Obturator hernia: A case report and review of the literature

Case report: Incarcerated obturator hernia, initially presenting as right hip pain!

INTRODUCTION

An incarcerated Obturator herniation is a rare external abdominal hernia. Abdominal CT-scanning is the first choice for the diagnosis of such an incarcerated Obturator hernia. Since intestinal incarceration leads to acute necrosis. Therefore emergency surgical treatment is required. However, due to the lack of specificity of the clinical manifestations of incarcerated Obturator hernia, a delay in adequate diagnostics may be higher than expected.

PRESENTATION OF CASE

An 82 year woman was admitted to the hospital because of right hip joint pain. She was initially evaluated and admitted by orthopedics team for suspected arthritis. A CT-scan with contrast was ordered, which showed an intestinal ischemic obstruction in a right sided obturator hernia, an acute laparotomy was carried out.

DISCUSSION

This case is important and differs from the well-known similar cases through the emergency admission at the orthopedic department because of the clear right hip pain and clinical history from the patient. An Obturator herniation (OH) is a rare external abdominal hernia accounting for only 0.07 %-1 % of all hernia cases. Because the female pelvis is wider which can lead to herniation of abdominal contents. The Howship-Romberg sign should be checked during physical examination.

CONCLUSION

Obturator hernia is very rare and difficult to diagnose. Moreover when elderly women suffer from long-term chronic diseases, a very thin body, or a history of multiple deliveries. Howship-Romberg sign should be checked in these situations during physical examination. Early diagnosis and treatment significantly reduces the occurrence of intestinal perforation, necrosis, sepsis and/or other severe adverse events, thereby, a significant prognostic improvement of patients.

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.

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

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

Case report: Obturator hernia: Diagnosis and surgical treatment

Background

Obturator hernia (OH) is a rare external abdominal hernia, accounting for only 0.07%-1% of all hernia cases. Because the female pelvis is wider and there is less preperitoneal adipose tissue, the obturator canal is larger, which can lead to herniation of abdominal contents when abdominal pressure increases in elderly women with thin body. The clinical symptoms of patients with obturator hernia included abdominal pain, nausea, vomiting, etc., and the mass in the inguinal region could not be touched. The positive Howship-Romberg sign is a specific sign of OH. CT is the first choice for the diagnosis of obturator hernia. Since intestinal incarceration in OH patients is prone to lead to intestinal necrosis, emergency surgical treatment is often required. However, due to the lack of specificity of its clinical manifestations, the misdiagnosis rate is high, which often leads to the delay of diagnosis and treatment.

Methods

We report the case of an 86-year-old woman with a thin body and a history of multiple deliveries. The patient presented with abdominal pain, bloating, and constipation for 5 days. Physical examination revealed a positive Howship-Romberg sign on the right side, and CT examination suggested intestinal obstruction. Therefore, an urgent exploratory laparotomy was performed.

Results

After opening the abdominal cavity we found that the wall of the ileum was embedded in the right obturator, and the proximal bowel was significantly dilated. We restored the embedded bowel wall to its original position, resected the necrotic bowel and performed an end-to-end anastomosis of the small intestine. The right hernia orifice was sutured, and OH was diagnosed during the operation.

Conclusion

This article summarizes the diagnosis and treatment of OH by sharing this case, so as to provide a more detailed plan for early diagnosis and treatment of OH.

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.

Laparoscopic management of obturator hernia in the setting of intestinal obstruction: A report of two cases and review of literature

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.

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.

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.

OUP accepted manuscript

An obturator hernia is the protrusion of an organ/tissue through the obturator canal. Fondly called ‘little old lady’s hernia’, as they typically affect elderly thin female patients [7]. They are rare and difficult to clinically diagnose [2]. Diagnosis is often delayed and presentation could vary from symptoms of bowel obstruction, and pain in the groin or medial thigh [6] to atypical presentations like in our case. We report a case of a 99-year-old female with a 3-day history of low back pain, nausea and constipation. Computerized tomography scan revealed small bowel obstruction with transition point in left obturator hernia. The obstruction was successfully relieved via surgery without the need for bowel resection. This case highlights the importance of a high index of suspicion when faced with vague symptoms. Obturator hernias carry a reasonable degree of morbidity and mortality without intervention but have good outcomes if promptly managed.

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.

Diagnostic difficulties in obturator hernia: a rare case presentation and review of literature

Hernia arising from obturator canal is rare and it contributes to about less than 1% of incidence of all hernias. Diagnosing an obturator hernia clinically is a challenging one and nearly impossible. These hernias usually present as an intestinal obstruction as more than 50% of obturator hernias goes in for strangulation. Here, we report an unusual presentation of an obturator hernia in a 70-year-old woman who presented to emergency room with acute abdomen and uncomplicated reducible inguinal hernia. Radiological imaging showed obstructed inguinal hernia while on diagnostic laparoscopy, a strangulated and perforated obturator hernia of Richter’s type was seen in addition to an uncomplicated inguinal hernia. Obturator hernia, although very rare, is associated with high morbidity and mortality as it is often underdiagnosed as in our case. Laparoscopy bailed us out from missing out a perforation from an occult obturator hernia.

Obturator hernia: Clinical analysis of 11 patients and review of the literature

Obturator hernia is a relatively rare type of abdominal hernia, in which abdominal contents protrude through the obturator canal, a condition that can lead to small bowel obstruction. Its rarity and nonspecific signs and symptoms make a preoperative diagnosis difficult. The present study analyzed the clinical manifestations, diagnostic methods and operative treatment outcomes in patients with obturator hernia.Between January 2012 and October 2019, 1028 adults underwent surgical repair of abdominal wall hernia at the Department of Surgery, Kyungpook National University Hospital. The medical records of eleven patients who were treated for small bowel obstruction due to obturator hernia were retrospectively evaluated. Patient characteristics, clinical presentation, preoperative radiological diagnosis, operative findings, treatment, complications, and outcomes were recorded.All 11 patients were elderly women, with a mean age of 80.2 years (range, 71-87 years). Their mean body mass index was 17.9 kg/m (range, 11.9-22.2 kg/m). Symptoms at presentation were abdominal pain and vomiting, with a mean duration of symptoms prior to admission of 5.6 days (range, 1-15 days). Based on abdominopelvic computed tomography (CT) scans, all 11 patients were preoperatively diagnosed with obturator hernia, followed by laparoscopic exploration or laparotomy as soon as possible. Of the 11 patients, 6 (54.5%) had left-sided, four (36.4%) had right-sided, and one (9.1%) had bilateral obturator hernias. Three patients (27.3%) required resection of the ileum due to perforation or strangulation. All underwent simple closure of the hernia defect with interrupted or purse-string sutures. Ten patients recovered uneventfully, whereas one had wound seroma and ileus. Recurrence has not been observed in the 8 surviving patients.Obturator hernia should be included in the differential diagnosis of intestinal obstruction of unknown origin, especially in emaciated elderly women with chronic disease. Early surgical intervention without delay is imperative to avoid postoperative morbidity and mortality associated with intestinal strangulation due to obturator hernia. Obturator hernia can be sufficiently repaired with simple suture closure without mesh.

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.

Asynchronous Bilateral Obturator Hernias: A Suggested Approach to Reduce Morbidity of Obturator Hernias

Obturator hernias (OHs) are rare pelvic hernias that involve the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator foramen. Risk factors for OH patients include female gender, chronic disease, age, malnourishment, history of multiple pregnancies, anatomical enlargement of obturator foramen, increased intraabdominal pressure, and defective collagen metabolism. Since OHs have the highest mortality rate of all abdominal hernias, prompt diagnosis and treatment are critical. Prior research has demonstrated an increased likelihood of bilateral OHs relative to unilateral. We present the case of a 79-year-old female who presented with an obstructed OH six months after an operation for an OH on the contralateral side. Due to the potential morbidity and mortality associated with OHs and delay in discovery, we suggest evaluation and treatment of the contralateral side in patients who present with unilateral OHs.

Laparoscopic Mesh Repair of Bilateral Obturator Hernias Post-Peritoneal Dialysis

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.

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 and the elderly

An 84-year-old woman with a history of weight loss, anorexia and episodic vomiting was admitted to hospital where she died soon afterwards. Her diagnosis was acute renal injury due to dehydration and malnutrition. At autopsy the body was cachectic with a small intestinal obstruction due to herniation through a defect at the anterolateral aspect of the obturator foramen. A poorly differentiated adenocarcinoma of the gastroesophageal junction was also identified with small peripheral pulmonary thromboemboli. Death was due to small bowel obstruction from a left obturator hernia with scattered peripheral pulmonary thromboemboli complicating cachexia due to gastroesophageal adenocarcinoma. Obturator hernias are called the "little old lady's hernia" and occur mainly in elderly, multiparous and malnourished women. The broader female pelvis and wider obturator canal with laxity of ligaments and loss of preperitoneal adipose tissue padding around the canal predispose to herniation. This rare hernia is often first identified at autopsy.

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.

Obturator hernia: a rare cause of bowel obstruction

An obturator hernia is a rare condition and an unusual cause of intestinal obstruction. With a challenging diagnosis, it has one of the highest mortality rates of all abdominal wall hernias. The authors present a case of an elderly woman with bowel obstruction secondary to an incarcerated obturator hernia. An 80-year-old woman presented at the emergency room with complaints for the last 2 days of nausea, vomiting, constipation and lower right abdominal pain that radiated down to the right medial thigh. Abdominal tenderness to deep palpation of the right iliac fossa and mildly distention were noted. A CT scan demonstrated bowel obstruction secondary to an incarcerated obturator hernia. The patient underwent emergency exploratory laparotomy. The incarcerated bowel was reduced and the defect was repaired with a plug of polypropylene mesh covered with peritoneum. The patient had an uneventful postoperative period and was discharged on the fifth postoperative day.

[Case report: Occlusion and intestinal necrosis by obturator hernia]

BACKGROUND

Obturator hernia is a rare variety of abdominal hernia, it accounts for 0.07%-1.0% of all hernias, and occurs most often in women of advanced age and multiparous.

CLINICAL CASE

A 78-year-old female was admitted to the Emergency Department due to nausea, vomiting, complaints of abdominal discomfort and obstipation for the last 7 days. Abdominal CT scan showed dilated small bowel loops and multiple air-fluid levels near to a small bowel loop obturator hernia, between external obturator and pectineus muscle. Emergency laparotomy was performed and during the surgery, loop of small intestine was revealed herniated into the obturator foramen, 130cm from the angle of Treitz. Necrosis of small intestine was found, without perforation. Resection of the 10cm affected jejunal segment was performed and a side-to-side bowel anastomosis was fashioned. Also simple suture closure of obturator foramen was performed.

CONCLUSION

Obturator hernia is relatively rare. However physicians should keep it in mind and have clinical suspicion for obturator hernia as a cause of intestinal obstruction in female, elderly and multiparous patients in order to make an appropriate diagnosis and avoid bowel ischaemia.

Multiple concurrent bilateral groin hernias in a single patient; a case report and a review of uncommon groin hernias: A possible source of persistent pain after successful repair

INTRODUCTION

The wide use of laparoscopy for groin hernia repair has unveiled "hidden hernias" silently residing in this area. During the open repair of the presenting hernia, the surgeon was often unaware of these occult hernias. These patients postoperatively may present with unexplained chronic groin or pelvic pain.

PRESENTATION OF CASE

Rare groin hernias are defined according to their anatomical position. Challenges in the diagnosis and management of occult rare groin hernias are discussed. These problems are illustrated by a unique case report of multiple (six) coexisting groin hernias, whereof five were occult and two were rare.

DISCUSSION

Rare groin hernias are uncommon because they are difficult to diagnose clinically and are not routinely looked for. They are often occult and may coexist with other inguinal hernias, thus posing a diagnostic and treatment challenge to the surgeon, especially if there is persistent groin pain after "successful" repair. MRI is the most accurate preoperative and postoperative diagnostic tool, if there is a clinical suspicion that the patient might have an occult hernia.

CONCLUSION

Preperitoneal endoscopic approach is the recommended method in confirming the diagnosis and management of occult groin hernias. A sound knowledge of groin anatomy and a thorough preperitoneal inspection of all possible sites for rare groin hernias are needed to diagnose and repair all defects. The preperitoneal mesh repair with adequate overlap of all hernia orifices is the recommended treatment of choice.

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.

Laparoscopic total extraperitoneal repair of preoperatively diagnosed bilateral obturator and incidental bilateral femoral herniae

Obturator hernia (OH), a rare type of hernia, is associated with high morbidity and mortality. Diagnosis is often delayed as clinical symptoms are typically non-specific. OH is frequently associated with other occult inguinopelvic herniae. Early diagnosis is vital to decrease morbidity and mortality. We report the case of a 75-year-old woman who presented to the surgical outpatients' department with non-specific bilateral groin pain radiating to the thighs. CT of the pelvis demonstrated bilateral OH with no radiological evidence of bowel obstruction. Semiurgent elective laparoscopic total extraperitoneal mesh repair was performed. Intraoperative findings confirmed bilateral obturator herniae as well as incidental bilateral femoral herniae. This case highlights the need for a high index of suspicion for such concomitant hernias that, in the presence of OH, may only be identified intraoperatively.

A case of a perforated obturator hernia with a femoral abscess treated a pectineus muscle flap

Background

An obturator hernia accompanied with a femoral abscess is rare, and leads to severe infection. Repeated draining is often required due to remnant abscess.

Case presentation

We herein reported a case of a perforated obturator hernia with a femoral abscess that was successfully treated via repair using the pectineus muscle. An 84-year-old Japanese woman was referred to our hospital with appetite loss and right femoral pain. Abdominal computed tomography (CT) revealed a right obturator hernia and abscess spreading to the right thigh. Emergency surgery was performed. Intraoperative findings revealed that the abscess had formed because of a perforation in the small intestine by an incarcerated obturator hernia. We performed partial resection of the small intestine, repaired the hernial orifice, drained the right femoral abscess, and filled the cavity using the pectineus muscle. A residual abscess was not detectable following surgery, and the patient was discharged on postoperative day 63.

Conclusion

Some patients with a perforated obturator hernia and femoral abscess have a residual abscess following surgery that requires redrainage. Nevertheless, we consider it possible to successfully treat a perforated obturator hernia with a femoral abscess via repair using the pectineus muscle.

Bilateral obturator hernia diagnosed by computed tomography: a case report with review of the literature

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.