Asian Journal of Case Reports in Surgery

Introduction: Richter's hernia, a rare but perilous form of abdominal wall hernia, is defined by the partial incarceration of the antimesenteric border of the bowel wall through a rigid fascial defect. This often spares the intestinal lumen, resulting in an insidious clinical presentation without the classic features of intestinal obstruction. Consequently, diagnosis is frequently delayed, allowing a progression to strangulation, ischemia, and perforation, setting the stage for catastrophic sequelae like enterocutaneous fistula and necrotising soft tissue infection. We report an extreme example of this progression—a neglected Richter’s inguinal hernia that evolved into a rare and lethal triad of a spontaneous entero-cutaneous fistula, Fournier’s gangrene and gangrenous orchitis.

Case Presentation: We present the case of a 40-year-old male with a one-year history of an intermittent left groin swelling who presented with a 6-day history of progressive, painful groin and scrotal swelling. This was complicated by the spontaneous development of a rapidly expanding scrotal wound draining faeculent material. Examination revealed an acutely ill patient with a full-thickness scrotal wound, necrotic skin changes consistent with Fournier's gangrene, and a gangrenous ipsilateral testis. Exploratory laparotomy confirmed a perforated Richter's hernia of the ileum incarcerated at the deep inguinal ring. Management involved segmental ileal resection and primary anastomosis, scrotal debridement, and orchidectomy.

Conclusion: This case underscores the lethal potential of Richter's hernia. It highlights the critical importance of early suspicion in any patient with a known hernia and persistent localised pain, even in the absence of obstruction. A midline laparotomy is the recommended approach for managing complex, fistulating cases to ensure adequate intra-abdominal control and repair.