24%), incisional hernias (4-25%) and laparoscopic port addition destinations. Distal ileum, caecum and sigmoid colon are most normally engaged with Richter's hernia, despite the fact that any piece of digestive tract may get captured [4]. As just a piece of periphery of the digestive system is ensnared in Richter's hernia, luminal congruity is kept up with negligible clinical signs.

Results: Diagnosing Richter's hernia clinically is testing. A considerable lot of the past cases were affirmed during medical procedure. Nitty gritty clinical history, careful physical assessment and radiology may help in the early analysis of the patients. Fistulation will decompress the entrail and ease intestinal deterrent. Be that as it may, there is expanded danger of septic confusions and mortality in patients with Richter's hernia, earnest careful investigation with entrail resection and essential anastomosis is normally ordered. Comparable cases have been accounted for, which were overseen carefully. Richter's hernia ought to be remembered while managing enterocutaneous fistula in the inguinal locale. Postponement in conclusion and looking for clinical consideration may bring about complexities like enterocutaneous fistula.

Biography: Ranendra Hajong is an Associate Professor in General Surgery at NEIGRIHMS, India. He has around 40 publications in various indexed journals and has presented papers in various scientific forums. His activities involve teaching undergraduate and postgraduate medical students, patient care services and research.