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Kumar A, Mehdi K. Laparoscopic management of obturator hernia in the setting of intestinal obstruction: A report of two cases and review of literature. Med J Armed Forces India 2023; 79:113-116. [PMID: 36605339 PMCID: PMC9807685 DOI: 10.1016/j.mjafi.2020.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/28/2020] [Indexed: 02/07/2023] Open
Abstract
Owing to its rarity and non-specific clinical features, a diagnosis of obturator hernia is often delayed until the patient presents with intestinal obstruction. Often the diagnosis is made on a Computed Tomography (CT) scan or during exploratory laparotomy. While a laparoscopic approach is well described in an elective scenario, open surgery through a midline laparotomy has been the preferred approach for obturator hernia with intestinal obstruction. However, a few cases of obstructed obturator hernia have been reported that have been managed laparoscopically. We present our experience of two elderly patients who presented with intestinal obstruction. A CT scan helped clinch the diagnosis of obturator hernia as the cause and both were managed laparoscopically.
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Affiliation(s)
- Ameet Kumar
- Senior Advisor (Surgery) & GI Surgeon, 5 Air Force Hospital, Jorhat, India
| | - K.M. Mehdi
- Graded Specialist (Surgery), 5 Air Force Hospital, Jorhat, India
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2
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Delgado A, Bhuller SB, Phan P, Weaver J. Rare case of obturator hernia: Surgical anatomy, planning, and considerations. SAGE Open Med Case Rep 2022; 10:2050313X221081371. [PMID: 35341101 PMCID: PMC8943527 DOI: 10.1177/2050313x221081371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/01/2022] [Indexed: 11/24/2022] Open
Abstract
Obturator hernia is a rare variation of abdominal hernias that cause significant
morbidity and mortality, especially in the elderly population. Incidence rates vary but
account for approximately 0.07%–1.0% of all hernias. Literature on laparoscopic versus
laparotomy, as well as types of closure (primary vs mesh) have not been well described in
the literature. Obturator hernias, although rare, require a high index of suspicion and
care in surgical management as many of these patients will be elderly with a multitude of
comorbid conditions. Further research and reporting on technique and type of closures
utilized when these rare hernias are encountered by surgeons would benefit the surgical
community on practices and management of obturator hernias. Here, we present a case of an
elderly female who presented with complaints of obstructive symptoms and abdominal pain
secondary to an obturator hernia.
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Affiliation(s)
- Adam Delgado
- Department of Surgery, Sky Ridge Medical Center, Lone Tree, CO, USA
| | - Sidra B Bhuller
- Department of Surgery, Sky Ridge Medical Center, Lone Tree, CO, USA
| | - Peter Phan
- Department of Surgery, Sky Ridge Medical Center, Lone Tree, CO, USA
| | - John Weaver
- Department of Surgery, Sky Ridge Medical Center, Lone Tree, CO, USA
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Schizas D, Apostolou K, Hasemaki N, Kanavidis P, Tsapralis D, Garmpis N, Damaskos C, Alexandrou A, Filippou D, Kontzoglou K. Obturator hernias: a systematic review of the literature. Hernia 2021; 25:193-204. [PMID: 32772276 DOI: 10.1007/s10029-020-02282-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/27/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Obturator hernias (OH) are extremely rare hernias, accounting for 0.07-1% of all hernias. This is the first systematic review investigating their presentation, imaging, treatment outcomes, and recurrence rate. METHODS After a detailed search in electronic search engines, 74 studies matched our criteria. A review of these reports was conducted and the full texts were examined. RESULTS A total of 146 patients with a mean age of 78.8 years were included in our analysis, with 40.1%, 29.9%, and 25.2% of patients suffering from either a right, a left or bilateral OH, respectively. OH were associated with non-specific symptoms and signs; bowel obstruction being the most common. Howship-Romberg sign was present in 56.2% of patients. Computed tomography (CT) scan was the most frequently used diagnostic modality, inversely associated with perioperative mortality. Mesh repair demonstrated a significantly improved perioperative morbidity rate, compared with non-mesh repair. Approximately 30% of patients underwent a laparoscopic operation, which was associated with significantly decreased morbidity and mortality rate as well as length of hospital stay, compared with the open repair. CONCLUSION OHs are not associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair.
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Herath M, Kanhere H. Loin to groin pain -A case report of an intermittent obturator hernia mimicking ureteric colic. Int J Surg Case Rep 2019; 66:356-359. [PMID: 31927400 PMCID: PMC6956747 DOI: 10.1016/j.ijscr.2019.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Obturator hernia is a rare condition and can cause significant diagnostic challenges due to a lack of reliable clinical examination signs. Presentations can have a variety of features and it is a diagnosis that needs to be considered - especially in elderly multiparous women. PRESENTATION OF CASE We present a 76-year-old female who has multiple presentations to the Emergency Department (ED) with transient episodes of severe loin to groin pain. Imaging Computer Tomography (CT) initially demonstrated a mild left hydronephrosis and she underwent an unremarkable ureteroscopy and stenting. Following stent removal she continued to have recurrent episodes of the pain. She presented to the ED with one such episode. A repeat CT scan was performed and this demonstrated an obturator hernia with partial small bowel obstruction. She underwent a laparoscopy by which time the hernia had reduced and her pain had settled. Laparoscopy revealed bilateral obturator herniae with the one on left larger than the right. Both were repaired laparoscopically and she made an uneventful recovery. DISCUSSION Obturator hernia is an uncommon condition and can have a varied presentation. Comprehensive review of literature demonstrates the difficulty in making accurate diagnosis. Open intervention was the initial gold standard of treatment but there is a growing body of evidence advocating for the use of laparoscopy in an emergency setting. CONCLUSION Early diagnostic imaging with CT while a patient is symptomatic can aid in making an accurate diagnosis. Laparoscopic repair can be safely used with good outcome in the context of an incarcerated obturator hernia.
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Affiliation(s)
- Matheesha Herath
- Port Augusta Hospital, 71 Hospital Road Port Augusta, South Australia, 5700, Australia; The Royal Adelaide Hospital, Port Road, Adelaide, South Australia, 5000, Australia.
| | - Harsh Kanhere
- Port Augusta Hospital, 71 Hospital Road Port Augusta, South Australia, 5700, Australia; The Royal Adelaide Hospital, Port Road, Adelaide, South Australia, 5000, Australia; The Queen Elizabeth Hospital, Woodville Road, Woodville, South Australia, Australia
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Abstract
Abdominal wall hernias are prevalent in patients undergoing peritoneal dialysis (PD). Obturator hernias, first described by Arnaud de Ronsil in 1724, are an uncommon type of hernia where intra-abdominal contents protrude through the obturator foramen. The following case highlights a rare presentation of bilateral obturator hernias with right femoral and inguinal hernia in an 82-year-old woman post-PD. This patient presented with 5 months of bilateral thigh pain and swelling and was found to only have a right-sided obturator hernia on computer tomography (CT) scan. Intraoperatively, bilateral obturator hernias were found along with right inguinal and femoral hernias, which were all repaired laparoscopically with polypropylene mesh. Postoperatively, the patient developed a self-limiting port site hematoma and resumed PD 1 month post-surgery. Due to the high morbidity and mortality from obturator hernias, prompt diagnosis and treatment are imperative. Compared with open hernia repair, laparoscopic hernia repairs are associated with quicker return to usual activities and less persisting pain and numbness. This case portrays that laparoscopic approach to bilateral obturator hernias can be considered in patients post-PD.
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Affiliation(s)
- Jonathan Ramkumar
- University of British Columbia, Division of General Surgery, Vancouver, BC, Canada
| | - Daphne Lu
- University of British Columbia, Division of General Surgery, Vancouver, BC, Canada
| | - Tracy Scott
- St. Paul's Hospital, Department of General Surgery, Vancouver, BC, Canada
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Daskalopoulou D, Kankam J, Plambeck J, Ambe PC, Zarras K. Intraoperative real-time fluorescence angiography with indocyanine green for evaluation of intestinal viability during surgery for an incarcerated obturator hernia: a case report. Patient Saf Surg 2018; 12:24. [PMID: 30154915 DOI: 10.1186/s13037-018-0173-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/20/2018] [Indexed: 12/16/2022] Open
Abstract
Background Bowel incarceration represents a dreaded complication amongst patients with hernias. The intraoperative evaluation of the bowel perfusion following hernia reduction with regard to the need for resection of ischaemic bowel can be challenging. In this case report we discuss intraoperative fluorescence angiography with indocyanine green (ICG) as an objective means of accessing bowel perfusion following hernia reduction. Case presentation The case of a 92-year-old, caucasian, female patient presenting with symptoms of small bowel obstruction secondary to an incarcerated left sided obturator hernia is presented. An incarcerated segment of the small bowel was reduced during emergency laparoscopy. Intraoperative ICG fluorescence angiography revealed ischaemic changes in the normal appearing bowel, so that the involved segment was resected. The postoperative course was uneventful and the patient was discharged home safely on postoperative day seven. Conclusion Intraoperative ICG fluorescence angiography provides an objective method of judging bowel perfusion and therefore represents a useful tool for assessing intestinal perfusion in patients with incarcerated hernia.
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Affiliation(s)
- Prakash Jayanthi
- Department of Surgery, Providence and Providence Park Hospitals, Southfield, Michigan
| | - Sunu Philip
- Department of Surgery, Providence and Providence Park Hospitals, Southfield, Michigan
| | - Peter Lopez
- Department of Surgery, Providence and Providence Park Hospitals, Southfield, Michigan
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Sá NC, Silva VCM, Carreiro PRL, Matos Filho AS, Lombardi IA. Rare case of incarcerated obturator hernia: Case report and review of literature. Int J Surg Case Rep 2017; 37:157-60. [PMID: 28686923 DOI: 10.1016/j.ijscr.2017.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 06/09/2017] [Accepted: 06/11/2017] [Indexed: 11/24/2022] Open
Abstract
Obturator hernia is a rare condition among abdominal hernias. Clinical diagnosis is challenging and it usually appears as an intestinal obstruction. 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.
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Liu J, Zhu Y, Shen Y, Liu S, Wang M, Zhao X, Nie Y, Chen J. The feasibility of laparoscopic management of incarcerated obturator hernia. Surg Endosc 2016; 31:656-660. [PMID: 27287915 DOI: 10.1007/s00464-016-5016-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 06/01/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Obturator hernia (OH), a rare cause of acute small bowel obstruction, requires immediate surgical intervention to prevent serious complications and mortality. We assessed the safety and efficacy of laparoscopic surgery in patients with incarcerated OH presenting with acute abdomen in an emergency setting. METHODS Data pertaining to patients diagnosed with incarcerated OH between 2011 and April 2015 at our hospital were reviewed. Patients' characteristics, operation details and postoperative outcomes were retrospectively analyzed. RESULTS All ten patients diagnosed with incarcerated obturator hernia during the reference period were females (average age 72.1 ± 11.8 years; average weight 44.1 ± 6.9 kg; average body mass index 17.8 ± 2.1 kg/m2; average operating time 63 ± 15 min; average hospital stay 6.2 ± 6.6 days). Twelve occult hernias, including six contralateral OHs, two ipsilateral femoral hernias and two bilateral femoral hernias were detected in six patients (60 %), which were simultaneously repaired after laparoscopic exploration. Nine patients (90 %) were successfully treated with synthetic mesh by laparoscopic technique. Only one case required intraoperative conversion to open surgery due to strangulated intestine with perforation. Wound infection was reported in one patient who had undergone bowel resection, but with an eventual complete recovery. Postoperative period was uneventful in the other nine patients. No recurrence or complications were reported on follow-up (mean duration of follow-up: 6-54 months). CONCLUSION In this study, laparoscopic technique was associated with a reduced duration of hospital stay and fewer complications. In addition to being a safe and minimally invasive strategy, it allowed for simultaneous diagnosis and treatment of occult hernias during the same procedure. The approach may be a better option for the treatment of incarcerated OH and occult hernias in selected patients.
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Affiliation(s)
- Jing Liu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Yilin Zhu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Yingmo Shen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Sujun Liu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Minggang Wang
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Xuefei Zhao
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Yusheng Nie
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China
| | - Jie Chen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100043, China.
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Wakasugi M, Masuzawa T, Tei M, Omori T, Ueshima S, Tori M, Akamatsu H. Single-incision laparoscopic totally extraperitoneal obturator hernia repair in a patient on antiplatelet therapy: a case report. Asian J Endosc Surg 2015; 8:83-6. [PMID: 25598062 DOI: 10.1111/ases.12132] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 06/06/2014] [Accepted: 07/13/2014] [Indexed: 11/29/2022]
Abstract
An 83-year-old woman who complained of right lower limb discomfort was diagnosed with a right obturator hernia by CT scan. On examination, she had a soft and flat abdomen without signs of peritoneal irritation. The Howship-Romberg sign was present. She had a history of vasospastic angina and paroxysmal supraventricular tachycardia, and took aspirin and dipyridamole until she was admitted to the hospital. Exploratory laparoscopy identified a spontaneously reduced small bowel from the right obturator canal, but there were no signs of ischemic and necrotic bowel. The patient underwent SILS for totally extraperitoneal obturator hernia repair without a dissection balloon. The patient recovered without perioperative complications such as hemorrhage and thrombotic episodes. She remains well, and CT scans showed no signs of obturator hernia recurrence at the 7-month follow-up.
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Khaladkar SM, Kamal A, Garg S, Kamal V. Bilateral obturator hernia diagnosed by computed tomography: a case report with review of the literature. Radiol Res Pract 2014; 2014:625873. [PMID: 25544896 DOI: 10.1155/2014/625873] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 11/20/2014] [Indexed: 11/18/2022] Open
Abstract
Obturator hernia is a rare form of abdominal hernia and a diagnostic challenge. It is commonly seen in elderly thin females. Its diagnosis is often delayed with resultant increased morbidity and mortality due to bowel ischemia/gangrene. It is mistakenly diagnosed as femoral or inguinal hernia on USG. Computed tomography is diagnostic and is a valuable tool for preoperative diagnosis. This report presents a case of 70-year-old thin female presenting with intestinal obstruction due to left sided obstructed obturator hernia. USG showed small bowel obstruction and an obstructed left sided femoral hernia. CT scan of abdomen and pelvis with inguinal and upper thigh region disclosed left sided obturator hernia. It also detected clinically occult right sided obturator hernia. Early diagnosis and surgical treatment contribute greatly in reducing the morbidity and mortality rate.
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Togawa Y, Muronoi T, Kawaguchi H, Chiku T, Sano W, Hashiba T, Ueda A, Kaneoya K. Minimal incision transinguinal repair for incarcerated obturator hernia. Hernia 2014; 18:407-11. [PMID: 23644742 DOI: 10.1007/s10029-013-1095-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 04/26/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with incarcerated obturator hernia are usually elderly, frail, and physically inactive women with serious comorbidities. Although a laparotomy is standard surgical intervention for emergency incarcerated or strangulated obturator hernia, it is invasive particularly for these high-risk patients. The aim of this study is to show the feasibility of minimum open inguinal approach to reduce surgical risk for preoperatively diagnosed incarcerated obturator hernia. METHODS Between April 2008 and July 2012, 3 consecutive incarcerated obturator hernia patients at Kamitsuga General Hospital who were diagnosed preoperatively by computed tomography underwent the following procedure. First a 4 cm inguinal hernia incision and preperitoneal dissection through the opening of the deep inguinal ring are made. The obturator hernia can be easily found 2 cm dorsally from the Cooper's ligament extraperitoneally. A small incision is made at medial sharp edge of the hernia defect. The hernia sac and its content can then be reduced. If the incarcerated bowel is viable, a prosthetic mesh is placed as a patch. If the bowel is necrotic, the damaged bowel loop is withdrawn through the wound and easily reconstructed extra-abdominally. RESULTS All operations were successfully completed with this procedure. All patients recovered without incident. CONCLUSIONS Minimal incision transinguinal repair for diagnosed incarcerated obturator hernia is feasible and provides an improved option to more invasive procedures.
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Affiliation(s)
- Y Togawa
- Department of Surgery, Kamitsuga General Hospital, 1-1033 Shimota-cho, Kanuma, Tochigi, Japan,
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Otowa Y, Kanemitsu K, Sumi Y, Nakamura T, Suzuki S, Kuroda D, Kakeji Y. Laparoscopic trans-peritoneal hernioplasty (TAPP) is useful for obturator hernias: report of a case. Surg Today 2013; 44:2187-90. [PMID: 23975587 DOI: 10.1007/s00595-013-0694-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Accepted: 07/16/2013] [Indexed: 10/26/2022]
Abstract
A 71-year-old female presented to our hospital due to pain from the right hip joint to the lower abdomen. The pain had suddenly appeared and spontaneously disappeared more than 10 times during the past 2 years. She had visited many hospitals, but remained undiagnosed. The patient underwent a computed tomography (CT) scan of the pelvis, and a soft tissue shadow was seen between the external obturator and pectineal muscles. She was diagnosed with a right obturator hernia and underwent elective repair by laparoscopic trans-peritoneal hernioplasty (TAPP). 1 year has passed since the surgery, without any recurrence of the abdominal pain. Obturator hernias are rare, and most cases are found as incarcerated hernias. It is rare to find an obturator hernia without intestinal obstruction, or with the recurrent pain as in our case. We herein report a case in which an obturator hernia was undiagnosed and intermittent pain was experienced for 2 years prior to TAPP, which appears to have successfully treated the hernia.
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Affiliation(s)
- Yasunori Otowa
- Division of Gastro-intestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kusunoki-chou 7-5-2, Chuo-ku, Kobe, 650-0017, Japan,
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Hodgins N, Cieplucha K, Conneally P, Ghareeb E. Obturator hernia: A case report and review of the literature. Int J Surg Case Rep 2013; 4:889-92. [PMID: 23973903 DOI: 10.1016/j.ijscr.2013.07.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 07/07/2013] [Accepted: 07/19/2013] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION An obturator hernia is a rare condition but is associated with the highest mortality of all abdominal wall hernias. Early surgical intervention is often hindered by clinical and radiological diagnostic difficulty. The following case report highlights these diagnostic difficulties, and reviews the current literature on management of such cases. PRESENTATION OF CASE We present the case of an 86-year-old lady who presented with intermittent small bowel obstruction, clear hernial orifices, and right medial thigh pain. Pre-operative CT imaging was suggestive of an obstructed right femoral hernia. However, intra-operatively the femoral canal was clear and an obstructed hernia was found passing through the obturator foramen lying between the pectineus and obturator muscles in the obturator canal. DISCUSSION Obturator hernias are notorious for diagnostic difficulty. Patients often present with intermittent bowel obstruction symptoms due to a high proportion exhibiting Richter's herniation of the bowel. Hernial sacs can irritate the obturator nerve within the canal, manifesting as medial thigh pain, and often no hernial masses can be detected on clinical examination. Increasing speed of diagnosis through early CT imaging has been shown to reduce the morbidity and mortality associated with obturator hernias. However, over-reliance on CT findings should be cautioned, as imaging and operative findings may not always correlate. CONCLUSION A high suspicion for obturator hernia should be maintained when assessing a patient presenting with bowel obstruction particularly where intermittent symptoms or medial thigh pain are present. Rapid clinical and appropriate radiological assessment, followed by early surgery is critical to successful treatment.
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Affiliation(s)
- Nicholas Hodgins
- General Surgery Department, South West Acute Hospital, 124 Irvinestown Road, Enniskillen BT74 6DN, United Kingdom.
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15
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Deeba S, Purkayastha S, Darzi A, Zacharakis E. Obturator hernias: A review of the laparoscopic approach. J Minim Access Surg 2013; 7:201-4. [PMID: 22022108 PMCID: PMC3193689 DOI: 10.4103/0972-9941.85642] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 01/05/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND: Obturator hernias (OH) account for a rare presentation to the surgical unit usually associated with bowel obstruction and strangulation. The treatment of this condition is classical laparotomy with repair of the hernia and bowel resection, if deemed necessary; recently, the laparoscopic approach has been reported in literature. This review examines the existing evidence of the safety and effectiveness of the laparoscopic approach for the management of OH. MATERIALS AND METHODS: We have conducted a systematic review of the cases reported in the literature between 1991 and 2009, using Medline with PubMed as the search engine, as well as Ovid, Embase, Cochrane Collaboration and Google Scholar databases to identify articles in English language reporting on laparoscopic management for the treatment of this condition. RESULTS: A total of 17 articles reporting on 28 cases were found. We describe the pooled data for demographics, operative time, hospital stay, morbidities and method of repair. We also compare to the results of the laparoscopic repair of other types of hernias in the literature. CONCLUSION: This approach was found to be a safe and effective approach for the repair of OH as compared to the classical open approach; however, its adoption as the gold standard needs further multicenter trials.
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Affiliation(s)
- Samer Deeba
- Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Praed Street, W2 1NY, UK
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Agresta F, Ansaloni L, Baiocchi GL, Bergamini C, Campanile FC, Carlucci M, Cocorullo G, Corradi A, Franzato B, Lupo M, Mandalà V, Mirabella A, Pernazza G, Piccoli M, Staudacher C, Vettoretto N, Zago M, Lettieri E, Levati A, Pietrini D, Scaglione M, De Masi S, De Placido G, Francucci M, Rasi M, Fingerhut A, Uranüs S, Garattini S. Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES). Surg Endosc 2012; 26:2134-64. [PMID: 22736283 DOI: 10.1007/s00464-012-2331-3] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 04/16/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases. METHODS Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011. RESULTS A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer). CONCLUSIONS Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.
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Affiliation(s)
- Ferdinando Agresta
- Department of General Surgery, Presidio Ospedaliero di Adria, Piazza degli Etruschi, 9, 45011 Adria, RO, Italy.
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Abstract
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.
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Affiliation(s)
- M Tasleem Mandarry
- Department of General Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
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Nasir BS, Zendejas B, Ali SM, Groenewald CB, Heller SF, Farley DR. Obturator hernia: the Mayo Clinic experience. Hernia. 2012;16:315-319. [PMID: 22138700 DOI: 10.1007/s10029-011-0895-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Accepted: 11/13/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Obturator herniae (OH) are rare, with nonspecific signs and symptoms, and diagnosis is usually delayed until laparotomy. The added benefit of preoperative diagnosis with computed tomography (CT) remains unclear. METHODS We reviewed the clinical characteristics and outcomes of OH repairs performed at our institution over a 58-year period. Outcomes were compared between patients who did or did not have a preoperative CT. RESULTS Between 1950 and 2008, 30 patients (median age 82 years, 29 women) underwent OH repair. The most common presenting signs and symptoms were bowel obstruction (63%), abdominal/groin pain (57%), and a palpable lump (10%). The pathognomonic Howship-Romberg sign was present in 11 patients (37%). The diagnosis was made preoperatively in nine patients: clinically in one (3%) and with CT in eight (27%). Nineteen patients (63%) presented emergently. Primary and prosthetic repair were performed in 23 (77%) and seven (23%) patients, respectively. Small-bowel resection was performed in 14 patients (47%). Perioperative morbidity (30%) and mortality (10%) rates were high. Patients with a preoperative CT were less likely to develop a postoperative complication of any type [odds ratio (OR) 0.8, P = 0.04]; however, time to operation, length of stay, need for bowel resection, and mortality rate did not differ (P = NS). No recurrences were detected at a median follow-up of 2 years (range 0-55). CONCLUSION Although CT imaging provides an excellent means of preoperative diagnosis, suggestive signs and symptoms in a "skinny old lady" should prompt immediate operative intervention without delay.
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Abstract
INTRODUCTION Obturator hernia (OH) is a rare condition and difficult to diagnose. While they account for as few as 0.073% of all hernias, mortality can be as high as 70%. The typical clinical presentation for OH is small bowel obstruction. Computed tomography is the diagnostic tool of choice. Surgical repair is mandatory in virtually all cases of OH and traditionally consists of performing an exploratory laparotomy. PRESENTATION OF CASE A 90-year-old female was admitted to our surgical service with signs of small bowel obstruction and a CT scan revealing incarcerated fatty tissue and small bowel within a left OH. DISCUSSION The role of laparoscopic surgery in the management of OH has been limited to elective repairs; most reports detail that the OH was found serendipitously during laparoscopic inguinal hernia operations or other pelvic procedures. A few reports describe the use of laparoscopy to treat OH associated with bowel obstruction in an emergency setting using a TAPP approach. A strict TEP hernia repair is not indicated for all patients with OH, and should rarely be performed in emergency situations given its limitation to assess or resect bowel if necessary. In selected cases, a formal exploratory laparoscopy that is negative for compromised bowel can be safely followed by a TEP repair using the same umbilical access as shown in our patient. CONCLUSION A 90-year-old female with a small bowel obstruction related to an incarcerated OH was treated effectively with an extraperitoneal laparoscopic approach.
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Affiliation(s)
- Marco Maricevich
- Department of Surgery, Mayo Clinic, 200 First Street, S.W., Rochester, MN 55905, United States
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Abstract
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.
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