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  • The insidiousness of its presentation and the

    2018-11-12

    The insidiousness of its presentation and the fact that pramipexole dihydrochloride patients may maintain bowel transit usually delay the diagnosis of Richter\'s hernia. The time span from the onset of symptoms to operation is called preoperative delay. An increase in the delay increases the risk of ischemia and necrosis of the incarcerated tissue, thus increasing the need for intestinal resection, which is associated with high morbidity and mortality rates. Steinke and Zellweger reported a series of 18 patients with strangulated Richter\'s hernia at Lopiding Hospital in northern Kenya who experienced preoperative delay. Sixteen of the patients had perforated Richter\'s hernias. Of these patients, 11 had an enterocutaneous fistula in the groin, one had a perforation of the labia majora, and four had a postnecrotic abscess (along with signs of septic shock). The timespan from the onset of these symptoms to hospital admission ranged from 5 days to 1 year (one patient had an enterocutaneous fistula for 1 year). Two of the 18 patients (11%) had intestinal obstruction for 6 days and 12 days. In Taiwan, Mou et al reported on six patients with Richter\'s groin hernia. Of these patients, four had a groin mass or tenderness, five patients had ileus, and only one patient had intestinal obstruction. Because of the absence of obvious symptoms of intestinal obstruction, the operations were delayed in each instance from 0.5 days to 3 days. In the diagnosis of Richter\'s hernia, initial symptoms can be silent or nonspecific and focal signs may be lacking. When diagnostic uncertainty persists after physical examination, imaging studies may be required. Various imaging modalities, including conventional radiography, ultrasonography (US), and CT can be used. Conventional radiography detects signs of mechanical ileus with bowel loop distension, thickening of intestinal folds, and air–fluid levels. US is noninvasive, enables comparison with the asymptomatic side, and can be performed in physiological positions with dynamic scanning. Thus, US plays a crucial role in evaluating the presence of complications such as strangulation or incarceration, and in some cases, US may detect further pathology in the hernial sac. Among radiological techniques, CT is more favorable than the others, providing an accurate and panoramic view of the abdomen. CT is particularly effective in diagnosing abdominal wall hernias because it enables accurate identification of a hernia and its contents, differentiation from other abdominal masses, and the identification of hernia complications (bowel obstruction, ischemia, gas gangrene, and abscesses). Manual reduction attempts should be avoided prior to directly inspecting and evaluating the viability of the intestine. Early operative intervention is central to the successful management of Richter\'s hernia. The type of surgical incision varies according to the location of Richter\'s hernia. For Richter\'s groin hernia, the favored location is the preperitoneal space. This approach affords the surgeon excellent access to repair the hernial defect and to inspect the bowel through one incision. In cases involving excessive inflammation and necrosis of the body wall hosting the hernia, a two-stage approach, whereby the abscess is initially drained and the hernia is subsequently repaired when the infection is controlled, can be applied. In conclusion, the high death rate associated with Richter\'s hernia can be lowered through accurate diagnosis and early surgery. Thorough investigation of patient history and careful physical examination are required for accurate diagnoses. Radiological imaging can be used to confirm the diagnosis and is highly recommended in cases in which Richter\'s hernia is suspected. If left untreated, the bowel wall may become ischemic and gangrenous, leading to rapid clinical deterioration. Thus, if a patient presents with unexplained subacute symptoms and signs of intestinal obstruction, then physicians should consider a diagnosis of Richter\'s hernia. Early operative intervention is the mainstay of successful management.