Obturator hernia: a diagnostic challenge

A rare case of left-sided obturator hernia diagnosed by computed tomography

Obturator hernia is a rare condition that is difficult to detect clinically. We highlight the importance of a CT scan in establishing an early diagnosis of an obturator hernia, effective surgical intervention planning, thereby enhancing the result.

Bowel obstruction in obturator hernia: A challenging diagnosis

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Obturator hernia is a rare entity; delayed diagnosis and treatment are associated with high rate of morbidity.

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It usually occurs in female and presents with bowel obstruction symptoms such as nausea, vomit and hydroelectrolyte imbalance.

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Surgery is the unique treatment: both laparoscopic transabdominal or laparotomic approaches are proposed.

Introduction

The obturator hernia is a rare pelvic hernia that often comes in the shape of bowel obstruction caused by the presence of an intestinal segment, more often ileum, passing trough the obturator foramen of the pelvic wall (Fig. 1). This type of hernia accounts for 0.5-1.4% of all hernias.

Case presentation

We report the clinical case of a 84-year-old woman with no previous surgical interventions, who went to the emergency room complaining of vomit and nausea, bowels closed to gas and stool, which she had experienced for three previous days. Routine blood test showed impaired renal function and hydrohelectrolyte imbalance. A CT scan revealed a right ileal, strangulated obturator hernia. The patient underwent an emergency surgical intervention with laparoscopic trans-abdominal peritoneal approach (TAP): after the reduction of the herniated segment, a primary suturing of the parietal defect was performed without ileal resection.

Discussion

Because of the non-specific symptoms the diagnosis of this kind of hernia is often unclear; female are 6–9 times more likely than men to be subject to the aforementioned pathology, mostly occurring in multiparous, emaciated, elderly woman so it is also called “the little old lady’s hernia”. Risk factors are loss of weight, chronic pulmonary disease and ascites which increase the abdominal pressure. An unfrequent presenting sign is a palpable mass, or the Howship-Romberg sign- a pain radiating from the inner tigh and knee − but it could be misleading when confused with symptoms of gonarthrosis or lumbar vertebral disc pathology. CT scan has superior sensitivity and accuracy with respect to other radiological exams to assess the presence of an obturator hernia.

Conclusion

Obturator hernia is a rare type of hernia due to his diagnosis, which is often unclear; a prompt suspect based for the non-specific symptoms is crucial for the diagnosis. Surgical management depends on early diagnosis and it is the only possible treatment for this pathology.

Rare case of incarcerated obturator hernia: Case report and review of literature

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Obturator hernia is a rare condition among abdominal hernias.

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Clinical diagnosis is challenging and it usually appears as an intestinal obstruction.

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Early diagnosis and surgical treatment reduce morbidity and mortality.

Introduction

Obturator hernia is a rare condition accounting for less than 1% of all intra abdominal hernias. Clinical diagnosis is considered a challenge for most surgeons. It usually appears as an intestinal obstruction. Confirmation of diagnosis is carried out by means of imaging or during surgery.

Case report

An 85-year-old female patient, with symptoms of intestinal obstruction of 24 h duration was admitted to the emergency room of Unimed Hospital – Belo Horizonte. Abdominal computed tomography (CT) demonstrated a herniation of the small bowel through the right obturator canal with an intestinal distension proximally. At laparotomy, the presence of a right obturator hernia with an ileal strangulation was confirmed. Segmental enterectomy with primary anastomosis and herniorrhaphy for the closure of the obturator foramen were performed.

Discussion

Obturator hernias typically affect women, elderly, emaciated and multiparous. Symptoms are non-specific and associated with an intestinal obstruction. Howship-Romberg sign, considered pathognomonic, is generally absent. Abdominal CT scan can aid in pre-operative diagnosis and the treatment is surgical.

Conclusion

Early diagnosis and surgical treatment are imperative in obturator hernias due to the high morbidity and mortality that occur in cases where the intervention is delayed.

Obturator hernia, a rare cause of small bowel obstruction: case report

Obturator hernia is a rare hernia in the world, diagnosed late since it has no specific symptoms and findings and generally occur in thin and old women with comorbidity.For this reason obturator hernia has high morbidity and mortality rates. In this study, we present an obturator hernia case that Howship-Romberg sign is positive and has typical appearance in computerized tomography. Laparotomy was performed on 89 years old female patient with body mass index 18.08 kg/m(2) by low middle line incision. Following the segmentectomy to the strangulated small bowel loop, obturator canal is repaired by retroperitoneal application. No complication occurred in the postoperative period. Obturator hernia should be taken into consideration in old and thin female patients with intestinal obstruction. Computerized tomography should be performed for early diagnosis of the obturator hernia.

Obturator hernia: A diagnostic challenge

INTRODUCTION

Obturator hernia is an extremely rare type of hernia with relatively high mortality and morbidity. Its early diagnosis is challenging since the signs and symptoms are non specific.

PRESENTATION OF CASE

Here in we present a case of 70 years old women who presented with complaints of intermittent colicky abdominal pain and vomiting. Plain radiograph of abdomen showed acute dilatation of stomach. Ultrasonography showed small bowel obstruction at the mid ileal level with evidence of coiled loops of ileum in pelvis. On exploration, Right Obstructed Obturator hernia was found. The obstructed Intestine was reduced and resected and the obturator foramen was closed with simple sutures. Postoperative period was uneventful.

DISCUSSION

Obturator hernia is a rare pelvic hernia and poses a diagnostic challenge. Obturator hernia occurs when there is protrusion of intra-abdominal contents through the obturator foramen in the pelvis. The signs and symptoms are non specific and generally the diagnosis is made during exploration for the intestinal obstruction, one of the four cardinal features. Others are pain on the medial aspect of thigh called as Howship Rombergs sign, repeated attacks of Intestinal Obstruction and palpable mass on the medial aspect of thigh.

CONCLUSION

Obturator hernia is a rare but significant cause of intestinal obstruction especially in emaciated elderly woman and a diagnostic challenge for the Doctors. CT scan is valuable to establish preoperative diagnosis. Surgery either open or laproscopic, is the only treatment. The need for the awareness is stressed and CT scan can be helpful.

Obturator hernia--a condition seldom thought of and hence seldom sought

PURPOSE

Obturator hernia is an extremely rare type of hernia with an incidence of less than 1% of all abdominal wall hernias occurring predominantly in elderly females characterized by protrusion of the intra-abdominal viscera into the obturator foramen. It presents with pain along the medial aspect of the thigh referred to the knee due to compressed obturator nerve and sometimes as an uncommon cause of intestinal obstruction. It remains a clinical diagnostic dilemma and often perplexing the decision for surgery. This explanatory review emphasizes and illuminates its various facets under the rationale of its diagnosis and management to familiarize surgeons with the condition.

METHODS

The data for the present review was obtained by searching in PubMed and other databases using key terms "obturator hernia", "abdominal hernia", "intestinal obstruction", and "Howship-Romberg sign". Many original articles, reviews, and case reports were selected.

RESULTS

Since it is very rare that a mass can be found on inspection of the medial aspect of the thigh and the clinical signs are not always present, hence obturator hernia is a condition which leads to both difficult and delayed clinical diagnosis and consequently having a significant morbidity and mortality rates, especially in the elderly.

CONCLUSION

Obturator hernia should always be in the differential diagnosis in septuagenarian to nonagenarian patients with nonspecific signs and symptoms of intestinal obstruction. Computed tomography of abdomen and pelvis has been found to be the gold standard for preoperative diagnosis and this condition necessitates immediate surgical reduction and repair of the defect either by open or laparoscopic approach.

Strangulated intestinal obstruction secondary to a typical obturator hernia: a case report with literature review

Obturator hernia is a rare pelvic hernia with incidence of 1%. It's a significant cause of intestinal obstruction in emaciated elderly women. Delayed diagnosis and surgical intervention contributed to its relatively high morbidity and mortality. We present a typical case of obturator hernia with positive Howship-Romberg sign and Hannington-Kiff sign. The diagnosis was confirmed by spiral CT preoperatively. During the emergency laparotomy, the incarcerated intestine was reduced and removed. Obturator foramen was repaired by simple suture. The patient recovered uneventfully and no recurrence occurred during the follow-up. The obturator hernia should be included in the differential diagnosis if clinically suspected. Early diagnosis and prompt surgical treatment are essential to reduce the morbidity and mortality associated with obturator hernia.

Obturator hernia: anatomy, embryology, diagnosis, and treatment

An obturator hernia is an infrequent but significant cause of intestinal obstruction. The incidence of obturator hernias is between 0.05 and 1.4% of all hernias. The mortality rate can be as high as 70% when acutely incarcerated due to the difficulty in diagnosis and delay in surgical treatment Three progressive stages of obturator herniation have been classified and can be one of three different varieties depending on the pathway the herniated sac follows. Knowledge of the anatomy and pathogenesis of obturator herniation is essential in diagnosis and treatment. The most common clinical presentation is intestinal obstruction (90%) and this is often seen in elderly, emaciated, multiparous women with predisposing conditions. Other classic signs, though not always present include obturator neuralgia, the Howship-Romberg sign and the Hannington-Kiff sign. Computed tomography scan is the most favored diagnostic imaging method. The abdominal surgical approach is most preferred when a diagnosis is uncertain and laparoscopy should be employed in elective early surgeries. This aim of this article is to review the diagnosis and treatment of obturator hernia by describing the anatomy, embryology, clinical presentation, diagnosis, and management currently in use. Increased awareness and proper management of this condition will result in decreased morbidity and mortality.

Obturator hernia: a diagnostic challenge of small-bowel obstruction

Obturator hernia is relatively rare and is a diagnostic challenge in the emergency department because the hernia mass is usually concealed beneath the pectineus muscle. We report the case of a 91-year-old emaciated woman with an incarcerated obturator hernia. The hernia was discovered early in the emergency department by computed tomography and was reduced by emergency laparotomy. The Howship-Romberg sign and pain from the ipsilateral thigh to the knee are important clinical manifestations raising suspicion of obturator hernia, but these did not occur in our patient. One of the clinical clues in our patient was small-bowel obstruction of unknown origin, diagnosed by computed tomography. We emphasize that emergency physicians should keep a high index of clinical suspicion for obturator hernia when encountering small-bowel obstruction in emaciated elderly women. Although we cannot shorten the time from onset of symptoms to hospital admission, we can make rapid evaluation and surgical intervention to reduce the morbidity and mortality of obturator hernia.

Ileum perforation due to delayed operation in obturator hernia: A case report and review of literatures

A 83-year-old woman was admitted to our hospital because of intermittent abdominal colicky pain and vomiting for 26 h. The pain localized over the periumbilical area with radiation along the medial side of the thigh. Computed tomography scan with three-dimensional reconstruction revealed a loop of small bowel protruding into the left obturator canal. Incarcerated obturator hernia was diagnosed and emergency laparotomy was arranged immediately. Unfortunately, her family refused surgery because of her worsening condition. On the third evening after admission, the patient developed peritonitis and sepsis. Perforation of small bowel due to the incarceration was noted during laparotomy. Bowel resection and an end-ileostomy were performed. She recovered well despite of the complication of multiple organ dysfunction syndrome. Literature is reviewed, and the pathogenesis, clinical manifestation, imaging features and treatment are discussed.

Pararectal and obturator hernias as incidental findings on gynecologic laparoscopy

Pararectal and obturator hernias are relatively rare and typically affect elderly emaciated women. They are difficult to diagnose preoperatively. A gynecologist may come across such hernias as a secondary finding during laparoscopy. Such findings are expected to increase with the aging population. We present two cases and the technique to treat them.