Iatrogenic uterine perforation resulting in Richter's hernia: a rare complication of dilatation and curettage

Introduction

Dilatation and curettage (D&C) is a common diagnostic and therapeutic procedure for the gynecologic-obstetric practice. This procedure is associated with a series of complications such as bleeding, perforation, infection, and intrauterine adhesion. The overall perforation rate for first trimester abortions is around 0.8–1.3 per 1,000 according to different authors [1, 2]. Herein, we present a rare complication of D&C iatrogenic uterine perforation resulting in Richter's hernia, which required segmental resection of the involved small intestine. To the best of our knowledge, we believe that this is the first case report in the literature.

Case presentation

A 32-year-old woman presented to the gynecology clinic complaining of persistent vaginal bleeding since her delivery of a 2,706-g healthy baby girl 2 weeks ago. The patient was under ergometrine for 1 week; however, her vaginal bleeding persisted. Pelvic sonogram disclosed increased endometrium thickness (about 15.3 mm). Under the impression of placenta retention, the patient was admitted for D&C with suction. The procedure was uneventful; however, approximately 2 h after the procedure, the patient began to feel severe abdominal pain when she was still in the recovery room. Laparoscopic exploration revealed uterine perforation with a segment of small intestine partially herniated over the perforated site (Fig. 1). General surgeon was then consulted, and the segment of small intestine was reduced from the uterine perforation hole (about 1 × 1 cm in size). The uterine perforation was repaired. The involved small intestine was located at about 90 cm proximal to the ileocecal valve. A circular ischemic patch of small bowel on the antimesenteric border was noticed (Fig. 2). The involved small intestine was resected segmentally. The postoperative course was uneventful, and the patient was discharged under a stable condition.

Fig. 1

The small intestine was partially herniated into the perforation hole of the uterus

Fig. 2

After reduction, the herniated small intestine showed ischemic change

Discussion

Richter's hernia is defined as “an abdominal hernia in which only part of the circumference of the bowel is entrapped in the hernial orifice” [3]. This will result in a rapid progression of the involved intestine to strangulation and perforation.

In 1606, Fabricius Hildanus described a 63-year-old women who suffered from right inguinal hernia; later, the disease was complicated by intestinal perforation and subsequent enterocutaneous fistula; fortunately, the enterocutaneous fistula closed spontaneously after 2 months, and this lady recuperated completely. This is probably the first description of Richter's hernia in the literature [3]. With the advancement of laparoscopic surgery and the use of large ports (10 mm or more), an increase of Richter's hernia at trocar sites has been reported [4, 5]; however, Richter's hernia is rarely mentioned in the literature of gynecology.

In spite of an extensive search in the medical literature, only a small number of reports about iatrogenic uterus perforation associated with internal herniation of small intestine could be found [6–9]. D&C is a common and almost daily procedure in certain gynecologic practice. According to some authors, the inexperience of the physician is one of the risk factors of uterine perforation; unfortunately, D&C is still performed “underground” by unqualified physicians in some countries [7]; therefore, the real complication rate of D&C is perhaps underestimated. When the iatrogenic uterine perforation and the herniation of small intestine occurs simultaneously, the diagnosis may be established quickly by the sonographic finding of intestine loop inside the uterine cavity; in more severe cases, the herniated small intestine may even be found prolapsing to the vagina or vulva. However, when the perforation hole is small, only part of the circumference of the bowel will be entrapped in the hernial orifice, making the diagnosis very difficult.

Conclusion

Physicians who practice D&C should be aware of any unusual abdominal pain after the procedure, because early detection and management is the key to avoid disastrous outcome after iatrogenic uterine perforation.