Obturator hernias: a systematic review of the literature

Time to symptom onset and manual reduction outcomes as predictors of bowel viability in incarcerated obturator hernias

The current study aimed to identify the indications for manual reduction in incarcerated obturator hernias (OH). Further, whether time to symptom onset and manual reduction outcomes can be predictors of bowel viability and the need for bowel resection in incarcerated OH were examined. This retrospective study included 26 patients with incarcerated OH who underwent surgery. All patients underwent manual reduction, and computed tomography scan after manual reduction confirmed hernia release. Multivariate analyses were performed to determine the predictors of bowel resection. The bowel resection group had a significantly longer average time to symptom onset than the nonbowel resection group (88 vs 36 h). Further, the bowel resection group was more likely to have failed manual reduction than the nonbowel resection group. A time to symptom onset of ≥ 72 h and failed manual reduction were significant predictors of bowel viability. Age, sex, hernia localization, American Society of Anesthesiologists physical status score, and laboratory findings did not differ significantly between the bowel resection and nonbowel resection groups. Time to symptom onset and manual reduction outcomes are significant predictors of bowel viability in incarcerated OH. Patients with a time to symptom onset of ≥ 72 h and failed manual reduction require surgical evaluation due to a high risk of bowel nonviability. Therefore, a cautious approach is required in the management of OH, and further research on optimized treatment protocols should be conducted.

Obturator hernia: a persisting clinical diagnostic challenge - a case report

Introduction

The presentation of a strangulated obturator hernia is rare, with it accounting for less than 0.04% of all hernias. Delay in presentation and diagnosis results in complications like bowel ischemia, necrosis, perforation, and peritonitis, thereby increasing morbidity and mortality.

Case presentation

The authors report the case of an 85-year-old multiparous woman who presented with a 3-day history of abdominal pain and vomiting. Upon examination, she exhibited hypotension, altered sensorium, and a distended abdomen with visible peristalsis. An abdominal pelvic computed tomography scan confirmed the diagnosis of 'intestinal obstruction secondary to an incarcerated obturator hernia'. Subsequently, a lower midline laparotomy was performed, successfully reducing the bowel and repairing the hernial orifice. The patient was discharged on the fourth postoperative day, and there has been no hernia recurrence as of her 3-month follow-up.

Discussion

The presentation of a strangulated obturator hernia can be elusive. During clinical examination, both the Howship-Romberg sign and the Hannington-Kiffs sign tests may be negative. Laparoscopic obturator hernia repair has been shown to reduce hospital stay and morbidity. A midline laparotomy has the advantage of easy manual reduction, minimizing bowel trauma, accurately accessing the bowel, and facilitating bowel resection.

Conclusion

Obturator hernias constitute rare subtypes of abdominal hernias. They typically occur in older women, and patients often present with poor functional status and multiple comorbidities. The clinical diagnostic tests are uncertain, even in patients with a high index of suspicion. Timely diagnosis and appropriate surgical management are crucial for a favorable outcome.

Robotic transabdominal preperitoneal repair for bilateral obturator hernia: a video vignette

Obturator hernias (OHs) are a rare cause of bowel obstruction that requires immediate surgical intervention to prevent morbidity and mortality. Patients with OHs present with acute intestinal obstruction secondary to incarceration, with a high morbidity and mortality rate due to delayed diagnosis and treatment. Although several surgical approaches have been reported, a standard approach for OH treatment has not yet been established. Here, we report the case of a 74-year-old woman who presented with bilateral OHs. The patient presented at our institution with pain in the left lower quadrant. Computed tomography revealed preperitoneal fat in both obturator foramen. Robotic transabdominal preperitoneal (R-TAPP) bilateral OH repair was performed, and a mesh was placed over both obturator foramen. The patient recovered without postoperative complications and was discharged on postoperative day 2. This suggests that the R-TAPP approach is safe for OH repair without incarceration.

Incidentally found obturator hernias during totally extraperitoneal (TEP) inguinal hernia repair: a single-center experience

PURPOSE

This study aimed to determine the occurrence of incidental obturator hernia and clinical risk factors of their appearance in patients undergoing totally extraperitoneal (TEP) inguinal hernioplasty.

METHODS

Data were collected retrospectively from patients who underwent TEP inguinal hernioplasty between June 2020 and December 2022.

RESULTS

A total of 251 patients were included in the study. Obturator hernias were found in 21 patients (8.4%). At admission, no patient presented clinical signs of an obturator hernia. There was a significant predominance of women in the obturator hernia compared to the non-obturator hernia group (28.6% vs. 10.9%, respectively, p=0.018). There was no correlation between age (p=0.479) and BMI (p=0.771) and the occurrence of obturator hernia. Additional obturator hernia repair within the TEP inguinal hernioplasty procedure did not influence the overall length of the surgery (60.86 minutes) compared to the standard TEP inguinal hernioplasty (61.09 minutes, p=0.876).

CONCLUSIONS

The TEP inguinal hernioplasty allows the detection and repair of incidental obturator hernia. Through thorough inspection of the obturator canal, an asymptomatic obturator hernia can be detected and adequately treated within the same procedure, without the impact on the surgery duration, when performed by an experienced hernia surgeon.

Emergency transabdominal preperitoneal (TAPP) repair of a strangulated obturator hernia: A literature review and video vignette

Obturator hernia (OH), a rare and potentially life-threatening condition, presents diagnostic and therapeutic challenges. This review article comprehensively delves into the clinical features, diagnosis, and management of OH, with a particular emphasis on the pivotal role of computed tomography (CT) in timely and accurate diagnosis. Delays, particularly in contrast-enhanced CT, dramatically increase mortality due to potential bowel strangulation. To illustrate the challenges and complexities surrounding OH, we present a video vignette of a 74-year-old female patient who presented with symptoms suggestive of bowel obstruction (BO) secondary to a strangulated left-sided OH. This patient case complements the theoretical framework established in the review, serving as a practical example for healthcare professionals. Her presentation included abdominal pain, absence of flatus and bowel movements, and abdominal distension. Laboratory tests demonstrated a mildly elevated white blood cell count and C-reactive protein. CT imaging confirmed the diagnosis of a strangulated OH with an ischemic small bowel. An emergency laparoscopy was undertaken, and the hernia was repaired using the transabdominal preperitoneal approach. A portion of the ischemic small bowel was resected through a 5-cm extension of the umbilical port, and an anastomosis was performed using a modified Barcelona technique. The surgery was successfully completed without immediate or long-term complications. This case highlights the crucial role of timely CT diagnosis and minimally invasive surgical management in achieving improved outcomes in acute BO secondary to OH, particularly when facilitated by pre-operative CT planning.

Obturator Hernia in a Patient Undergoing Hemodialysis

Obturator hernia is a rare condition that commonly affects frail older women. A 54-year-old woman presented to our hospital with left hip joint pain. She had suffered a left pubic bone fracture and commenced maintenance hemodialysis. Pelvic computed tomography (CT) showed an incarcerated small intestine through the left obturator foramen, while abdominal CT showed marked intestinal dilatation. She underwent emergency laparotomy, and the incarcerated small intestine was found to be necrotic. Partial small intestinal resection and bilateral obturator hernioplasty were performed. Because obturator hernia is a potentially fatal condition, early detection and treatment are important.

Epidemiology and surgical management of 184 obturator hernias: a nationwide registry-based cohort study

PURPOSE

We aimed describe the patient characteristics, surgical details, postoperative outcomes, and prevalence and incidence of obturator hernias. Obturator hernias are rare with high mortality and no consensus on the best surgical approach. Given their rarity, substantial data is lacking, especially related to postoperative outcomes.

METHODS

The study was based on data from the nationwide Danish Hernia Database. All adults who underwent obturator hernia surgery in Denmark during 1998-2023 were included. The primary outcomes were demographic characteristics, surgical details, postoperative outcomes, and the prevalence and incidence of obturator hernias.

RESULTS

We included 184 obturator hernias in 167 patients (88% females) with a median age of 77 years. Emergency surgeries constituted 42% of repairs, and 72% were laparoscopic. Mesh was used in 77% of the repairs, with sutures exclusively used in emergency repairs. Concurrent groin hernias were found in 57% of cases. Emergency surgeries had a 30-day mortality of 14%, readmission rate of 21%, and median length of stay of 6 days. Elective surgeries had a 30-day mortality of 0%, readmission rate of 10%, and median length of stay of 0 days. The prevalence of obturator hernias in hernia surgery was 0.084% (95% CI: 0.071%-0.098%), with an incidence of one per 400,000 inhabitants annually.

CONCLUSIONS

This was the largest cohort study to date on obturator hernias. They were rare, affected primarily elderly women. The method of repair depends on whether the presentation is acute, and emergency repair is associated with higher mortality.

Obturator hernia: An uncommon cause of intestinal obstruction: A case report

INTRODUCTION AND IMPORTANCE

An obturator hernia is a rare cause of bowel obstruction. Due to its narrow passage in the obturator canal, these are more susceptible to becoming incarcerated and subsequently strangulated. Due to its challenging detection, obturator hernia is often diagnosed late.

CASE PRESENTATION

A 75-year-old thin-built female with COPD presented to the emergency room with symptoms of abdominal obstruction. Abdominal examination revealed distension, firmness, rigidity, and tenderness with no bowel sounds. An erect abdominal X-ray showed multiple air-fluid levels, indicating an acute abdomen due to intestinal obstruction. Emergency exploratory laparotomy revealed an obturator hernia with strangulated ileum and perforation, necessitating resection and double barrel ileostomy. Unfortunately, despite all medical interventions, the patient succumbed to hospital-acquired pneumonia following the surgery.

DISCUSSION

Obturator hernia, known as 'the skinny old woman hernia,' is rarely externally visible or palpable, leading to frequent undiagnosed cases. It presents with bowel obstruction or perforation and carries the highest morbidity among abdominal hernias. Timely intervention is crucial to prevent complications like bowel strangulation.

CONCLUSION

This case report highlights the challenges of diagnosing and managing obturator hernia, a rare condition with significant morbidity. Early detection through imaging or operative findings is crucial to prevent complications like bowel strangulation, especially in older women at higher risk.

Concurrent strangulated obturator hernia and femoral hernia repair via TAPP approach: A case report

An obturator hernia is a rare pelvic hernia with high mortality. Early diagnosis and treatment are essential to reduce postoperative complications. The treatment of choice for obturator hernias is surgery. In an emergency, laparotomy to resolve herniated viscera and complications is often the choice. However, some researchers have shown the feasibility of laparoscopy. The laparoscopic approach has several benefits over the open approach, including reduced postoperative pain, early mobilization, shorter length of stay, and lower postoperative morbidity rates. We report the case of an 81-year-old woman with a right-side obstructed obturator hernia. The patient was hospitalized with an acute onset of inner thigh pain and bowel obstruction. The obturator hernia was diagnosed preoperatively by an abdominopelvic CT scan with the image of protrusion of an ileal loop in the right obturator foramen. The patient was treated by an emergency laparoscopy. The right obturator hernia and a concurrent right femoral hernia were confirmed during the operation. The hernia defect was repaired with a mesh large enough to cover all hernia foramen. The patient recovered without any complications. Emergency laparoscopic repair for obstructed obturator hernia was safe and effective.

Obturator Hernia in a 71-Year-Old Patient: A Diagnostic Challenge

An obturator hernia is a relatively rare form of pelvic hernia, wherein abdominal organs protrude through an opening in the pelvis known as the obturator foramen. The majority of patients with this condition present to the emergency room with symptoms of bowel obstruction. Due to the non-specific nature of these symptoms, making a preoperative diagnosis of obturator hernia can be challenging. Any delay in the diagnosis and treatment of this condition can lead to a significant risk of mortality. In this report, we present the case of a 71-year-old patient who presented to the emergency department complaining of lower abdominal pain and nausea. An abdominal X-ray revealed bowel dilation, and based on the patient's symptoms, a diagnosis of bowel obstruction was suspected. A CT scan of the abdomen and pelvis was performed to investigate the reason for bowel dilation, and the existence of an obturator hernia was confirmed.

Management and outcomes of obturator hernias: a systematic review and meta-analysis

PURPOSE

Obturator Hernia (OH) is a rare type of abdominal wall hernia. It usually occurs in elderly women with late symptomatic presentation, increasing mortality rates. Surgery is the standard of care for OH, and laparotomy with simple suture closure of the defect is commonly used. Given the rarity of this disease, large studies are lacking, and data to drive management are still limited. This systematic review and meta-analysis aimed to describe current surgical options for OHs, with a focus on comparing the effectiveness and safety of mesh use with primary repair.

METHODS

PubMed, EMBASE, and Cochrane were searched for studies comparing mesh and non-mesh repair for OH. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4.

RESULTS

One thousand seven hundred and sixty studies were screened and sixty-seven were thoroughly reviewed. We included 13 observational studies with 351 patients surgically treated for OH with mesh or non-mesh repair. One hundred and twenty (34.2%) patients underwent mesh repair and two hundred and thirty-one (65.81%) underwent non-mesh repair. A total of 145 (41.3%) underwent bowel resection, with the majority having a non-mesh repair performed. Hernia recurrence was significantly higher in patients who underwent hernia repair without mesh (RR 0.31; 95% CI 0.11-0.94; p = 0.04). There were no differences in mortality (RR 0.64; 95% CI 0.25-1.62; p = 0.34; I² = 0%) or complication rates (RR 0.59; 95% CI 0.28-1.25; p = 0.17; I² = 50%) between both groups.

CONCLUSION

Mesh repair in OH was associated with lower recurrence rates without an increase in postoperative complications. While mesh in clean cases is more likely to offer benefits, an overall recommendation regarding its use in OH repair cannot be made due to potential bias across studies. Given that many OH patients are frail and present emergently, the decision to use mesh is complex and should consider the patient's clinical status, comorbidities, and degree of intraoperative contamination.

Manual reduction for incarcerated obturator hernia

Emergent surgery is a common approach for incarcerated obturator hernias, with high morbidity and mortality rates. Moreover, there have been reports of elective surgery cases after noninvasive manual reduction. For a decade, the initial approach in our institution is also manual reduction unless bowel viability is poor. This study aimed to clarify the efficacy and safety of manual reduction followed by elective surgery. We retrospectively reviewed 50 cases of incarcerated obturator hernia from 2010 to 2022 at Iwate Prefectural Iwai Hospital. Manual reduction was attempted in 31 (62%) patients. The reduction was successful in 21 (42%) patients, and most of them received mesh repair using the extraperitoneal approach as elective surgery. However, two patients underwent emergent surgery in the waiting period because of late-onset constriction and a small bowel perforation. Patients with irreducible hernia underwent emergent surgery, except for two patients who received the best supportive care. Postoperative complications were observed in 5% and 22% of reducible and irreducible cases, respectively. Postoperative mortality was zero in both groups. Manual reduction is useful in some cases, but careful observation is needed because late-onset constriction and perforation could occur.

Laparoscopic repair of an obturator hernia; a case report of a contemporary surgical technique

INTRODUCTION AND IMPORTANCE

Small bowel obstruction secondary to an obturator hernia is a rare presentation associated with high mortality. Prior to the development of laparoscopic surgery, a laparotomy would have been the management technique of choice for this rare presentation.

CASE PRESENTATION

An elderly female with a bowel obstruction secondary to an obturator hernia presented via the Emergency Department. A laparoscopic approach with the use of a haemostatic gauze plug was performed to repair the defect.

CLINICAL DISCUSSION

The evolution of surgical techniques, particularly with laparoscopy has resulted in overall benefits regarding patient outcomes. These benefits include lower post operative morbidity, shorter length of stay and decreased post operative pain. This report discusses a laparoscopic approach and the use of a gauze plug to manage an emergent small bowel obstruction secondary to an obturator hernia.

CONCLUSION

The use of a haemostatic gauze agent is an alternate and potentially advantageous approach for an obturator hernia repair in the emergency setting.

Obturator hernia (the little old lady's hernia) diagnosed via computed tomography: a case report

Obturator hernia is an infrequent clinical entity of abdominal wall hernia, accounting for an incidence rate ranging from 0.073 to 2.2% of all hernias and being responsible for 0.2-1.6% of all cases of mechanical intestinal obstruction. The computed tomography (CT) scan, as an imaging modality, is critical in improving the diagnostic rate of obturator hernia.

Case presentation

The authors herein report an 87-year-old thin male patient with a known history of chronic obstructive pulmonary disease who presenting with complaints of abdominal pain for 3 days and constipation for 2 days, as well as one episode of vomiting without any features of peritoneal irritation, which was diagnosed early as a right-sided obturator hernia via CT and managed with exploratory laparotomy with hernia reduction and polypropylene mesh repair.

Discussion

Obturator hernia is a rare surgical phenomenon with a varied clinical spectrum, ranging from asymptomatic to presenting as intestinal obstruction. The CT scan plays a critical role in the detection of obturator hernias, which ameliorates the possible significant postoperative morbidity and mortality.

Conclusion

This report demonstrates that a high index of suspicion combined with CT imaging aids in early diagnosis and management, thus overcoming the reluctant morbidity.

Evaluation of 4-hand reduction for obturator hernia with the guidance of sonography as a new treatment strategy: A retrospective study

To evaluate the effectiveness of 4-hand reduction for obturator hernia with the guidance of sonography (FROGS) as a new treatment strategy for obturator hernia. Since November 2019, FROGS was performed for all patients with obturator hernia at our emergency department. We retrospectively compared the clinical data of 20 patients who underwent FROGS (after FROGS group) to those of 23 patients who did not (before FROGS group). All patients except one were female. The male-to-female ratio, age, duration of symptoms, lesion site, and predisposing factors did not significantly differ between groups. However, the diameter of the prolapsed bowel and the body mass index of the after FROGS group were significantly larger and lower, respectively. Manual reduction was successfully performed for all 20 patients in the after FROGS group, and bowel resection was avoided for all 20 cases. However, 14 patients in the before FROGS group underwent manual reduction; of these, only one was successfully treated using a method other than FROGS, and 8 patients underwent bowel resection. There were no significant differences between groups in terms of postprocedural complications or mortality within 30 days of hernia presentation. The FROGS technique was safe and reproducible and could be used as the first choice of treatment for patients with obturator hernia.

Laparoscopic transabdominal preperitoneal repair for recurrent obturator hernia initially treated by open mesh plug repair: A case report with video

An 80-year-old woman presented to our emergency department with vomiting which had begun half a day prior to presentation. She had undergone open mesh plug repair for a right obturator hernia 1 year prior to presentation. Computed tomography detected recurrence of the right obturator hernia. Since intestinal viability was maintained, manual reduction of the incarcerated intestine was performed. The patient was admitted to our department to monitor delayed intestinal perforation. Laparoscopic transabdominal preperitoneal repair for obturator hernia was performed 5 days after admission. A self-fixating mesh was placed over the obturator hernia defect and femoral ring without tacking. The patient was discharged on postoperative day 6 without postoperative complications. At the 4-month follow-up, no signs of hernia recurrence or neuropathy were observed. Laparoscopic transabdominal preperitoneal repair for recurrent obturator hernia status post-open mesh plug repair by using self-fixating mesh is a safe and suitable procedure.

Recurrent abdominal pain in an older woman: Enlarged OE‐P gap on computed tomography as an indicator of non‐strangulated obturator hernia

Obturator hernia (OH) is a relatively rare abdominal wall hernia with a high mortality rate. The diagnosis of OH is challenging because of symptomatic variations and spontaneous reduction in hernia on imaging. An 89‐year‐old woman presented to our emergency department with pain in the abdomen and right groin. Computed tomography (CT) revealed an incarcerated small bowel in the gap between the obturator externus and pectineus (OE‐P gap). Symptoms disappeared after manual reduction. She experienced these same symptoms intermittently during the past year and underwent abdominal CT 4 times after disappearance of symptoms. The CT scans at each previous visit showed an enlarged OE‐P gap (an average of 80 mm) compared with the asymptomatic side (an average of 34 mm). An enlarged OE‐P gap on CT images taken after disappearance of symptoms could be a sign of spontaneously reduced OH.

Early CT Ameliorates the Diagnostic Dilemma of "Little Old Lady's Hernia": A Case Report

Encountering an obturator hernia itself is a rare entity for practicing surgeons globally. Synonymously known as the "old lady's hernia" is usually seen in fragile geriatric multiparous female patients. We share our experience of this rare entity where the patient presented with features of small bowel obstruction. Her diagnosis was delayed in the previously attended other centre as the possibility of an obturator hernia was overlooked. A timely clinical examination of the patient complemented by a computed tomography scan of the abdomen and pelvis helped us to obtain a diagnosis and proceed with immediate surgery. Intraoperatively the rarity was present bilaterally although the obstruction was on one side only. Prompt diagnosis and treatment benefits patients in this potentially lethal condition.

Keywords

case report; computed tomography; obturator hernia; X-ray.

Two cases of obturator hernia in patients undergoing hemodialysis: case report and literature review

Background

Obturator hernia (OH) is an extremely rare abdominal wall hernia with risk factors including aging, female sex, emaciation, and increased abdominal pressure. Its symptoms are nonspecific, and diagnosis is often delayed; however, this delay can lead to a fatal course. Therefore, early diagnosis and surgical intervention are necessary to reduce the mortality rate associated with OH. Considering the risk factors for OH, patients currently undergoing hemodialysis (HD) may be particularly vulnerable to OH. Here, we report two cases of OH in patients undergoing HD along with a review of the relevant literature.

Case presentation

Case 1 included a 76-year-old female undergoing HD due to autosomal dominant polycystic kidney disease. She was hospitalized for upper abdominal pain, vomiting, and diarrhea. On the day of hospitalization, she was diagnosed with OH using computed tomography and underwent emergency surgery. Case 2 included a 90-year-old emaciated female who was admitted to our hospital for projectile vomiting while undergoing HD. She was diagnosed with OH and shock, but surgery was not performed due to shock. Nonetheless, her blood pressure gradually increased, and she completely recovered. Spontaneous reduction in OH was confirmed on the third day of hospitalization. Both patients recovered well.

Conclusions

The symptoms of OH are non-specific, and certain symptoms such as vomiting and anorexia are often overlooked because they are common in patients undergoing HD. It is important to include OH in the differential diagnosis of digestive organ symptoms in patients undergoing HD, especially in those with risk factors for OH, such as elderly female patients on HD due to autosomal dominant polycystic kidney disease.

Hernia obturatriz: Aspectos clínicos, imagenológicos y tratamiento

Introducción. Debido a la rareza de la hernia obturatriz y la imposibilidad para desarrollar estudios controlados de alto grado de evidencia, la mayoría de la literatura al respecto proviene de reportes de casos. Lo anterior, aunado al poco conocimiento del área anatómica de presentación y el cuadro clínico, la convierte en la hernia con mayor mortalidad. Métodos. Se realizó una búsqueda de la literatura en las principales bases de datos, ilustrado con pacientes manejados en el Servicio de Cirugía general de la Clínica Santa María de Sincelejo, Colombia. Discusión. La hernia obturatriz se puede descubrir en mujeres ancianas con antecedentes de cirugía abdominal o multiparidad. El signo de Howship–Romberg, que se presenta en la mitad de los pacientes, puede acompañarse de dolor abdominal en hipogastrio, vómitos y distensión progresiva. La radiografía de abdomen simple muestra tardíamente niveles hidroaéreos con ausencia de gas en ampolla rectal, pero como es poco específica para demostrar el sitio de obstrucción, es preferible la Tomografía computarizada. Conclusión. La hernia obturatriz requiere alto índice de sospecha, que ayude a la detección temprana e intervención quirúrgica inmediata, para evitar las complicaciones.

Obturator hernia: A case report of intestinal obstruction with challenging diagnosis and non-standardized treatment

Introduction and importance

Obturator Hernia (OH) is a rare clinical entity that constitue less than 1% of all abdominal hernias. It happens in elderly thin women malnourished. The diagnosis is usually delayed because symptoms are non-specific, and patients commonly have features of intestinal obstruction. There are no international guidelines for treatment and the best surgical approach still unknown.

Case presentation

We report a case of strangulated OH in a 75 year woman who consulted in our service for an acute intestinal obstruction. Intra-operatively findings showed loop of ileum entering through a defect in the right obturator canal. The obturator defect was closed by approximation flap of peritoneum and covered by right ovair and fallopian tube.

Clinical discussion

This case is reported because of its an uncommon type of abdominal wall hernia with high probability of bowel strangulation and highest morbidity and mortality rates. There are no international guidelines for treatment and the best surgical approach still unknown.

Conclusion

The diagnosis of OH should be suspected every time there is an intestinal obstruction of unknown origin in emaciated elderly women. Open or laparoscopic sutured repair surgery and placement of mesh remain the most common method of repair.

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Obturator Hernia is an uncommon type of abdominal wall hernia.

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It has the highest morbidity and mortality rates of all abdominal wall hernias.

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Emergency surgery is crucial for the treatment of strangulated obturator hernia.

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The ideal treatment and the best surgical approach still unknown.

Rare case of obturator hernia: Surgical anatomy, planning, and considerations

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.

Laparoscopic transabdominal preperitoneal obturator hernioplasty with self-gripping mesh: A case report with operative video

INTRODUCTION

We investigated the effectiveness of a self-gripping mesh, which has microgrips attached to fibrous tissue, in laparoscopic transabdominal preperitoneal (TAPP) obturator hernia (OH) repair to minimize the risk of postoperative pain and obturator nerve injury.

PRESENTATION OF CASE

The patient was an 80-year-old woman who was transferred to our emergency department with abdominal pain in the right lower quadrant and low back pain that began half a day prior to presentation. Computed tomography (CT) detected right OH. Based on the results of the laboratory examination and dynamic CT, intestinal viability was maintained. Ultrasonography-assisted manual reduction of the incarcerated intestine was performed, followed by admission to our department to check for delayed perforation of the intestine. Laparoscopic TAPP OH repair was performed on day seven as an elective surgery. A self-gripping mesh was placed over the OH defect and the femoral ring without tacking. The patient was discharged on postoperative day four, without any complications.

DISCUSSION

Tacking of the mesh at the lateral and dorsal sides of the obturator canal is dangerous due to the presence of the obturator nerve and vessels. Self-gripping mesh use in laparoscopic TAPP OH repair is a rational decision in terms of avoiding tacking or suturing around the obturator canal while maintaining stable fixation of the mesh to prevent recurrence.

CONCLUSION

Laparoscopic TAPP OH repair with self-gripping mesh is a rational treatment option that reduces the risk of obturator nerve injury while maintaining the secure fixation of a mesh to prevent recurrence.

Critical view of the myopectineal orifice: a scoring system to objectively evaluate transabdominal preperitoneal inguinal hernia repair

BACKGROUND

More than 20 million inguinal hernia repair (IHR) procedures are performed worldwide every year. The critical view of the myopectineal orifice (CV of the MPO) is a stepwise guide to the achievement and standardization of minimally invasive IHR (MI IHR). We propose a scoring system as an objective method for fulfillment of the CV of the MPO.

METHODS

The scoring system was employed for evaluation of the transabdominal preperitoneal (TAPP) technique in 15 video-recorded procedures. Two variants of the score were used: the simple CV of the MPO score (s-CVMPO score) and the extended CV of the MPO score (e-CVMPO score). The inter-rater agreement and internal consistency for both scores and the correlation between the two scores were assessed.

RESULTS

Inter-rater agreement with respect to satisfactory/unsatisfactory achievement of the CV of the MPO was high for both the s-CVMPO and e-CVMPO scores (κ = 1, p < 0.001). The Finn coefficient for inter-rater agreement was 0.97 for the s-CVMPO score and 0.99 for the e-CVMPO score (p < 0.001 for both). Both the s-CVMPO and e-CVMPO scores showed internal consistency with Cronbach's α of 0.89 and 0.87, respectively. The correlation coefficient between the two scores for the average score of each procedure was ρ = 0.96 (p < 0.001).

CONCLUSION

The CVMPO score is a reliable tool for expert evaluation of TAPP repair. Implementing the CVMPO score facilitates objective assessment of the safety and quality of the procedure.

CHALLENGES TO THE 10 GOLDEN RULES FOR A SAFE MINIMALLY INVASIVE SURGERY (MIS) INGUINAL HERNIA REPAIR: CAN WE IMPROVE?

Background:

Since publication of our paper “Ten Golden Rules for a Safe MIS Inguinal Hernia Repair” we have received many questions. As the authors, we feel it is important to address these topics as a follow-up to our paper.

Aim:

To discuss in more details the main points of controversy, review the rules and update de recommendations.

Method:

The questions and discussions came mainly over five rules, numbered 3, 5, 6, 7, 10. We analyzed all the comments about recommendations and update some technical principles.

Results:

Rule 3 - Removing normal fat plugs from the obturator canal is unnecessary and therefore is not recommended; Rule 5 - transection of the uterine round ligament (1 cm proximal to the deep ring) facilitates adequate dissection. When performed in this way it does not appear to be associated with complications; Rule 6 - transection of huge sacs are safer than over-dissection of the cord structures. Whether dissecting completely the sac or abandon the distal part it results in less postoperative seromas is an ongoing debate; Rule 7 - any retroperitoneal structure traversing the internal ring is or play a role like a hernia. Failing to identify and remove the lipoma will ultimately result in the patient experiencing a recurrence; Rule 10 - in TAPP peritoneum should preferably be closed with suture than tackes.

Conclusion:

10 Golden Rules emphasize the most important surgical tips and technical steps that allow the safe performance of MIS repairs of inguinal hernias, regardless the technique.

A delayed diagnosis of obturator hernia hoodwinked by previous laparoscopic inguinal hernia repair

Obturator hernia is a rare and diagnostically challenging type of pelvic hernia with associated high morbidity and mortality. It is frequently seen in frail, elderly female multiparous patients with non-specific symptoms and signs that may be clouded by multiple gastrointestinal or musculoskeletal comorbidities. This report discusses the case of an 84-year-old woman with refractory groin pain and previous laparoscopic inguinal hernia repair that was misdiagnosed leading to a delayed diagnosis and mortality. Previous laparoscopic repair was a misleading factor that hoodwinked clinicians and surgeons until computed tomography (CT) imaging proved otherwise. In emaciated, elderly female patients presenting with non-specific abdominal or hip pain, early CT imaging can assist in diagnosis when signs or symptoms are unclear. Clinical vigilance and serial examination are important in elderly patients who are often under the care of geriatricians allowing early discovery and treatment of this hernia.

Laparotomy with suture repair is the most common treatment for obturator hernia: a scoping review

BACKGROUND

Obturator hernias are rare and associated with high mortality. However, the optimal surgical approach remains unknown. We aimed to investigate the available evidence and examine the surgical details regarding obturator hernia defect closure as well as the recurrence rates of the different approaches.

METHODS

We reported this scoping review according to the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analysis Extension for Scoping Reviews) and registered the protocol online. A comprehensive literature search in five different databases was conducted. The population was patients undergoing surgery for obturator hernia. Articles were included for data charting if the management of the hernia defect was reported. Data regarding surgical details, and hernia recurrence were extracted.

RESULTS

A total of 1299 patients from 313 articles were included. In total, 937 patients underwent open obturator hernia repair, in which 992 hernias were repaired (including some bilateral obturator hernias). A total of 295 patients underwent laparoscopic repair for 341 obturator hernias, and for the remaining 67 patients, type of surgery was not reported. For open surgery, suture repair was the most common method of repair (n = 508, 51%) with a recurrence rate of 10%. For laparoscopic surgery, the most common repair of the defect was mesh repair (n = 299, 88%) with no reported recurrences.

CONCLUSION

Open surgery with primary suture repair is the most common method of repair for obturator hernia but is associated with a recurrence rate of 10%. Laparoscopic mesh repair is becoming more common and have seemingly very low recurrence rates and may be a better method of repair.

A decade review of emergency obturator hernia repairs

BACKGROUND

Obturator hernia is a rare pelvic hernia associated with a high morbidity and mortality. It most commonly occurs in elderly, multiparous females with symptoms and signs of small bowel obstruction. We present an Australian hospital network experience on emergency presentations of obturator hernias highlighting differences between clinical profile and surgical management.

METHODS

A retrospective review of adult patients diagnosed with acute obturator hernia during a 10 year period (2010-2020) was conducted across 10 major Sydney hospitals in New South Wales, Australia.

RESULTS

Obturator hernia was diagnosed in 18 patients (mean 82.7 years, range: 60-96 years old), all confirmed on pre-operative computed tomography imaging. The most common presentations were elderly women demonstrating clinical features of a small bowel obstruction. The mean onset of symptoms from home to hospital admission was 49.4 h. Non-survivors had a significantly elevated urea level (15.6 vs. 7.8 mmol/L, p = 0.036) at presentation and a longer delay from onset of presenting symptoms to diagnosis (84.0 vs. 36.2 h, p = 0.028). Eleven patients underwent urgent laparotomy and six laparoscopic repairs. The mean operative time was 101.0 min. The average hospital length of stay was 16.2 days with a mortality rate of 27.8%.

CONCLUSION

Timely diagnosis and operative intervention for obturator hernia is the cornerstone of management.