Missed Ventral Richter Hernia Following Laparoscopic Endometriosis Surgery

Case at a Glance

A 34-year-old Caucasian female with BMI 28.7 presented with severe systemic symptoms for 15 months following laparoscopic endometriosis surgery. Multiple imaging studies initially reported as normal, with ventral Richter hernia eventually identified on ultrasound and retrospective CT review.

Patient's Story

The patient underwent laparoscopic surgery with adhesiolysis for endometriosis in March 2024. Post-operatively, the surgeon verbally mentioned freeing twisted bowel from the abdominal wall, though this was not documented in the operative report. Fourteen days post-surgery, she developed severe, life-altering symptoms including intense abdominal pain, nausea, vomiting, profound fatigue, drenching night sweats with acidic odor, recurrent infections, and dramatic weight loss of 50kg over three months. She described feeling 'poisoned' and systemically unwell. Initial medical evaluations attributed symptoms to anxiety or irritable bowel syndrome.

Initial Assessment

34-year-old female, height 167cm, weight 80kg, non-smoker with significant medical history including IgA deficiency (immunocompromised status) and heterozygous Prothrombin G20210A mutation (increased thrombotic risk). Patient presented with complex symptomatology following recent abdominal surgery, initially dismissed as functional disorders.

The Diagnostic Journey

Over 15 months, the patient underwent extensive imaging workup including approximately 7 CT scans and multiple MRI studies, all initially reported as normal. Persistent symptoms and clinical suspicion led to abdominal ultrasound evaluation. The ultrasonographer identified a Richter hernia and noted its visibility on previous CT imaging. Retrospective review of prior CT scans revealed: ventral/incisional hernia, abdominal wall bulging, mesenteric fat stranding suggestive of adhesions, and free fluid - findings that had not been previously reported.

Final Diagnosis

Ventral Richter hernia, likely incisional, present for 15+ months post-laparoscopic surgery. Contributing factors include previous abdominal surgery with documented bowel manipulation and underlying immunodeficiency potentially complicating healing and inflammatory response.

Treatment Plan

Patient referred to general surgery for definitive management. Surgical consultation arranged to evaluate hernia characteristics, assess bowel viability, and plan appropriate repair technique considering patient's complex medical history and prolonged symptomatic period.

Outcome and Follow-up

Case highlights the challenges in diagnosing ventral hernias on cross-sectional imaging, particularly when clinical presentation is atypical. The significant delay in diagnosis resulted in prolonged patient morbidity and raises important considerations about imaging interpretation protocols and the value of directed clinical correlation in radiology reporting.