Obturator hernia presenting as small bowel obstruction

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.

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 (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.

The Feasibility and Potential Advantages of Laparoscopic Management of Incarcerated Obturator Hernia Over the Open Approach

PURPOSE

The purpose of this study was to explore the feasibility and potential advantages of laparoscopic surgery in the treatment of incarcerated obturator hernia (IOH).

MATERIALS AND METHODS

Clinical data of 23 patients with IOH who underwent emergency surgery at our hospital from June 2015 to October 2020 were retrospectively analyzed. The clinical characteristics and surgery outcomes were compared between the laparoscopic group, open group, and the previously published data.

RESULTS

Twelve patients with IOH were treated by laparoscopic management, while 11 patients with IOH underwent open surgery. There was no statistically significant difference in preoperative general data between the 2 groups, while the laparoscopic group had less intraoperative blood loss, shorter postoperative hospital stay, and lower postoperative complications compared with open group. Furthermore, when compared with the open group reported in previous literature, which showed similar conclusions.

CONCLUSION

Laparoscopic surgery for IOH showed more favorable advantages including less intraoperative blood loss, shorter postoperative hospital stay, and lower postoperative complications compared with an open approach, which is a safe and feasible minimally invasive strategy and has certain advantages.

Prediction of bowel obstruction caused by obturator hernia using risk factor categories on clinical characteristics and multidetector computed tomographic findings

PURPOSE

To detect risk factors on clinical characteristics and multidetector computed tomographic (MDCT) findings for predicting bowel obstruction in patients with obturator hernia.

METHODS

We retrospectively reviewed 47 patients who had an obturator hernia diagnosed by MDCT and/or surgery. The patients were divided into obstruction and non-obstruction group based on the presence or absence of bowel obstruction on MDCT images. Uni- and multivariate analyses were performed to identify risk factors for predicting bowel obstruction.

RESULTS

There were 26 patients (55.32%) in the obstruction group and 21 patients (44.68%) in the non-obstruction group. Patients in the obstruction group were older (P = 0.002) and had more women (P = 0.033) and lower body mass index (BMI) (P = 0.0001) than patients in the non-obstruction group. The non-obstruction group suffered fewer bowel obstruction symptoms (P = 0.0001), Howship-Romberg (HR) sign (P = 0.012), deaths (P = 0.008) and major postoperative complications (P = 0.047). The hernia sac in the obstruction group had greater mean major diameter (P = 0.0001) and volume (P = 0.001) than those in the non-obstruction group. Multivariate analysis showed that age [odds ratio (OR) 1.18, 95% confidence interval (CI) 1.00-1.39, P = 0.046] and major diameter of hernia sac (OR 68.17, 95% CI 4.52-1027.70, P = 0.002) were independent risk factors associated with bowel obstruction in patients with obturator hernia.

CONCLUSIONS

Patient's age and major diameter of hernia sac are independent risk factors resulting in bowel obstruction in patients with obturator hernia. Obturator hernia repair before bowel obstruction development may result in better outcomes and fewer postoperative complications.

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.

Obturator hernia: a case report

Background

Obturator hernia is rare and accounts for less than 1% of all abdominal wall hernias. It represents a diagnostic challenge due to its nonspecific signs and symptoms.

Case presentation

We present a case of an 89-year-old caucasian female with a 12-hour history of right medial thigh pain. Computed tomography scan revealed a right obturator hernia with small bowel obstruction. The hernia was successfully repaired laparoscopically without any need for small bowel resection. She was discharged on postoperative day 2 with an uneventful recovery and zero complications.

Conclusion

This case report highlights the importance of rapid diagnosis and repair of obturator hernia even in the setting of an improving clinical picture. It also demonstrates the safety of laparoscopic repair in this setting.

Obturator hernias: a systematic review of the literature

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.

An Unusual Case of Obturator Hernia Detected in an Elderly Man by Computed Tomography

Obturator hernia is a rare condition, characterized by the herniation of an intestinal segment between the obturator and the pectineus muscles through the obturator foramen. Obturator hernias usually occur in the elderly and are less common in males than in females, with a male-to-female ratio of about 1/14. In recent years, the use of diagnostic imaging, especially CT, to determine the causes of intestinal obstruction has been improved to allow for an early and accurate diagnosis, even of obturator hernias, which are extremely rare in male patients. We report a thin elderly man, without a history of surgery and with chronic constipation and an unremarkable Howship-Romberg sign, which was correctly diagnosed before surgery as an obturator hernia using CT.

Which Patients Are a Better Candidate of Laparoscopic Repair in Obturator Hernia Patients?

PURPOSE

Obturator hernia is a difficult disease to diagnose. If a surgical treatment is delayed in obturator hernia, a bowel resection may be required due to strangulation. The surgical treatment of this disease is to use a classical laparotomy. Recently, the laparoscopic approach has been reported and reviewed for efficiency. We checked the indicators that determine the most appropriate surgical method according to the patient's condition.

METHODS

In the study, a single-institution, retrospective analysis of surgical patients undergoing an obturator hernia surgery between 2003 and 2018 was performed. The patients were divided into a laparoscopic group (5 patients underwent laparoscopic repair; no intestinal resection) and an open group (13 patients who underwent open repair; 10 with and 3 without intestinal resection). The outcomes were compared between the groups. We analyzed the relevant factors that could predict the proper method of surgery.

RESULTS

A total 18 patients were included in the study. All patients were female, with body mass index (BMI) of under 21 kg/m². Of the various factors, only the WBC and CRP counts were the factors that had shown significant differences between the two groups. It is noted that patients with open surgery had a higher WBC counts (10406 versus 6520/μl; p=0.011) and CRP counts (7.84 vs. 0.32 mg/dl; p=0.027).

CONCLUSION

Obturator hernia can be treated with a laparoscopic surgery. The choice of surgical treatment can be considered in advance through the review of the patient's WBC count or CRP count.

Laparoscopic assisted repair of strangulated obturator hernia-Way to go

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Heightened awareness and understanding of Obturator Hernias is important.

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Delays in diagnosis and treatment increase Morbidity and Mortality.

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Laparoscopic techniques of repair are met with increasing success in both elective and an emergency setting.

Introduction

Obturator hernias are a rare subtype of intra-abdominal hernias that present with considerable challenges in both diagnosis and surgical repair. Delays in diagnosis and management significantly increases the Morbidity and Mortality.

Presentation of case

An elderly 70-year-old female presented with Lower abdominal pain radiating to the medial side of the left leg over a year that has become persistent and continuous over the 3 day period. Patient was found to have a Richter's type of strangulated obturator hernia on diagnostic laparoscopy. A laparoscopic assisted resection of the strangulated small bowel and repair of the Hernia was performed. Postoperatively patient had an uneventful recovery.

Discussion

Surgical treatment is the standard of care for an obturator Hernia. Increasing number of laparoscopic repairs are being performed in the recent past. Minilaparotomy greatly facilitates the resection and anastomosis of a dead bowel without jeopardizing cosmesis and mesh placement at the time of repair.

Conclusion

Heightened awareness of the condition combined with our proposition of a Hybrid repair achieves optimal results in an emergency setting. A Laparoscopic assisted repair of a strangulated hernia provides a durable repair and at the same time offers the patient benefits of minimally invasive surgery.

Case report: Laparoscopic totally extraperitoneal repair of an obturator hernia with self-gripping mesh under spinal anaesthesia

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Laparoscopic repair of obturator hernia with self-gripping mesh can adopted to reduce the morbidity of open repairs.

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It is safe to perform laparoscopic TEP repairs under spinal anesthesia.

Introduction

Obturator hernias account for less than 0.073% of all hernias and less than 1.6% of all cases of mechanical bowel obstructions.

Presentation of Case

We present a case of a 79 year-old elderly female with two recurrent bowel obstructions that have resolved with conservative management. On the third presentation we performed a totally extraperitoneal repair (TEP) with conscious sedation and a L3/4 spinal block. An obturator defect was patched with a self gripping mesh (progrip). The patient was discharged day 2 post operatively.

Discussion

Laparoscopic surgery can be safely performed in high risk patients with careful monitoring. Laparoscopic surgery is usually associated with a shorter post-operative length of stay.

Conclusion

This case demonstrates the successful but unconventional repair of an obturator hernia in a patient who had a high risk of significant morbidity and mortality with a more conventional anaesthesia and surgery.

Rare Case of Peritonitis due to Ileal Perforation Secondary to Richter's Type of Obturator Hernia

Obturator hernia is an extremely rare condition accounting for almost 0.07%-1% of all abdominal wall hernias, usually occurring in the elderly and emaciated females with a history of previous abdominal surgery. The symptoms of this particular hernia are non-specific; therefore, a high index of clinical suspicion should always be made. This rare condition may lead to acute small intestinal obstruction. The pre-operative diagnosis is challenging and often misleading on occasions, especially in co-morbid cases. This leads to delayed diagnosis and surgical intervention, hence causing an increased morbidity and mortality rate. The computed tomography (CT) scan of the abdomen and pelvis is the gold standard for diagnosis. We present a case of an 80-year-old female, with known comorbid of hypertension, initially diagnosed as peritonitis and on further examination revealed strangulated obturator hernia with proximal perforation, that underwent lower midline laparotomy with resection of necrotic bowel, an end-to-end anastomosis, and repair of the defect by vicryl suture.

Effective Treatment for Incarcerated Obturator Hernia With Bowel Dilatation by Combined Laparoscopy and Preperitoneal Approach: A Case Report

Background:

We report a case of a 90-year-old woman with intestinal obstruction due to left-sided incarcerated obturator hernia, which was revealed using computed tomography.

Methods:

Emergency surgerywas performed using laparoscopy, which showed a dilated small intestine and bilateral obturator hernia in the intraperitoneal space. After reducing incarceration of the small intestine using laparoscopy, we approached the bilateral preperitoneal space and inserted a Kugel patch via a small lower abdominal median incision (approximately 4 cm).

Results:

The patient was discharged on postoperative day 10 and showed no recurrence at the 18-month follow-up. Although relatively rare, obturator hernia can significantly cause intestinal obstruction. It has no specific clinical symptoms and is thus often difficult to diagnose. Treating obturator hernia is essential; however, mesh infection, recurrence, and opposite side of the obturator hernia should be carefully monitored.

Conclusions:

Although laparoscopy is used for treating obturator hernia, it may be difficult in patients with intestinal obstruction. In this case, a surgical technique combining laparoscopy and preperitoneal space approach via a small lower abdominal median incision was used to effectively treat an incarcerated occult bilateral obturator hernia.

Obturator Hernia in Elderly Female Patients

Obturator hernia (OH) constitutes 0.07% to 0.4% of all intraabdominal hernias and 0.2% to 5.8% of small intestinal hernias. OH is usually seen in elderly, multiparous females and patients with a low body weight. This multicenter study includes patients who were treated in Adnan Menderes University Medical Faculty Hospital, Bozyaka Education and Research Hospital and İnönü University Medical Faculty Hospital between January 2010 and June 2015. The diagnosis of OH was made preoperatively or perioperatively in patients who underwent emergency laparotomy for the treatment of ileus. A total of 14 patients were included in this study; 3 patients were treated by laparoscopic method (transabdominal approach) under general anesthesia and 2 of these patients (66.6%) died after the surgery. A total of 7 patients were treated by laparotomy. The remaining 4 patients were treated with a minimally invasive approach by using an epidural block without general anesthesia (3 patients with Pfannenstiel and 1 patient with a median inferior incision). The overall mortality rate was 42.8%. Anesthesia and surgery types have an important effect on mortality in elderly OH patients with multiple comorbidities. Minimally invasive approach with the use of epidural anesthesia can reduce the mortality rates in patients with OH. Abdominal computed tomography is the golden standard in the diagnosis of OH.

Is the Laparoscopic Approach Feasible for Reduction and Herniorrhaphy in Cases of Acutely Incarcerated/Strangulated Groin and Obturator Hernia?: 17-Year Experience from Open to Laparoscopic Approach

Purpose: Management strategies for acutely incarcerated/strangulated groin and obturator hernias may differ from institution to institution, although, conventionally, the open approach has been used. Recently, laparoscopic transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair have become commonly used operative procedures for the repair of groin hernias. It is unclear whether laparoscopic reduction and herniorrhaphy can be successfully accomplished in all cases. This study was aimed at assessing the effectiveness of laparoscopic treatment. Methods: We conducted a prospective clinical trial of the laparoscopic approach from December 2011 and comparatively analyzed the surgical outcomes between the open and laparoscopic approaches for incarcerated/strangulated hernias seen from December 2000 to March 2017. Results: The open approach for repair was used in 54 patients (50.9%) and the laparoscopic approach in 52 patients (49.1%). There was 1 case in which from the laparoscopic approach to laparotomy (1.9%) was required. The operation time treated by the laparoscopic approach was significantly longer than the open approach (126.4 minutes versus 104.6 minutes; P = .0079); however, the incidence of postoperative complications and the postoperative length of hospitalization were also less in the former group than in the latter group (3.9% versus 18.5%; P = .0172 and 5.6 days versus 14.7 days; P = .0096). Second-stage TAPP herniorrhaphy was performed in 7 patients (15.2%) after bowel resection or closure of bowel perforation, and first-stage TEP herniorrhaphy was performed in 1 patient after bowel resection. There was no case of mesh infection in the group treated by the laparoscopic approach, and there was 1 case of mesh infection in the group treated by the open approach. The mortality rate was 0% in the group treated by the laparoscopic approach. Conclusions: Laparoscopic reduction and herniorrhaphy for acutely incarcerated/strangulated groin and obturator hernias is effective, safe, and feasible.

Obturator hernia as a frequent finding during laparoscopic pelvic exploration: A retrospective observational study

Hernia through the obturator canal is usually unsuspected and hence undiagnosed. Patients with obturator hernias present as acute cases of intestinal obstruction secondary to strangulation or incarceration, with high rate of morbidity and mortality due to delayed diagnosis and treatment. The know incidence of obturator hernia is low, representing 0.073% (11 of 15,098) of all hernias repaired at the Mayo Clinic in a retrospective study of 15 years. In this study, we conducted a retrospective analysis of laparoscopic extraperitoneal hernia repairs that were performed between the years 2003 and 2007. All procedures were undertaken by 2 experienced surgeons who performed more than 150 previous surgeries. In 293 patients who underwent repair of bilateral or recurrent inguinal hernia, exploration of the obturator foramen was conducted looking for obturator hernia, which was found in 20 cases (6.82% of patients). The true incidence of obturator hernia is greater than that reported in the literature, and the chances of detecting hernia are greater if an equal number of men and women are scanned could be higher if pelvic scanning was performed.

Difficult diagnosis: strangulated obturator hernia in an 88-year-old woman

The obturator hernia is a rare type of hernia that can present a diagnostic challenge for the clinician. We report a case of an 88-year-old woman who presented with a history of right iliac fossa pain, bilious vomiting and diarrhoea. Non-specific findings on examination and blood tests made the diagnosis difficult, however, a CT scan of her abdomen revealed the site of the obstruction and the patient was taken to theatre for emergency surgery. We review the literature with focus on the diagnosis of obturator hernias and the different surgical approaches used. The authors believe that this case is of educational value to healthcare professionals, particularly those working in general practice, emergency departments and on surgical teams. It highlights to doctors that patients with incarcerated obturator hernias can present with or without overt signs of intestinal obstruction and emphasises the fact that an obturator hernia can be an important cause of intestinal obstruction in a thin, elderly woman.

The feasibility of laparoscopic management of incarcerated obturator hernia

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.

Endoscopic TEP inguinal hernia repair in the management of occult obturator and femoral hernias

PURPOSE

The gold standard technique for the repair of groin hernias has always been a controversial issue. Richard Ger introduced the endoscopic approach for the repair of groin hernias in 1991.The endoscopic technique follows the basic principle of preperitoneal placement of a polypropylene mesh over the myopectineal orifice. During the course of dissection of the preperitoneal space, occult obturator and femoral hernias were discovered.

METHODS

Patients who underwent endoscopic totally extraperitoneal repair of inguinal hernias over a period of 2 years were included in this retrospective study.

RESULTS

A total of 305 cases of groin hernias were operated in 208 patients over a period of 2 years from January 2010 to January 2012 in a single institution. Eleven synchronous clinically occult obturator hernias were found in 8 patients (3.84%) and 5 synchronous clinically occult femoral hernias were found in 5 patients (2.40%) during repair.

CONCLUSIONS

Preoperative and perioperative findings were discordant in quite a few cases. Preperitoneal dissection discovered coincidental occult hernias in 6.25% of patients.

Laparoscopic reduction and repair for incarcerated obturator hernia: comparison with open surgery

PURPOSE

Transabdominal preperitoneal (TAPP) repair for obturator hernia (OH) is not well established. Therefore, we evaluated the efficacy of TAPP for OH repair compared with open surgery.

METHODS

We retrospectively analyzed patients who underwent surgery for OH at our hospital between 2006 and 2011. Since 2009, we have used TAPP repair for OH instead of open surgery. The clinical results of TAPP repair were compared with those of open surgery performed before 2008.

RESULTS

Six patients with OH were treated by TAPP repair; occult contralateral OH was found by laparoscopic exploration in three (50 %) patients and was simultaneously repaired. Bowel incarceration was reduced by water pressure through Nelaton catheter in all but one patient. Bowel resection was performed in two patients after the laparoscopic assessment. For incarcerated OH, five of six cases were repaired using synthetic mesh, and the remaining case was addressed with simple peritoneal closure. Before 2008, six patients with OH underwent open surgery. The background of patients was comparable in the TAPP group and the open surgery group. There were no deaths in either group, but one metachronous contralateral OH occurred in the open surgery group within a short time frame, whereas none occurred in the TAPP group.

CONCLUSIONS

TAPP repair, including the inspection of the viability of the incarcerated intestine and protective reduction and assessment of the entire groin area is an effective and minimally invasive strategy for OH patients.

Incarcerated obturator hernia-laparoscopic repair with intraoperative view of the corona mortis

Obturator hernias are a rare form of abdominal wall hernias. We present a case of a patient with an obturator hernia diagnosed by the classical signs of lower abdominal pain, a positive Howship–Romberg sign (painful internal rotation of the hip) and a computed tomography scan showing a herniated loop of small bowel. During the emergency laparoscopic hernia repair (transabdominal preperitoneal approach) a variant vessel, the corona mortis, was detected.

Obturator hernia: a rare case of acute mechanical intestinal obstruction

Obturator hernia is a rare type of pelvic hernia which generally occurs in elderly patients with accompanying diseases. Because it is difficult to diagnose before surgery, the morbidity and mortality rates for obturator hernia are high. The most common symptom is strangulation combined with mechanical intestinal obstruction.

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.

Fifteen-year experience in managing obturator hernia: from open to laparoscopic approach

PURPOSE

Obturator hernia is a rare disease and preoperative diagnosis is always difficult. There are increasing reports employing laparoscopic approach in the recent literature. Our aim was to review and compare the open and laparoscopic approach in repairing obturator hernia.

METHODS

All patients with obturator hernia from 1997 to 2011 were recruited. Patient's demographics, presentation, operative details, morbidity, and mortality were retrospectively collected and reviewed.

RESULTS

There were 36 patients during the 15-year period. All of them were elderly ladies (median 83). Nineteen underwent open surgery while 16 received laparoscopic surgery. Both age and ASA were comparable. The median operative time was 68 and 65 min for laparoscopic and open group, respectively (p = 0.690). The median hospital stay was significantly longer in the open group (19 vs 5 days, p = 0.007). There were less major complications (p = 0.004) and mortality (p = 0.049) in the laparoscopic group. Two recurrences were reported in the laparoscopic group, although statistically not significant (p = 0.202).

CONCLUSIONS

Laparoscopic repair can achieve a shorter hospital stay and has lesser major complications and mortality in selected patients.

Obturator hernia: the relationship between anatomical classification and the Howship-Romberg sign

BACKGROUND

The obturator hernia sac may follow the anterior or posterior branch of the obturator nerve, and thus, it can be classified anatomically. The relationship between the symptoms and the anatomical classification of obturator hernia has not yet been clearly described in the literature.

METHODS

Multidetector-row computed tomography (MDCT) examinations of 35 consecutive cases of new-onset obturator hernia admitted from March 2005 to April 2012 were reviewed retrospectively. Obturator hernia was classified anatomically using MDCT. Patient characteristics and clinical presentations were compared among the anatomical classifications.

RESULTS

Fifteen cases were classified as type I (anterior branch type) and 20 cases as type II (posterior branch type). There were no significant differences regarding time from onset of symptoms to diagnosis, presence of small bowel obstruction, and need for bowel resection. The Howship-Romberg sign was seen in 6 cases (30 %) of type II and 10 cases (67 %) of type I (p = 0.044).

CONCLUSIONS

The Howship-Romberg sign was present significantly more often with the anterior than the posterior branch type of obturator hernia.

Obturator hernia presenting as hip pain: a case report

We report an 86-year-old women with an obturator hernia presenting with recurrent right hip pain. Obturator hernia is a diagnostic challenge because the hernial mass is usually concealed beneath the pectineus. It should be suspected in emaciated, multiparous, elderly women presenting with unexplained pain in the groin, hip, thigh, or knee. High levels of clinical suspicion of the high-risk patients and recourse to investigation by computed tomography are important, as delay in diagnosis and treatment is associated with increased morbidity and mortality.

Transabdominal preperitoneal repair for obturator hernia

BACKGROUND

A laparoscopic surgical approach for obturator hernia (OH) repair is uncommon. The aim of the present study was to assess the effectiveness of laparoscopic transabdominal preperitoneal (TAPP) repair for OH.

METHODS

From 2001 to May 2010, 659 patients with inguinal hernia underwent TAPP repair at in our institutes. Among these, the eight patients with OH were the subjects of this study.

RESULTS

Three of the eight patients were diagnosed as having occult OH, and the other five were diagnosed preoperatively, by ultrasonography and/or computed tomography, as having strangulated OH. Bilateral OH was found in five patients (63%), and combined groin hernias, either unilaterally or bilaterally, were observed in seven patients (88%), all of whom had femoral hernia. Of the five patients with bowel obstruction at presentation, four were determined not to require resection after assessment of the intestinal viability by laparoscopy. There was one case of conversion to a two-stage hernia repair performed to avoid mesh contamination: addition of mini-laparotomy, followed by extraction of the gangrenous intestine for resection and anastomosis with simple peritoneal closure of the hernia defect in the first stage, and a Kugel hernia repair in the second stage. There was no incidence of postoperative morbidity, mortality, or recurrence.

CONCLUSIONS

Because TAPP allows assessment of not only the entire groin area bilaterally but also simultaneous assessment of the viability of the incarcerated intestine with a minimum abdominal wall defect, we believe that it is an adequate approach to the treatment of both occult and acutely incarcerated OH. Two-stage hernia repair is technically feasible in patients requiring resection of the incarcerated intestine.

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 Revisited: Surgical Anatomy, Embryology, Diagnosis, and Technique of Repair

Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator canal. The first case was published by de Ronsil in 1724. Obturator hernia is more common in older malnourished women due to loss of supporting connective tissue and the wider female pelvis. The hernia sac usually contains small bowel, especially ileum. It may follow the anterior or posterior division of the obturator nerve. In most cases, obturator hernia presents with intestinal obstruction of unknown cause. It may present with obturator neuralgia, as a palpable mass or, in cases of bowel necrosis, as ecchymosis of the thigh. A correct diagnosis is made in 20 to 30 per cent of cases. CT scan is considered the gold standard for diagnosis, whereas ultrasonography, contrast studies, herniography and plain films are less specific. Surgery is the only treatment option for obturator hernia. Hesitancy to intervene surgically for chronically ill patients results in high mortality. Transabdominal approach is indicated in cases of complete bowel obstruction or suspected peritonitis. The extra-abdominal approach is used in preoperatively diagnosed cases and in absence of bowel strangulation. The laparoscopic approach is minimally invasive and effectively reduces morbidity. The defect is closed using sutures, tissue flaps, or prosthetic mesh.

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.

Current management of small bowel obstruction

SBO is a common disease with multiple causes. The most significant advances over the past several years have involved, first, decision-making techniques to promptly and accurately identify patients who will require exploration, and, second, the increasing use of laparoscopic techniques. "Complete" bowel obstruction is becoming an outdated term, as treatment algorithms use predictive models and oral contrast challenges to select patients for operation without recourse to the notion of "complete obstruction." Laparoscopic techniques are gaining acceptance as a primary modality in the treatment of SBO. Appropriate patient selection is necessary for success, but successful laparoscopic SBO management can reduce postoperative pain, minimize hospital stay, and may lead to fewer adhesions, possibly preventing further adhesive SBO. Strangulation obstruction is the major cause of morbidity and mortality in SBO. Although unrecognized strangulation obstructions remain, their incidence is decreasing with the new protocols in development. Future efforts should focus on incorporating predictive models into management with the goal of eliminating unrecognized strangulation obstructions. Further refinement of the predictive models incorporating outcomes of oral contrast challenges and molecular biomarker data may allow surgeons to reach this goal. In addition, the benefit of the elimination of interpractitioner variability conferred by standardized protocols will in itself improve patient outcomes.

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.

Incarcerated obturator hernia: pitfalls in the application of ultrasound

Objective

To describe ultrasonographic appearance and diagnoses of incarcerated obturator hernia.

Methods

Three consecutive cases of incarcerated obturator hernia examined preoperatively with ultrasound were presented to show the pitfalls in the application of ultrasound for the recognition of the entity. Retrospectively reviewed, ultrasound directly demonstrated an incarcerated obturator hernia in all the cases.

Results

The herniated segment was delineated posterior to the pectineus muscle in the femoral triangle. However, the sonographer mistakenly interpreted it showed a femoral hernia in the first case. In the third case, the sonographer did not scan the femoral regions in the initial examination although he confirmed the evidence of small bowel obstruction. The evidence of an incarcerated obturator hernia was detected in the re-examination with ultrasound after it had been revealed by CT scan. Consequently, ultrasound was evaluated as applicable and useful for the recognition of incarcerated obturator hernia.

Conclusion

Ultrasound is an useful tool for detecting obturator hernia. However, adequate education and training for examiners are required to prevent false interpretation or overlooking of the entity.