Complexities in the management of a Richter’s supraumbilical hernia with colocutaneous fistula in a patient with morbid obesity: A case report with a review of literature

Abdominal wall Richter's hernia is rare. The usual presentation is with irreducibility, obstruction and strangulation. Occasionally, enterocutaneous fistula containing small bowel has been reported. Management is frequently difficult due to emergency presentation and contamination. A 60-year-old male with a history of suture repair of umbilical hernia presented with faecal discharge from a long-standing recurrent hernia in the background of obesity and history of pulmonary embolism. There were no features of peritonitis or obstruction. After optimisation, we took the patient for a diagnostic laparoscopy with curative intent. Diagnostic laparoscopy revealed a Richter's hernia containing transverse colon. The patient was treated with resection of the involved colonic segment, anastomosis, complete excision of the fistula tract along with surrounding skin, negative pressure wound therapy and delayed skin closure. To our knowledge, this is the first report of a spontaneous umbilical Richter's hernia complicated with a colocutaneous fistula. Management was challenging due to emergency presentation, multiple comorbidities as well as faecal contamination. Minimal access approach may have helped by decreasing the contamination and surgical site infection in the postoperative period.